Download HIV Infection in PHT Staff Policy

HIV INFECTED HEALTH CARE WORKERS: GUIDANCE ON
SCREENING, MANAGEMENT AND PATIENT NOTIFICATION
Version
7
Name of responsible (ratifying) committee
Health and Safety Committee
Date ratified
02 November 2016
Document Manager (job title)
Consultant Occupational Health physician
Date issued
05 December 2016
Review date
30 November 2018
Electronic location
Health and Safety Policies
Related Procedural Documents
Hepatitis B Virus (HBV); protecting employees and
patients.
Hepatitis C Virus (HCV); protecting employees and
patients.
Prevention and management of Needlestick (‘sharps’)
injuries and contamination incidents.
Key Words (to aid with searching)
Work Health Assessment; Exposure Prone Procedure
(EPP); Patient Notification Exercise (PNE); Blood
Borne Virus (BBV); HIV Post Exposure Prophylaxis
HIV PEP).
Version Tracking
Version
Date
Ratified
Brief Summary of Changes
Author
7
02.11.16
No changes
-
6.1
Sept 2016
Extension to review date to 30.11.16
-
6
07.05.14
In January 2014 the Department of Health announced a change in
policy to remove restrictions on Healthcare Workers (HCW) with
HIV practicing Exposure Prone Procedures (EPP).
Dr Susan
Harvey
HIV Infected Health Care Workers: Guidance on Screening, Management and Patient Notification
Version: 7
Issue Date: 05 December 2016
Review Date: 30 November 2018 (unless requirements change)
Page 1 of 12
CONTENTS
QUICK REFERENCE GUIDE .......................................................................................................... 3
1.
INTRODUCTION ......................................................................................................................... 4
2.
PURPOSE ................................................................................................................................... 4
3.
SCOPE ........................................................................................................................................ 5
4.
DEFINITIONS .............................................................................................................................. 5
5.
DUTIES AND RESPONSIBILITIES .............................................................................................. 6
6.
PROCESS ................................................................................................................................... 7
7.
TRAINING REQUIREMENTS ...................................................................................................... 8
8.
REFERENCES AND ASSOCIATED DOCUMENTATION ............................................................ 8
9.
EQUALITY IMPACT STATEMENT .............................................................................................. 8
10.
MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS .................................... 10
HIV Infected Health Care Workers: Guidance on Screening, Management and Patient Notification
Version: 7
Issue Date: 05 December 2016
Review Date: 30 November 2018 (unless requirements change)
Page 2 of 12
QUICK REFERENCE GUIDE
For quick reference the guide below is a summary of actions required. This does not negate the need
for the document author and others involved in the process to be aware of and follow the detail of this
policy.
1.
Healthcare workers who are new to the NHS and who will perform Exposure Prone
Procedure (EPP) (see page 4 for definition) and existing healthcare workers who are new to
EPP are required to have HIV and hepatitis C tests in addition to the standard pre-placement
health checks.
2. Healthcare workers who are new to the NHS and not performing Exposure Prone Procedures
can be offered testing for HIV and hepatitis C in addition to their usual pre-placement health
checks.
3. A healthcare worker who has any reason to believe they may have been exposed to infection
with HIV, in whatever circumstances, must promptly seek and follow confidential professional
advice on whether they should be tested for HIV and must seek advice from the Occupational
Health Department with regard to workplace activities. Failure to do so may breach the duty of
care to patients.
4. Provided appropriate infection control procedures are scrupulously adhered to, the majority of
procedures in the healthcare setting pose no risk of transmission of the human
immunodeficiency virus (HIV) from an infected healthcare worker to a patient.
5. In January 2014 the Department of Health announced a change in policy to remove
restrictions on Healthcare Workers (HCW) with HIV practicing Exposure Prone
Procedures (EPP). This change reflects accumulated evidence that shows there is an
extremely low risk of transmission from an infected HCW to a patient. All HCW with HIV
who wish to perform EPP must: be on effective combination antiretroviral drug therapy
(cART), and have a plasma viral load<200 copies/ml, and be subject to plasma viral
load monitoring every 12 weeks, and be under joint supervision of a consultant
occupational physician and their treating physician. In addition, these HIV infected
HCW wishing to perform EPP must be registered on a confidential national register.
6. There may be occasions when an HIV infected HCW is aware of accidentally exposing a
patient to their blood. HCW should be advised of the action to take in this scenario.
Exposure to the blood of a HCW who is on cART and who has a low and stable HIV
viral load is likely to pose an extremely low risk of transmission. There is no
requirement to advise patients of a possible exposure where the HCW was fully
compliant with this policy. If there is concern that the viral load might be detectable,
the HCW viral load should be tested immediately and the patient commenced on PEP
where required after discussion with the HCW treating physician, occupational health
consultant and patient’s consultant.
7. Patient Notification Exercises (PNE) for patients who have undergone EPP by an
untreated HIV infected HCW would take place according to current guidance; in most
cases the decision will be made locally by the Director of Public Health, who may seek
advice from the United Kingdom Advisory Panel on Healthcare Workers Infected with
Blood Borne Viruses (UKAP). The Medical Director will also be informed. PNE
connected with HIV infected HCWs on cART would only be considered in
circumstances in which their viral load had risen above 1000copies/ml. The need for a
PNE would be determined by a risk assessment on a case-by-case basis, and the
UKAP should be consulted for advice.
HIV Infected Health Care Workers: Guidance on Screening, Management and Patient Notification
Version: 7
Issue Date: 05 December 2016
Review Date: 30 November 2018 (unless requirements change)
Page 3 of 12
1. INTRODUCTION
Since March 2007 it has been a requirement of the Department of Health that healthcare workers
who are new to the NHS and who will perform Exposure Prone Procedures (EPP; definition page
4), and existing healthcare workers who are new to EPP, are required to have HIV and hepatitis
C tests in addition to the standard pre-placement health checks.
Healthcare workers who are new to the NHS and not performing Exposure Prone Procedures
(EPP) can be offered testing for HIV and hepatitis C in addition to their usual pre-placement
health checks. These tests will be carried out by the Occupational Health Department with
appropriate advice, information and consent.
In January 2014 the Department of Health announced a change in policy to remove restrictions
on Healthcare Workers (HCW) with HIV practicing Exposure Prone Procedures (EPP). This
change reflects accumulated evidence that shows there is an extremely low risk of transmission
from an infected HCW to a patient. All HCW with HIV who wish to perform EPP must: be on
effective combination antiretroviral drug therapy (cART), and have a plasma viral load<200
copies/ml, and be subject to plasma viral load monitoring every 12 weeks, and be under joint
supervision of a consultant occupational physician and their treating physician. In addition, these
HIV infected HCW wishing to perform EPP must be registered on a confidential national register.
Provided appropriate infection control procedures are scrupulously adhered to, the majority of
procedures in the healthcare setting pose no risk of transmission of the human immunodeficiency
virus (HIV) from an infected healthcare worker to a patient. There is a greater risk of transmission
of HIV from infected patients to healthcare workers. Up to December 2002, there had been 106
cases worldwide of healthcare workers with documented seroconversion after occupational
exposure to HIV. Five of these were cases occurred in the UK.
There may be occasions when an HIV infected HCW is aware of accidentally exposing a patient
to their blood. HCW should be advised of the action to take in this scenario. Exposure to the
blood of a HCW who is on cART and who has a low and stable HIV viral load is likely to pose an
extremely low risk of transmission. There is no requirement to advise patients of a possible
exposure where the HCW was fully compliant with this policy. If there is concern that the viral
load might be detectable, the HCW viral load should be tested immediately and the patient
commenced on PEP if required, after discussion with the HCW treating physician, occupational
health consultant and patient’s consultant.
Patient Notification Exercises (PNE) for patients who have undergone EPP by an untreated HIV
infected HCW would take place according to current guidance; in most cases the decision will be
made locally by the Director of Public Health, who may seek advice from the United Kingdom
Advisory Panel on Healthcare Workers Infected with Blood Borne Viruses (UKAP). The Medical
Director will also be informed. PNE connected with HIV infected HCWs on cART would only be
considered in circumstances in which their viral load had risen above 1000copies/ml. The need
for a PNE would be determined by a risk assessment on a case-by-case basis, and the UKAP
should be consulted for advice.
2. PURPOSE
This policy applies to all healthcare workers within Portsmouth Hospitals NHS Trust. The policy
reflects the need to protect patients, to retain public confidence and to safeguard the confidentiality
and employment rights of HIV infected healthcare workers.
HIV Infected Health Care Workers: Guidance on Screening, Management and Patient Notification
Version: 7
Issue Date: 05 December 2016
Review Date: 30 November 2018 (unless requirements change)
Page 4 of 12
3. SCOPE
This Policy applies to all staff who have direct contact with patients and to the staff who
manage these employees
‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises
that it may not be possible to adhere to all aspects of this document. In such circumstances,
staff should take advice from their manager and all possible action must be taken to
maintain ongoing patient and staff safety’
4. DEFINITIONS
Exposure Prone Procedures (EPP): invasive procedures where there is a risk that injury to
the worker may result in the exposure of the patient’s open tissues to the blood of the worker
(‘bleed-back’). These include procedures where the worker’s gloved hands may be in contact
with sharp instruments, needle tips or sharp tissues (e.g. spiccules of bone or teeth) inside a
patient’s open body cavity, wound or confined anatomical space where the hands or fingertips
may not be completely visible at all times. Other situations, such as pre-hospital trauma care
should be considered to be EPP
Procedures where the hands and finger tips of the worker are visible and outside the patient’s
body at all times, and internal examinations or procedures that do not involve possible injury to
the worker’s gloved hands from sharp instruments and/or tissues, are considered not to be
exposure prone provided routine infection control procedures are adhered to at all times.
Examples of such non-EPP procedures include:
 Taking blood
 Setting up and maintaining intravenous lines or central lines (provided any skin
tunneling procedure used for the latter is performed in a non-exposure prone manner)
 Minor surface suturing
 Incision of external abscesses
 Routine vaginal or rectal examinations
 Simple endoscopic procedures
 Normal vaginal delivery in itself is not an EPP but an infected healthcare worker must
not perform procedures involving the use of sharp instruments such as infiltrating local
anaesthetic or suturing of a tear or episiotomy, since the fingertips may not be visible at
all times. Neither can they perform an instrumental delivery requiring forceps or suction
if infiltration of local anaesthetic or internal suturing is required.
Further information on specific procedures can be obtained from the Occupational Health
Department (02392 283352) or from Annex A to ‘HIV Infected Healthcare Workers; Guidance
on Management and Patient Notification’ (reference 1).
Blood Borne Virus (BBV): viruses found mainly in blood or bodily fluids.
United Kingdom Advisory Panel for Health Care Workers infected with Blood Borne
Viruses (UKAP). UKAP was originally set up to advise on action regarding healthcare workers
with HIV infection although its remit was extended in 1993 to include other blood borne viruses,
in particular hepatitis B and more recently hepatitis C. UKAP is accountable to the Department
of Health through the Health Protection Agency (HPA).
Health Care Worker (HCW): all staff working in hospitals and General Practice, including
medical and nursing staff as well as others who may have direct patient contact, e.g. cleaners
on wards, some catering staff, ambulance staff, some reception and some clerical staff
HIV Infected Health Care Workers: Guidance on Screening, Management and Patient Notification
Version: 7
Issue Date: 05 December 2016
Review Date: 30 November 2018 (unless requirements change)
Page 5 of 12
5. DUTIES AND RESPONSIBILITIES
The Trust (the employer) is responsible for:
 Ensuring that new and existing staff (including agency and locum staff and visiting
health care workers) are aware of the contents of this Policy.
 Giving assurance that HIV infected healthcare workers’ status and rights as employees
will be safeguarded so far as practicable.
 Making every effort to arrange suitable alternative work and retraining opportunities, or
where appropriate, early retirement for HIV infected workers, where indicated after
Occupational Health input.
Occupational Health Department is responsible for:
 Co-ordination of all matters arising from and relating to the employment of HIV infected
healthcare workers, including screening of new healthcare workers where indicated.
 Ensuring all HCW with HIV who wish to perform EPP must: be on effective combination
antiretroviral drug therapy (cART), and have a plasma viral load<200 copies/ml, and be
subject to plasma viral load monitoring every 12 weeks, and be under joint supervision
of a consultant occupational physician and their treating physician. In addition, these
HIV infected HCW wishing to perform EPP must be registered on a confidential national
register
 Ensuring appropriate medical and occupational health supervision of HIV infected
healthcare workers. Liaising with the HIV physician providing the regular care to an
infected healthcare worker, where appropriate
 Providing the necessary closer and more frequent occupational supervision once a
healthcare worker has symptomatic HIV disease. As well as offering support to the
worker, the aim of this is to detect at the earliest opportunity any physical or
psychological impairment that may render a worker unfit to practice, or may place their
health at risk.
 Considering the impact of HIV positivity on the individual’s resistance to infection when
advising on suitability for particular posts, especially if the duties involve exposure to
known or undiagnosed TB.
 Acting as an advocate for the worker on issues of retraining and redeployment, or, if
indicated, medical retirement.
 Contacting UKAP for advice in specific cases where indicated.
Healthcare workers
 All healthcare workers who have direct clinical care of patients, have a duty to keep
themselves informed and updated on the codes of professional conduct and guidelines
on HIV infection laid down by their regulatory bodies and any relevant guidance issued
by the Department of Health. The General Medical Council, General Dental Council and
the Nursing and Midwifery Council all provide statements about the ethical
responsibilities of healthcare workers towards their patients and the full statements can
be obtained directly from these organisations or from Annex B of ‘HIV infected
Healthcare Workers: Guidance on Management and Patient Notification’ (reference 1).

A healthcare worker who has any reason to believe they may have been exposed to
infection with HIV, in whatever circumstances, must promptly seek and follow
confidential professional advice on whether they should be tested for HIV. Failure to do
so may breach the duty of care to patients. Examples of how a healthcare worker may
have been exposed to HIV infection include if they have:
o
o
o
Engaged in unprotected sexual intercourse between men
Had unprotected intercourse in, or with a person who had been exposed in, a
country where transmission of HIV through sexual intercourse between men and
women is common
Shared injecting equipment whilst misusing drugs
HIV Infected Health Care Workers: Guidance on Screening, Management and Patient Notification
Version: 7
Issue Date: 05 December 2016
Review Date: 30 November 2018 (unless requirements change)
Page 6 of 12
o
o
Had a significant occupational exposure to HIV infected material in any
circumstances
Engaged in invasive medical, surgical, dental or midwifery procedures, either as a
practitioner or patient, in parts of the world where infection control precautions may
have been inadequate, or with populations with a high prevalence of HIV infection.
Additionally, a person who has had unprotected sexual intercourse with someone in any of the
above categories may also have been exposed to HIV infection.

All HCWs who are HIV positive and wish to perform EPP must meet the following criteria:
must be under the care of a designated consultant occupational physician; must accept
that it is a condition of undertaking EPP that they consent to ongoing monitoring while
they continue to practice exposure-prone procedures, including:
i. the registration of their details and monitoring data on the UKAP-OHR
ii. the release of monitoring information to the consultant occupational physician and the
treating physician
iii. to provide an IVS for viral load monitoring at the appointed times
iv. to seek advice if change in health condition may affect their fitness to practise or impair
their health
v. to notify OH when they are changing their practice or their place of employment
6. PROCESS
6.1 Work Health Assessment
From March 2007 it has been required by the Department of Health that healthcare workers
who are new to the NHS and who will perform EPP and existing healthcare workers who are
new to EPP are required to have HIV and hepatitis C tests in addition to the standard preplacement health checks. Healthcare workers who are new to the NHS and not performing
EPP can be offered testing for HIV and hepatitis C in addition to their usual pre-placement
health checks.
From January 2014 ensure all HCW with HIV who wish to perform EPP must: be on effective
combination antiretroviral drug therapy (cART), and have a plasma viral load<200 copies/ml,
and be subject to plasma viral load monitoring every 12 weeks, and be under joint supervision
of a consultant occupational physician and their treating physician. In addition, these HIV
infected HCW wishing to perform EPP must be registered on a confidential national register.
A detailed Occupational Health procedure has been developed.
6.2 Employment issues
HIV infected healthcare workers must promptly seek and follow appropriate expert medical and
Occupational Health advice. Those who perform, or who may perform, EPP must obtain further
expert advice from the Occupational Health Department and their treating physicians.
The final decision about the type of work that may be undertaken by an HIV infected health
care worker should be made on an individual basis, by a specialist consultant Occupational
Health physician, taking into account the specific circumstances, including working practices, of
the worker concerned. Occupational Health physicians may consult with UKAP
HIV infected healthcare workers who do not perform EPP, but who continue to provide clinical
care to patients, must remain under regular medical supervision and in regular contact with
Occupational Health if there are change in health or employment status. Once any healthcare
worker has symptomatic HIV disease, closer and more frequent Occupational Health
supervision is necessary. As well as providing support to the worker, the aim of this is to detect
HIV Infected Health Care Workers: Guidance on Screening, Management and Patient Notification
Version: 7
Issue Date: 05 December 2016
Review Date: 30 November 2018 (unless requirements change)
Page 7 of 12
at the earliest opportunity any physical or psychological impairment that may render a worker
unfit to practice, or may place their health at risk.
As in all cases of ill health assessed in the Occupational Health Department, confidentiality is of
the utmost importance and information about the HIV status of individual employees will not be
disclosed to managers or human resource advisors without the full informed consent of the
employee. It may be necessary to inform management that individuals may not undertake EPP
without disclosing the specific reason why. In exceptional cases where the health of patients is
considered to be at risk from a HIV infected healthcare worker, and the staff member will not
give consent for disclosure of relevant information, it may be necessary for Occupational Health
to disclose information without consent.
6.3 Patient Notification Exercises
Patient Notification Exercises (PNE) for patients who have undergone EPP by an untreated HIV
infected HCW would take place according to current guidance; in most cases the decision will
be made locally by the Director of Public Health, who may seek advice from the UKAP. The
Medical Director will also be informed. PNE connected with HIV infected HCWs on cART would
only be considered in circumstances in which their viral load had risen above 1000copies/ml.
The need for a PNE would be determined by a risk assessment on a case-by-case basis, and
the UKAP should be consulted for advice.
Every effort should be made to avoid disclosure of the infected worker’s identity, or information
that would allow deductive disclosure. This may include the use of a media injunction to prevent
publication or other disclosure of a worker’s identity. The duties of confidentiality still apply even
if the infected health care worker has died, or has already been identified publicly.
7. TRAINING REQUIREMENTS
Information contained in this policy will be made available during the pre-employment Work
Health Assessment process; during the staff induction process; and as part of the management
of sharps injuries and contamination incidents.
8. REFERENCES AND ASSOCIATED DOCUMENTATION
1. HIV Infected Health Care Workers: Guidance on Management and Patient Notification:
Department of Health. July 2005.
2. Health clearance for hepatitis B, hepatitis C and HIV: New healthcare workers: Department
of Health. March 2007.
3. The management of HIV infected Healthcare Workers who perform exposure prone
procedures; updated guidance, January 2014. Public Health England.
9. EQUALITY IMPACT STATEMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably
practicable, the way we provide services to the public and the way we treat our staff reflects
their individual needs and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly
HIV Infected Health Care Workers: Guidance on Screening, Management and Patient Notification
Version: 7
Issue Date: 05 December 2016
Review Date: 30 November 2018 (unless requirements change)
Page 8 of 12
Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They
are beliefs that manifest in the behaviours our employees display in the workplace.
Our Values were developed after listening to our staff. They bring the Trust closer to its vision
to be the best hospital, providing the best care by the best people and ensure that our patients
are at the centre of all we do.
We are committed to promoting a culture founded on these values which form the ‘heart’ of our
Trust:
Respect and dignity
Quality of care
Working together
Efficiency
This policy should be read and implemented with the Trust Values in mind at all times.
HIV Infected Health Care Workers: Guidance on Screening, Management and Patient Notification
Version: 7
Issue Date: 05 December 2016
Review Date: 30 November 2018 (unless requirements change)
Page 9 of 12
10.
MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS
Minimum requirement to be
monitored
Compliance with
health screening
pre-placement
Lead
Consultant and Clinical
Lead OHD
Tool
Audit
notes
Frequency of Report of
Compliance
of
Annually
This document will be monitored to ensure it is effective and to assurance compliance.
HIV Infected Health Care Workers: Guidance on Screening, Management and Patient Notification
Version: 7
Issue Date: 05 December 2016
Review Date: 30 November 2018 (unless requirements change)
Page 10 of 12
Reporting
arrangements
Health
&
Committee
Lead(s) for acting on
Recommendations
Safety
Health & Safety Committee
Equality Impact Screening Tool
To be completed and attached to any procedural document when submitted to the
appropriate committee for consideration and approval for service and policy
changes/amendments.
Stage 1 - Screening
Title of Procedural Document: HIV Infection - Members of PHT Staff
Date of Assessment
02.11.16
Responsible
Department
Health, Safety & Wellbeing
Name of person
completing
assessment
Jenny Cattle
Job Title
Health & Safety Advisor
Does the policy/function affect one group less or more favourably than another on the basis
of :
Yes/No
 Age
N
 Disability
Learning disability; physical disability; sensory
impairment and/or mental health problems e.g.
dementia
N
 Ethnic Origin (including gypsies and travellers)
N
 Gender reassignment
N
 Pregnancy or Maternity
N
 Race
N
 Sex
N
 Religion and Belief
N
 Sexual Orientation
N
Comments
If the answer to all of the above questions is NO,
the EIA is complete. If YES, a full impact
assessment is required: go on to stage 2, page 2
More Information can be found be following the link
below
www.legislation.gov.uk/ukpga/2010/15/contents
HIV Infected Health Care Workers: Guidance on Screening, Management and Patient Notification
Version: 7
Issue Date: 05 December 2016
Review Date: 30 November 2018 (unless requirements change)
Page 11 of 12
Stage 2 – Full Impact Assessment
What is the impact
Level of
Impact
Mitigating Actions
(what needs to be done to minimise /
remove the impact)
Responsible
Officer
Monitoring of Actions
The monitoring of actions to mitigate any impact will be undertaken at the appropriate level
Specialty Procedural Document:
Specialty Governance Committee
Clinical Service Centre Procedural Document:
Clinical Service Centre Governance Committee
Corporate Procedural Document:
Relevant Corporate Committee
All actions will be further monitored as part of reporting schedule to the Equality and Diversity
Committee
HIV Infected Health Care Workers: Guidance on Screening, Management and Patient Notification
Version: 7
Issue Date: 05 December 2016
Review Date: 30 November 2018 (unless requirements change)
Page 12 of 12