UK considering lifting restrictions on health workers with HIV – as long as viral load is undetectable

The Department of Health has opened a consultation on possible changes to its policy on the employment of people with HIV. The current ban on people with HIV performing specific procedures in surgery, dentistry and gynaecology may be lifted, so that staff who are taking antiretroviral therapy and have a viral load below 200 copies/ml could work in the NHS.

Implementation of the proposal will, in part, depend on the responses received during the public consultation that is open until 9 March 2012. Patient safety in the NHS is a sensitive political issue and if public discussion is not informed by scientific evidence, the proposals could be controversial.

Current UK policy is for a total ban on HIV-positive healthcare workers performing ‘exposure-prone procedures’. As a result, a number of medical jobs are not open to people with HIV and the consequences for someone diagnosed in the middle of their career can be devastating.

An exposure-prone procedure is one in which injury to the healthcare worker could result in the worker’s blood contaminating the patient’s open tissues. These procedures involve a combination of sharp objects and the worker’s hands being in a body cavity. Surgery is the most obvious example, but many dental procedures are also considered ‘exposure-prone’.

Only a few other developed countries (including Australia, Ireland and Italy) have a policy as restrictive as that of the UK. It is more common for the management of an HIV-positive healthcare worker to be determined on a case-by-case basis. This is the situation in Austria, Belgium, Canada, France, New Zealand and Sweden, for example.

A current court case, in which a dentist with HIV is claiming the current ban is discriminatory and unlawful, helps explains why the government is considering the change.

A working group of experts examined the evidence on the risk of transmission occurring in healthcare settings, especially when patients have been treated by an HIV-positive health worker. Internationally, there have only been four cases of transmission, none of them in the UK. In the United States, testing of 22,171 patients who had been treated by 51 different HIV-positive workers, including surgeons, obstetricians and dentists, did not identify any new HIV infections. 

During some of the less invasive ‘exposure-prone procedures’ (such as a local anaesthetic injection or a routine tooth extraction), the experts consider the transmission risk to be “negligible”. During the most invasive procedures (such as a caesarean section or open cardiac surgery), they consider the risk to be “extremely low”.

But the experts consider that the risk of HIV transmission will vary, depending on the infectiousness of the health worker, as measured by viral load.

They therefore recommend that HIV-positive workers should be allowed to perform exposure-prone procedures as long as:

They are taking combination antiretroviral therapyTheir viral load is consistently below 200 copies/ml (tests taken every three months)They are under the joint supervision of a consultant in occupational medicine and their usual doctor.

The recommendations therefore open the possibility of individuals taking HIV treatment for occupational health reasons, when it would not otherwise be recommended.

Workers whose viral load rebounded or who ceased to comply with the testing requirements would be asked not to perform exposure-prone procedures until the situation was resolved.

Based on the prevalence of HIV in the England and the number of NHS employees who perform exposure-prone procedures, the experts estimate that the measures could affect around 110 HIV-positive workers (including those with undiagnosed infection).

England’s Chief Medical Officer, Dame Sally Davies, commented: "We need to ensure that the guidelines and restrictions imposed are evidence-based and achieve a fair balance between patient safety and the rights and responsibilities of healthcare workers with HIV. This consultation will seek wide views on the expert advice and whether it should be accepted."

The chairman of the Expert Advisory Group on AIDS, Professor Brian Gazzard, said: "Our careful review of the evidence suggests that the current restrictions on healthcare workers with HIV are now out of step with evidence about the minimal risk of transmission of infection to patients and policies in most other countries. This risk can be reduced even further if the healthcare worker is taking effective drug therapy for HIV and being monitored by HIV and occupational health specialists."

As healthcare is a responsibility of the devolved administrations in the United Kingdom, there are likely to be parallel consultations in the four countries. England and Scotland have already issued consultation documents, both of which are open until 9 March 2012.

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Electrocautery ablation: safe and effective treatment of high-grade pre-cancerous anal lesions in gay men

A clinic-based intervention offers safe and effective treatment for high-grade pre-cancerous anal lesions, US investigators report in the online edition of the Journal of Acquired Immune Deficiency Syndromes.

Doctors at the Mount Sinai School of Medicine, New York, used a technique called electrocautery ablation to treat pre-cancerous anal lesions in 232 gay men, 132 of whom were HIV-positive.

Eighteen months after treatment, 83% of HIV-negative men and 69% of those with HIV were free of high-grade pre-cancerous anal lesions.

“Electrocautery ablation of high-grade anal squamous intraepithelial lesions is a safe and effective office-based procedure comparable to other available treatments,” comment the investigators.

Incidence of anal cancer has increased dramatically among gay men in recent years. HIV-positive gay men appear to be especially vulnerable to the disease, and its incidence is five-times higher in these patients compared to HIV-negative men.

Infection with high certain high-risk strains of human papillomavirus can cause cell changes in the anus, resulting in the formation of lesions. The severity of these changes is graded, and between 9% and 13% of high-grade lesions progress to anal cancer.

There are a number of treatments for these pre-cancerous lesions including infrared coagulation and topical creams such as imiquimod.

Another therapy is electrocautery ablation. The investigators described the procedure thus: “Using a gentle brushing technique the lesion was ablated [worn down] by moving [a] blade lightly across the surface like a paint-brush.” The therapy has a number of advantages and can be performed in clinics without the need for anaesthetic or sedation.

Investigators wished to assess the safety and effectiveness of this procedure. They therefore retrospectively analysed the notes of gay men who had the treatment between 2006 and 2010. The patients received an initial treatment and were then followed at intervals of three to six months and were provided with additional treatment if necessary.

At the first treatment session, a total of 375 lesions were treated in HIV-infected men compared to 226 lesions in the HIV-negative patients, a significant difference (p = 0.006).

Lesions recurred in 53% of HIV-negative men (mean number of lesions, 1.6) and in 61% of HIV-positive men (mean number of lesions, 1.9).

The number of lesions present at the time of the initial treatment session was associated with the risk of recurrence. Patients with only one lesion at this time were 55% and 73% less likely to experience a recurrence than individuals with two or three lesions (p = 0.008 and p < 0.001 respectively).

The persistence of individual lesions after the initial session of treatment was also examined by the researchers. They found a cure rate of 85% in HIV-negative individuals and 75% in HIV-positive patients.

The first treatment session appeared to offer the best chance of eradicating lesions. In HIV-negative patients the persistence rate after a second ablation treatment was 3.03 times greater than that observed after the first session.

Further analysis showed that lesions were a significant 2.34 times more likely to recur in HIV-positive men compared to HIV-negative men after a second treatment (p = 0.008).

“Extensive dysplastic tissue may indicate either infection with more oncogenic virus or a more immune compromised host,” suggest the investigators.

Nevertheless, at the last follow-up visit, 83% of HIV-negative individuals and 69% of men with HIV were free of high-grade anal lesions.

Such a level of efficacy is comparable to that achieved with alternative therapies.

“Given that infrared coagulation and electrocautery ablation have similar outcomes when treating high-grade anal squamous intraepithelial lesions, the choice of modality should be based on clinician comfort and preference,” comment the authors. “In our hands the overall impression was that electrocautery ablation seemed faster, more hemostatic and allowed more extensive disease to be treated in office.”

Pain after treatment was the most commonly reported side-effect. However, this was adequately controlled with mild painkillers. One HIV-positive patient progressed to anal cancer, despite multiple ablation treatments.

“While we documented a single progression (0.4%), rates were far lower tan series advocating a ‘watch and wait’ approach,” conclude the authors.

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