This article was downloaded by: [University of Aberdeen] On: 15 February 2015, At: 11:37 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
Health care workers and HIV/AIDS J. Elford
a
a
Lecturer in Epidemiology, Department of Public Health and Primary Care , Royal Free Hospital School of Medicine , London, NW3, UK Published online: 25 Sep 2007.
To cite this article: J. Elford (1990) Health care workers and HIV/AIDS, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 2:4, 367-370, DOI: 10.1080/09540129008257755 To link to this article: http://dx.doi.org/10.1080/09540129008257755
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
AIDS CARE, VOL. 2, NO. 4,1990
367
Health care workers and HIWAIDS J. ELFORD
Downloaded by [University of Aberdeen] at 11:37 15 February 2015
Lecturer in Epidemiology, Department of Public Health and Rimary Care, Royal Free Hospital School of Medicine, London NW3, UK
exposed to HIV infection at work (following parenteral, open wound or skin/mucous membrane exposure) reported two seroconversions after a mean follow up of 9 months (0.17%, 95% confidence interval 0.024.63%) (Ippolito, FC 34). By the end of December 1989,1,281 HCWs reported to CDC, Atlanta had been tested at least 6 months after occupational exposure to HIV. Of the 1,127 HCWs with percutaneous exposure, four seroconverted (0.3546, upper bound 95% CI=O.80%). No seroconversions occurred among the 154 HCWs with either mucous membrane or skm exposures (Tokars e? al., SC766). A longitudinal study at the NIH, Bethesda, also reported no seroconversions among 346 HCWs with mucous membrane exposure to HIV-infected blood and only one seroconversion among 179 HCWs with parenteral accidental exposure (0.56%) (Fahey et d.,ThC599). In a Brazilian hospital, 84 HCWs were followed up for at least 6 months after accidental exposures to blood and body fluids of AIDS patients. None seroconverted (Abreu & Fernandes, SC565). In the same study, among 361 HCWs with no accidental exposures, six were HIV positive. All had confirmed personal risk factors. This emphasizes that Risk of occupational transmission of HCWs, like all occupational groups, face a HIV risk of HIV infection outside the workplace. Whi!e the Conference verified the low risk The low risk of occupational transmission of of occupational transmission, the total numHIV was confirmed by the Conference. An ber of occupationally-acquired infections Italian study of 1,154 HCWs accidentally Was it simply a coincidence that during the week of the Sixth International Conference on AIDS the New England Journal of Medicine carried an article on the risk faced by health care workers (HCWs) of exposure to patients’ blood during surgery? This study reported that neither knowledge of diagnosed HIV nor awareness of a patient’s high risk status for such infection influenced the HCWs’ rate of accidental exposures during surgery. In this report Julie Gerberding and her co-authors at San Francisco General Hospital (1990) found no evidence that preoperative testing for HIV infection would reduce the frequency of accidental exposures to blood. This article certainly strengthened the agenda on health care workers set by the Sixth International Conference on AIDS. As well as occupational exposure to HIV, the poster and verbal presentations covered universal precautions; the use of prophylactic zidovudine (AZT)after a needlestick injury; perceived risk of HIV infection among HCWs; attitudes of HCWs towards HIV; and staff training.
Downloaded by [University of Aberdeen] at 11:37 15 February 2015
368
SAN FRANCISCO SUMMARLES: J. ELFORD
may nonetheless rise in the future as the prevalence of HIV in the population increases (Tokars et al., FC33). How big a risk does a health care worker with HIV present to hs or her patients? A reassuring answer came from Tenessee, USA (Mishu et al., SD864). In January 1989 a local surgeon was diagnosed with AIDS. Two thousand one hundred and sixty patients operated on by the surgeon in the preceding 7 years were identified. Two hundred and s i x t y four had already died but none from AIDS or other HIV-related disease. Of the 1,896 remaining patients, 1,652 were contacted and offered free HIV antibody testing. Of these, 616 (37%) were tested. Only one patient was found to be HIV antibody positive; he was both an IV drug user and a client of prostitutes. While the majority of patients were not actually tested for HIV, the results are nonetheless encouraging.
Universal precautions How can HCWs reduce their risk of accidental exposure to HIV (and other pathogens) at work? By adopting universal precautions with all patients? Or by identifying patients with HIV, or those thought to be at risk, and taking extra care with these people alone? The conference provided some clues. Among obstemc personnel in a large urban public hospital in the USA, there was considerable risk of contact with blood and amniotic fluid during delivery. However, knowing that the mother had, or was at risk for, a blood borne infection did not substantially affect the frequency of these exposures among the staff (P&O et al., ThC603). This is in keeping with the study among surgeons published in the New England Journal of Medicine and suggests that prior knowledge of a patient’s risk status does not necessarily reduce the risk of accidental exposure. In hospital emergency departments in the USA, wearing gloves significantly re-
duced the risk of blood contact during commonly performed procedures. For example, when obtaining an arterial blood sample, 0.5% of those health care workers who wore gloves had blood contact compared with 10.3% among those who did not wear gloves -a 20-fold difference in risk. While HIV seroprevalence rates were highest among male inner city patients between the ages of 15 and 44 years, HIV infections were also found in other age groups and in suburban emergency departments, indicating the need for universal precautions with all patients (Marcus et al., ThC604). However, introducing a policy of universal precautions (UPS) may not always be easy. In a Minnesota (USA) study, considerable non-compliance with UPS was reported by emergency department personnel. Reasons for non-compliance included not having enough time, reduced dexterity, believing patients to be at low risk for HIV, or non-availability of equipment (Campbell et d.,FC38). Even though compliance with UPS in a Lausanne (Switzerland) hospital was only partial, the overall frequency of blood contact/procedure fell after their introduction. However, needlestick injuries showed no such decline (Francioli et al., ThC602). The poor design of currently available equipment presents a further obstacle to risk reduction in the workplace (Jagger, J., FC37). And in the Third World many hospitals simply canaot afford the protective spectacles, gloves and other equipment that are part and parcel of universal precautions. Traditional birth attendants and healers working outside hospitals may also face an occupational risk. Such problems require imaginative solutions using locally and cheaply available materials (Nkanda, FC36).
Prophylactic zidovudine (AZT) after a needlestick injury A growing number of hospitals are prescribing zidovudine to health care workers, after occupational exposure to HIV-infected
Downloaded by [University of Aberdeen] at 11:37 15 February 2015
HEALTH CARE WORKERS AND HIVIAIDS
blood, in an attempt to reduce their risk of seroconversion. However its efficacy remains unproven. And the correct dosage is unknown. Between October 1988 and December 1989, 261 HCWs were reported to CDC Atlanta following an occupational exposure to HIV-infected blood. None seroconverted. Among the 261 HCWs were 17 who took zidovudine post exposure (16 after a percutaneous injury and one after mucous membrane contact). Prescribed regimens varied from 600 to 1,200 mg/day, taken for between 3 days up to 6 weeks. Possible toxicity, including headache, nausea, vomiting and a fall in haemoglobin, occurred in seven of the 14 HCWs for whom data were complete. Zidovudine was stopped because of side effects in four HCWs (Tokars et al., SC766). An Italian study of 21 HCWs given zidovudine after occupational exposure to HIV-infected blood reported a dose-related toxicity. Dosage varied from 500 to 1,200mg day with duration of treatment ranging from 5 days to 6 weeks. Nausea, gasmc pain and vomiting were reported more frequently in HCWs taking over 800mg per day (Puro et al., SC767). San Francisco General Hospital prescribed 200mg of zidovudine five times a day for 4 weeks, starting within 1 hour of exposure, for 16 HCWs following M accidental exposure. Most reported some symptoms but none experienced serious toxicity (Gerberding et al., FC35). On the other hand, among 17 HCWs taking prophylactic zidovudine after an accidental exposure in the NIH longitudinal study, four did not complete the course because of side effects. These were mild to moderate and all reversible (Fahey et al., ThC599). None of the HCWs seroconverted in these studies. While the use of post-exposure prophylactic zidovudine is increasing, M e r evaluation is required. Neither its efficacy, as a prophylaxis, nor its safety have been established. Clearly, the two recent reports of people who seroconverted after a needlestick injury, despite being prescribed zidovudine, raises important questions about its
369
efficacy (Lange et ul., 1990; Looke & Grove, 1990). A clinical trial of prophylactic zidovudine would require about 2,000 HCWs, accidentally exposed to HIV, which would present formidable recruitment problems (Tokars et al., SC766). Nonetheless, postexposure observational studies of HCWs prescribed prophylactic zidovudine will provide valuable information on the toxicity of this drug in supposedly healthy individuals.
Perceived risk of HIV infection among health care workers There remains a discrepancy between how HCWs perceive their occupational risk of HIV and the risk described by epidemiological studies. Physicians in Quebec perceived the risk of HIV transmission by a contaminated needle to be ten times greater than the CDC estimated risk of 0.5%. As in other studies, surgeons saw themselves as being a group at high professional risk of HIV transmission. Some physicians also believed a seropositive doctor presented a bgh risk to hs or her patients (Nadeau et al., FC735). In a Californian s w e y , a quarter of physicians overestimated the risk of seroconversion after a needlestick injury by a factor of 10 or more. The motbidiry associated with seroconversion may have influenced the physicians’ perceptions of occupational risk, in spite of the low seroconversion rates shown by epidemiologic studies (Owens & Nease, SD875). A study of Kenyan nurses revealed that more than half of them worked ‘under fear’ of becoming infected with HIV in the hospital (Nyambaka, FB498).
Health care workers’ attitudes towards HIV infection, and staff training There is growing evidence that the HIV/ AIDS status of a patient may influence clinical decision-making, and lead to denial of appropriate care (Powderly & Levin, SD856; Stocking et al., SD857). A survey
Downloaded by [University of Aberdeen] at 11:37 15 February 2015
370
S A N FRANCISCO SUMMARIES:J. ELFORD
among gay men in Baltimore and Los Angeles revealed that those with AIDS were more likely to have been refused treatment, especially by dentists, than those who were HIV positive, but symptom free. Those who were seronegative were least Lkely to have been refused treatment (Kass, ThD812). Over 25% of first and second year medical students from four Massachusetts’ m d c a l schools wanted to be able to refuse treating people with HIV or AIDS. More females than males were w h g to treat people with HIV, as were students who knew somebody with AIDS (Culbert & Strunin, SD871). On the other hand, the career choices among medical students at Johns Hopkins University, Baltimore, did not appear to have been substantially influenced by the AIDS epidemic (Loring & Kelen, SR873). A variety of educational strategies have been considered. While some misconceptions about HIV/AIDS among Brazilian melcal students were m d f i e d through an intensive training programme, prejudices concerning professional day-to-day contact were harder to change (Greco et al., SD866). A Canadian study identified gaps in the medical curriculum, specifically in epidemiology and public health, but also found that trainees needed help in overcoming prejudice and intolerance of differences (Mills, SD867). AIDS support groups could play an essential role in educating health care professionals, especially for those with little direct experience of HIV infection, by providing opportunities to talk to people with HIV (Ogden et al., SD890). There certainly seemed to be a desire for further training. In both Cleveland (USA) and Quebec physicians viewed specialized instruction in HIV favourably (Calbrese & Kelley, SD992; Bernard et al., SD893). ‘Mmsabbaticals’ for nurses work-‘ ing wi;h a increasing number of patients in lWral aceas Of the USA were also recommended, to promote appropriate attitudes, beliefs and behaviours
(Anderson et al., SD869). And a training programme for nursing personnel in Brazil appears to have resulted in a loss of fear in working with HIV patients and their families (Libuy Araya er d.,SD896).
Health care workers with HIV infection While the risk of occupationally-acquired HIV infection is small, HCWs may become infected as a result of risks they face in their personal lives. When hospital staff become ill, as a result of HIV, the stress experienced by their peers must also be addressed. At the San Francisco Veterans Administration Medical Center, providing opportunities for staff to learn about HIV/AIDS and to discuss their fears improved attitudes and reduced anxiety (Hadley et al., SD902). Dr Hacib Aoun described to the Conference what may happen if such anxieties are not addressed. Dr Aoun was infected with HIV as a result of an accidental exposure at work in 1983. Today no hospital and no melcal centre in the USA will employ him. He told his spell-bound audience that organized medicine had no place for a physician with AIDS. Dr Aoun asked the conference delegates, “If medical institutions discriminate against their own members, why should the general public know or do better?” Why indeed? References J.L., LITTELL, C., TARRINGTON, A,, BROWN, A. & SCHECTER,W.P.(1990) h s k of exposure of surpcal ~ C C S O M C ~to patients’ blood during surgery at San Francisco General Hospital, New England Journal of Medicine, 322, pp. 1788-1 793. LANCE, J.M.A., BOUCHER,C.A.B., HOLLACK, C. E. M. er ul. (1990) Failure of zidovudine prophylaxis after accidental exposure KO HIV-1,New E n g h d Journal of Medicine, 322, pp. 1375-77. Loom, D.F.M. & GROVE,D.I. (1990) Failed prophylactic zidovudine after needlestick injury, Luncrf, 335, p. 1280.
GERBERDING,
AIDS Care: Psychological and Sociomedical Aspects of AIDS/HIV Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/caic20
Health care workers and HIV/AIDS J. Elford
a
a
Lecturer in Epidemiology, Department of Public Health and Primary Care , Royal Free Hospital School of Medicine , London, NW3, UK Published online: 25 Sep 2007.
To cite this article: J. Elford (1990) Health care workers and HIV/AIDS, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV, 2:4, 367-370, DOI: 10.1080/09540129008257755 To link to this article: http://dx.doi.org/10.1080/09540129008257755
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
AIDS CARE, VOL. 2, NO. 4,1990
367
Health care workers and HIWAIDS J. ELFORD
Downloaded by [University of Aberdeen] at 11:37 15 February 2015
Lecturer in Epidemiology, Department of Public Health and Rimary Care, Royal Free Hospital School of Medicine, London NW3, UK
exposed to HIV infection at work (following parenteral, open wound or skin/mucous membrane exposure) reported two seroconversions after a mean follow up of 9 months (0.17%, 95% confidence interval 0.024.63%) (Ippolito, FC 34). By the end of December 1989,1,281 HCWs reported to CDC, Atlanta had been tested at least 6 months after occupational exposure to HIV. Of the 1,127 HCWs with percutaneous exposure, four seroconverted (0.3546, upper bound 95% CI=O.80%). No seroconversions occurred among the 154 HCWs with either mucous membrane or skm exposures (Tokars e? al., SC766). A longitudinal study at the NIH, Bethesda, also reported no seroconversions among 346 HCWs with mucous membrane exposure to HIV-infected blood and only one seroconversion among 179 HCWs with parenteral accidental exposure (0.56%) (Fahey et d.,ThC599). In a Brazilian hospital, 84 HCWs were followed up for at least 6 months after accidental exposures to blood and body fluids of AIDS patients. None seroconverted (Abreu & Fernandes, SC565). In the same study, among 361 HCWs with no accidental exposures, six were HIV positive. All had confirmed personal risk factors. This emphasizes that Risk of occupational transmission of HCWs, like all occupational groups, face a HIV risk of HIV infection outside the workplace. Whi!e the Conference verified the low risk The low risk of occupational transmission of of occupational transmission, the total numHIV was confirmed by the Conference. An ber of occupationally-acquired infections Italian study of 1,154 HCWs accidentally Was it simply a coincidence that during the week of the Sixth International Conference on AIDS the New England Journal of Medicine carried an article on the risk faced by health care workers (HCWs) of exposure to patients’ blood during surgery? This study reported that neither knowledge of diagnosed HIV nor awareness of a patient’s high risk status for such infection influenced the HCWs’ rate of accidental exposures during surgery. In this report Julie Gerberding and her co-authors at San Francisco General Hospital (1990) found no evidence that preoperative testing for HIV infection would reduce the frequency of accidental exposures to blood. This article certainly strengthened the agenda on health care workers set by the Sixth International Conference on AIDS. As well as occupational exposure to HIV, the poster and verbal presentations covered universal precautions; the use of prophylactic zidovudine (AZT)after a needlestick injury; perceived risk of HIV infection among HCWs; attitudes of HCWs towards HIV; and staff training.
Downloaded by [University of Aberdeen] at 11:37 15 February 2015
368
SAN FRANCISCO SUMMARLES: J. ELFORD
may nonetheless rise in the future as the prevalence of HIV in the population increases (Tokars et al., FC33). How big a risk does a health care worker with HIV present to hs or her patients? A reassuring answer came from Tenessee, USA (Mishu et al., SD864). In January 1989 a local surgeon was diagnosed with AIDS. Two thousand one hundred and sixty patients operated on by the surgeon in the preceding 7 years were identified. Two hundred and s i x t y four had already died but none from AIDS or other HIV-related disease. Of the 1,896 remaining patients, 1,652 were contacted and offered free HIV antibody testing. Of these, 616 (37%) were tested. Only one patient was found to be HIV antibody positive; he was both an IV drug user and a client of prostitutes. While the majority of patients were not actually tested for HIV, the results are nonetheless encouraging.
Universal precautions How can HCWs reduce their risk of accidental exposure to HIV (and other pathogens) at work? By adopting universal precautions with all patients? Or by identifying patients with HIV, or those thought to be at risk, and taking extra care with these people alone? The conference provided some clues. Among obstemc personnel in a large urban public hospital in the USA, there was considerable risk of contact with blood and amniotic fluid during delivery. However, knowing that the mother had, or was at risk for, a blood borne infection did not substantially affect the frequency of these exposures among the staff (P&O et al., ThC603). This is in keeping with the study among surgeons published in the New England Journal of Medicine and suggests that prior knowledge of a patient’s risk status does not necessarily reduce the risk of accidental exposure. In hospital emergency departments in the USA, wearing gloves significantly re-
duced the risk of blood contact during commonly performed procedures. For example, when obtaining an arterial blood sample, 0.5% of those health care workers who wore gloves had blood contact compared with 10.3% among those who did not wear gloves -a 20-fold difference in risk. While HIV seroprevalence rates were highest among male inner city patients between the ages of 15 and 44 years, HIV infections were also found in other age groups and in suburban emergency departments, indicating the need for universal precautions with all patients (Marcus et al., ThC604). However, introducing a policy of universal precautions (UPS) may not always be easy. In a Minnesota (USA) study, considerable non-compliance with UPS was reported by emergency department personnel. Reasons for non-compliance included not having enough time, reduced dexterity, believing patients to be at low risk for HIV, or non-availability of equipment (Campbell et d.,FC38). Even though compliance with UPS in a Lausanne (Switzerland) hospital was only partial, the overall frequency of blood contact/procedure fell after their introduction. However, needlestick injuries showed no such decline (Francioli et al., ThC602). The poor design of currently available equipment presents a further obstacle to risk reduction in the workplace (Jagger, J., FC37). And in the Third World many hospitals simply canaot afford the protective spectacles, gloves and other equipment that are part and parcel of universal precautions. Traditional birth attendants and healers working outside hospitals may also face an occupational risk. Such problems require imaginative solutions using locally and cheaply available materials (Nkanda, FC36).
Prophylactic zidovudine (AZT) after a needlestick injury A growing number of hospitals are prescribing zidovudine to health care workers, after occupational exposure to HIV-infected
Downloaded by [University of Aberdeen] at 11:37 15 February 2015
HEALTH CARE WORKERS AND HIVIAIDS
blood, in an attempt to reduce their risk of seroconversion. However its efficacy remains unproven. And the correct dosage is unknown. Between October 1988 and December 1989, 261 HCWs were reported to CDC Atlanta following an occupational exposure to HIV-infected blood. None seroconverted. Among the 261 HCWs were 17 who took zidovudine post exposure (16 after a percutaneous injury and one after mucous membrane contact). Prescribed regimens varied from 600 to 1,200 mg/day, taken for between 3 days up to 6 weeks. Possible toxicity, including headache, nausea, vomiting and a fall in haemoglobin, occurred in seven of the 14 HCWs for whom data were complete. Zidovudine was stopped because of side effects in four HCWs (Tokars et al., SC766). An Italian study of 21 HCWs given zidovudine after occupational exposure to HIV-infected blood reported a dose-related toxicity. Dosage varied from 500 to 1,200mg day with duration of treatment ranging from 5 days to 6 weeks. Nausea, gasmc pain and vomiting were reported more frequently in HCWs taking over 800mg per day (Puro et al., SC767). San Francisco General Hospital prescribed 200mg of zidovudine five times a day for 4 weeks, starting within 1 hour of exposure, for 16 HCWs following M accidental exposure. Most reported some symptoms but none experienced serious toxicity (Gerberding et al., FC35). On the other hand, among 17 HCWs taking prophylactic zidovudine after an accidental exposure in the NIH longitudinal study, four did not complete the course because of side effects. These were mild to moderate and all reversible (Fahey et al., ThC599). None of the HCWs seroconverted in these studies. While the use of post-exposure prophylactic zidovudine is increasing, M e r evaluation is required. Neither its efficacy, as a prophylaxis, nor its safety have been established. Clearly, the two recent reports of people who seroconverted after a needlestick injury, despite being prescribed zidovudine, raises important questions about its
369
efficacy (Lange et ul., 1990; Looke & Grove, 1990). A clinical trial of prophylactic zidovudine would require about 2,000 HCWs, accidentally exposed to HIV, which would present formidable recruitment problems (Tokars et al., SC766). Nonetheless, postexposure observational studies of HCWs prescribed prophylactic zidovudine will provide valuable information on the toxicity of this drug in supposedly healthy individuals.
Perceived risk of HIV infection among health care workers There remains a discrepancy between how HCWs perceive their occupational risk of HIV and the risk described by epidemiological studies. Physicians in Quebec perceived the risk of HIV transmission by a contaminated needle to be ten times greater than the CDC estimated risk of 0.5%. As in other studies, surgeons saw themselves as being a group at high professional risk of HIV transmission. Some physicians also believed a seropositive doctor presented a bgh risk to hs or her patients (Nadeau et al., FC735). In a Californian s w e y , a quarter of physicians overestimated the risk of seroconversion after a needlestick injury by a factor of 10 or more. The motbidiry associated with seroconversion may have influenced the physicians’ perceptions of occupational risk, in spite of the low seroconversion rates shown by epidemiologic studies (Owens & Nease, SD875). A study of Kenyan nurses revealed that more than half of them worked ‘under fear’ of becoming infected with HIV in the hospital (Nyambaka, FB498).
Health care workers’ attitudes towards HIV infection, and staff training There is growing evidence that the HIV/ AIDS status of a patient may influence clinical decision-making, and lead to denial of appropriate care (Powderly & Levin, SD856; Stocking et al., SD857). A survey
Downloaded by [University of Aberdeen] at 11:37 15 February 2015
370
S A N FRANCISCO SUMMARIES:J. ELFORD
among gay men in Baltimore and Los Angeles revealed that those with AIDS were more likely to have been refused treatment, especially by dentists, than those who were HIV positive, but symptom free. Those who were seronegative were least Lkely to have been refused treatment (Kass, ThD812). Over 25% of first and second year medical students from four Massachusetts’ m d c a l schools wanted to be able to refuse treating people with HIV or AIDS. More females than males were w h g to treat people with HIV, as were students who knew somebody with AIDS (Culbert & Strunin, SD871). On the other hand, the career choices among medical students at Johns Hopkins University, Baltimore, did not appear to have been substantially influenced by the AIDS epidemic (Loring & Kelen, SR873). A variety of educational strategies have been considered. While some misconceptions about HIV/AIDS among Brazilian melcal students were m d f i e d through an intensive training programme, prejudices concerning professional day-to-day contact were harder to change (Greco et al., SD866). A Canadian study identified gaps in the medical curriculum, specifically in epidemiology and public health, but also found that trainees needed help in overcoming prejudice and intolerance of differences (Mills, SD867). AIDS support groups could play an essential role in educating health care professionals, especially for those with little direct experience of HIV infection, by providing opportunities to talk to people with HIV (Ogden et al., SD890). There certainly seemed to be a desire for further training. In both Cleveland (USA) and Quebec physicians viewed specialized instruction in HIV favourably (Calbrese & Kelley, SD992; Bernard et al., SD893). ‘Mmsabbaticals’ for nurses work-‘ ing wi;h a increasing number of patients in lWral aceas Of the USA were also recommended, to promote appropriate attitudes, beliefs and behaviours
(Anderson et al., SD869). And a training programme for nursing personnel in Brazil appears to have resulted in a loss of fear in working with HIV patients and their families (Libuy Araya er d.,SD896).
Health care workers with HIV infection While the risk of occupationally-acquired HIV infection is small, HCWs may become infected as a result of risks they face in their personal lives. When hospital staff become ill, as a result of HIV, the stress experienced by their peers must also be addressed. At the San Francisco Veterans Administration Medical Center, providing opportunities for staff to learn about HIV/AIDS and to discuss their fears improved attitudes and reduced anxiety (Hadley et al., SD902). Dr Hacib Aoun described to the Conference what may happen if such anxieties are not addressed. Dr Aoun was infected with HIV as a result of an accidental exposure at work in 1983. Today no hospital and no melcal centre in the USA will employ him. He told his spell-bound audience that organized medicine had no place for a physician with AIDS. Dr Aoun asked the conference delegates, “If medical institutions discriminate against their own members, why should the general public know or do better?” Why indeed? References J.L., LITTELL, C., TARRINGTON, A,, BROWN, A. & SCHECTER,W.P.(1990) h s k of exposure of surpcal ~ C C S O M C ~to patients’ blood during surgery at San Francisco General Hospital, New England Journal of Medicine, 322, pp. 1788-1 793. LANCE, J.M.A., BOUCHER,C.A.B., HOLLACK, C. E. M. er ul. (1990) Failure of zidovudine prophylaxis after accidental exposure KO HIV-1,New E n g h d Journal of Medicine, 322, pp. 1375-77. Loom, D.F.M. & GROVE,D.I. (1990) Failed prophylactic zidovudine after needlestick injury, Luncrf, 335, p. 1280.
GERBERDING,
