Download HIV and employment - Oxford Academic

Occupational Medicine 2012;62:242–253
doi:10.1093/occmed/kqs051
IN-DEPTH REVIEW
HIV and employment
C. McGoldrick
Department of Infectious Diseases, Monklands Hospital, Airdrie ML6 0JS, UK.
Correspondence to: C. McGoldrick, Department of Infectious Diseases, Monklands Hospital, Airdrie ML6 0JS, UK.
e-mail: [email protected]
Abstract
According to 2009 statistics, the human immunodeficiency virus (HIV) infected an estimated
86 500 individuals within the UK, although around one-quarter were unaware of their infection. In
the majority of cases, it is now considered a long-term controllable but incurable infection. Indeed,
most HIV-positive individuals are able to work. Employment is across most, if not all, workforce
sectors and protection against workplace discrimination is provided by the Equality Act 2010. Issues
including confidentiality, workplace adjustments, vaccinations and travel restrictions may be relevant to the occupational health of HIV-positive workers. There are special considerations concerning
HIV-infected health care workers, including avoidance of performing exposure-prone procedures.
Prevention of HIV acquisition in the workplace is relevant to a diverse range of occupational environments, and HIV post-exposure prophylaxis should be considered after potential HIV exposure
incidents. If a worker contracts HIV by occupational means, financial help may be available.
Key words
Employment; HIV; occupational health; occupational medicine.
Introduction
Literature search
An estimated 86 500 people in the UK are infected with
human immunodeficiency virus (HIV), with around
one-quarter unaware of their infection [1]. Since the initial recognition of the acquired immunodeficiency syndrome (AIDS) in 1981, a major shift in HIV’s prognosis
has been observed. Whereas in the past it was considered
almost universally fatal with increasing time since infection, due to the success of highly active antiretroviral
therapy (HAART), it is now considered a long-term controllable condition in the majority of individuals [2–4].
Currently licensed antiretroviral drugs function by
decreasing effective viral replication, viral entry into cells
or integration with the host cell genome. In doing so,
plasma viral loads reduce, further decreasing the amount
of virus that can invade and destroy CD4 T cells [5,6].
CD4 count rises and/or further prevention of CD4
decline results, thereby decreasing the risk of opportunistic and other HIV-associated illness. Consequently,
many people who would otherwise have become too
unwell to work can remain in employment or re-enter
the job market [7].
This review will primarily focus on current UK policy and thinking concerning HIV infection in relation
to employment, although some examples from other
countries will be given. It will cover issues relating to the
employment of HIV-positive individuals and prevention
of occupational exposure and acquisition of HIV.
A search was conducted of guideline and publication lists
embedded within various UK governmental and nongovernmental websites for documents relevant to the
topic of ‘HIV and employment’. Websites searched were
those of the British HIV Association; the UK Expert
Advisory Group on AIDS (EAGA); the UK Department
of Health; the UK Advisory Panel for Healthcare
Workers Infected with Bloodborne Viruses (UKAP); the
Health Protection Agency; Health Protection Scotland;
Department of Health, Social Services and Public Safety,
Northern Ireland; the National Public Health Service
for Wales; the National AIDS Trust; the UK Ministry of
Defence; the UK Civil Aviation Authority (CAA); Her
Majesty’s Prison Service; the Scottish Prison Service; and
the Organization of the Petroleum Exporting Countries.
Relevant documents were identified in this manner. An
additional Pubmed search was made using the search
terms ‘HIV AND employment’ and setting limits of
‘English language’, ‘Humans’ and publication within
10 years. Of the 691 Pubmed references generated, only
those considered to be relevant both to the subject and to
UK policy were considered for inclusion. Articles relating
to prostitution and those within patient advocacy journals
were excluded. The review was formed by drawing on
information obtained from the above searches, as well
as from a personal collection of documents/articles/
resources, and from papers identified from the reference
© The Author 2012. Published by Oxford University Press on behalf of the Society of Occupational Medicine.
All rights reserved. For Permissions, please email: [email protected]
C. McGOLDRICK: HIV AND EMPLOYMENT 243
lists of such articles. Although it provides an overview of
many employment issues pertaining to HIV infection, it
cannot be fully comprehensive. The reader is therefore
directed to the relevant UK policy/guidance documents
for further information where required.
medication scheduling and concerns about how health
will affect their work [21]. Medication reminders aiding antiretroviral adherence, e.g. alarms set on mobile
phones, may be particularly helpful for those with erratic
shift patterns.
HIV and employment in general
Recruitment of HIV-positive workers
Roles in the workforce
Although questions that would lead to HIV disclosure
may be asked within pre-employment health questionnaires, this should not affect recruitment except in some
circumstances. These include where the illness is severe
enough to affect work performance, and there are also
some recruitment restrictions for the armed forces, ­airline
pilots and air traffic controllers [22–25]. In a­ddition,
health care workers (HCWs) have been restricted from
roles involving exposure-prone procedures (EPPs) (see
Box 1) although there is currently a consultation ongoing
regarding changing these regulations [26–28].
HIV status should not be disclosed by occupational
health departments, without the employee’s express consent, consistent with General Medical Council (GMC)
guidance on confidentiality [29]. However, they may
advise if a change of duties is required [26,27]. An
infected worker’s identity may, however, be disclosed,
where necessary to prevent the spread of infection, but
this must be justifiable [26,27,30,31].
Employment of individuals with HIV occurs across all
employment sectors. In one survey undertaken in 2009
within a large HIV clinic, 74% (401/545) were in some
kind of work, 51% were in full-time paid employment,
9% in full-time self-employment, 4% in part-time paid
employment, 5% in part-time self-employment, 3% in
training and 1% looked after family dependants [8]. In
another survey, conducted by the National AIDS Trust,
utilizing Gaydar (a large social networking site for men
who have sex with men (MSM)), 84% (n = 1830) of
HIV-positive MSM were in stable permanent employment. Employment sectors included hospitality (10%),
health care/medicine (9%), retail (7%), education (7%),
information technology (6%) and financial services (6%).
About 58% felt that HIV had no adverse effect on their
working life [9]. Indeed, employment itself may be therapeutic, allowing improved self-esteem, self-­
fulfilment,
better social networks, lower fatigue levels and an overall
better quality of life [10–14].
Factors limiting ability to work
Factors that may limit ability to work include HIVassociated neuropsychological impairments (e.g. problems in executive functioning and memory), ­psychosocial
problems, depression, medical factors such as fatigue
and illness related to opportunistic/other illnesses and
side-effects of antiretrovirals (e.g. potentially reversible
efavirenz-related dizziness) [13,15–19]. However, in
the initial survey described previously, 83% (333/401)
of HIV-positive people in work perceived no barriers to
remaining in employment [8].
Another study of HIV-positive people (n = 1627) in
London undertaken between June 2004 and June 2005
found unemployment to be significantly a­ssociated
with time since HIV diagnosis (adjusted odds ratio
(aOR) = 1.13 per year, 95% confidence interval
(CI) = 1.07–1.19), previous hospital admission for
HIV-related symptoms (aOR = 1.94, 95% CI = 1.17–
3.21), visible physical signs of HIV (aOR = 2.01, 95%
CI = 1.21–3.33), detectable viral load (aOR = 2.10,
95% CI = 1.06–3.79) and lower education (aOR = 3.85,
95% CI = 2.27–6.25) [20].
Employment concerns of HIV-positive individuals
Employment concerns felt by HIV-infected individuals
include fear of discrimination/stigma, concerns regarding
Discrimination against HIV-infected workers
In the previously mentioned National AIDS Trust ­survey
using Gaydar, 62% had disclosed their diagnosis to
someone at work, contrasting with a survey of London
clinic attendees where only 37% had disclosed [8,9]. In
the latter study, although stigma and fear of discrimination were of concern for almost half of individuals, only
11% of those in work reported actually experiencing it,
indicating that the problem may not be as great in reality
as perceived [8].
The situation can differ in other countries. China’s
national policy for recruiting civil servants specifies that
Box 1. Definition of exposure-prone
procedures (EPPs)
Exposure-prone procedures are invasive procedures
where there is a risk that a w
­ orker’s blood, in circumstances of injury, may contaminate a patient’s
open tissues (bleed-back). E
­ xamples include those
where the worker’s gloved hands may be in contact
with sharp instruments, needle tips or sharp tissues
(e.g. bone spicules or teeth) inside a patient’s open
body cavity, wound or confined anatomical space
where hands or fingertips may not always be completely visible.
244 OCCUPATIONAL MEDICINE
individuals with HIV will be disqualified. Additionally,
similar exclusions apply to the Chinese police force and
working in bars, hotels, restaurants, beauty parlours
and hairdressing salons, although this contravenes their
Employment Promotion Law (2007) [32].
Closer to home, a French study reported workplace
discrimination to be associated with increased risk of
employment loss among those who had achieved only
a primary/secondary educational level but not among
those further educated. Risk of job loss was lower among
those holding managerial or executive positions compared with other occupational positions [33].
In October 2010, the Equality Act 2010 came into
force and replaced various acts including much of the
Disability Discrimination Act [25,34]. For the purposes
of the act, HIV is considered a disability and is covered
by it from the point of diagnosis. The act legally protects
people with disabilities from discrimination, providing
rights in respect of various aspects of life including
employment [25–27,34]. Workplace discrimination
because of infection is therefore unlawful, as is denial of
employment related to HIV status, unless the employer
has justification based on a material and substantial
reason [25,34]. As before, an example would be an HCW
undertaking/potentially undertaking EPPs, although this
is under review [26–28].
Workplace adjustments for individuals living
with HIV
The act also provides a duty on the part of the employer
to consider what workplace adjustments within an
employee’s role are reasonable [27,34]. Such adjustments include (where available) moving an HCW to a
post where EPPs can be avoided. Medical and occupational health supervision should, however, continue
[27,30,31]. In the previously mentioned National AIDS
Trust study of HIV-positive MSM, 89% of requests for
reasonable adjustments were granted, including time off
for clinic attendance in 67% of requests. About 34% of
HIV-positive respondents had not taken any time off for
clinic attendance during the preceding 12 months, 46%
used existing flexibility within working arrangements and
9% used annual leave to attend clinics [9]. Individuals
with HIV commonly attend clinic every 3 months, sometimes less frequently when the disease is stable. It may,
however, be more frequent at certain times, e.g. early after
diagnosis, around the time of antiretroviral initiation, or
during periods of disease instability or p
­ rogression [9].
Some workplace adjustments may be necessary to
allow a worker to take antiretroviral medication at the
correct times, as delayed therapy may encourage antiretroviral resistance. Simpler regimens are now available,
although they will not be suitable for everyone. They are
simpler in terms of administration frequency and lack
of need for refrigeration. Not all HIV-positive workers
will require antiretroviral therapy, with current UK guidance suggesting, with exceptions, that it be considered
when CD4 count is below 350 cells/mm3 [35]. However,
­guidance may change in future to higher CD4 ­cut-offs
for treatment initiation. With few exceptions, once antiretroviral therapy has been initiated, this is l­ifelong
although individual components of therapy may change
over time [36].
Employment of HIV-infected HCWs
Regulations and considerations
In terms of managing HIV-infected HCWs, Department
of Health guidance exists, with a similar document used
in Scotland, and is also applicable to students in health
care, the independent health care sector and volunteer
HCWs [26,27]. Although many principles will be similar
where infection with hepatitis B or C is present, these
have not been considered here due to the narrower remit
of this review.
Within the UK, no reported HIV transmissions
from HCWs to patients have occurred, with nine international reports involving four HCWs. However, global
­figures may be falsely low due to reporting bias [28,37].
Using a model based on transmission from an HCW to
a patient in a single procedure following a single injury
to the HCW, the risk of transmission from an HCW to a
patient is estimated to be as low as between 1 in 42 000
and 1 in 420 000 [37,38]. Despite this, it has been considered necessary to protect patients with restriction of
HIV-positive HCWs from performing EPPs [26,27,37].
However, the Department of Health and the devolved
administrations launched a consultation exercise in
December 2011, concerning a change to these recommendations, on the guidance of a tripartite group comprising the EAGA, the Advisory Group on Hepatitis and
UKAP [28,39]. At the time of writing this review, the
proposal remains at a consultation stage. The proposed
change states that an HIV-infected HCW may be permitted to perform EPPs if they are established on combination antiretroviral therapy and have a consistently
suppressed plasma viral load (<200 copies/ml on two
consecutive plasma samples), prior to starting/resuming EPPs [28,39]. Viral load testing would occur every
3 months while performing EPPs, and significant rises
above 200 copies/ml would preclude continuation of
EPPs until it again drops to below this level. Patient notification exercises to cover the period of potential infectiousness may be required, and decisions regarding the
need for this, as well as when EPPs may start, resume
or cease would be made by a consultant in occupational
medicine, informed by the relevant experts. The HCW
would remain under joint supervision by this consultant
and their HIV physician. Some HCWs may even opt to
start antiretroviral therapy for occupational reasons, in
C. McGOLDRICK: HIV AND EMPLOYMENT 245
order to be able to undertake EPPs, when such treatment would not necessarily be recommended otherwise
[28].
Apart from EPPs, other circumstances exist where
there is potential to transmit infection from an infected
HCW, e.g. during physical assault by a patient where
bleeding of both parties occurs [40]. In addition, infected
HCWs should cover wounds, skin lesions and breaks in
exposed skin with waterproof dressings/gloves [26,27].
For HIV-positive dentists, where undertaking EPPs
is essential to their role and redeployment/retraining
would be difficult, UKAP and the EAGA have
previously granted permission to two positive dentists to
provide dental care to HIV-infected patients, subject to
conditions. These were that they remain under regular
occupational health supervision, had clearance from
the General Dental Council (GDC), and performed
restricted procedures, and that patients gave informed
consent to treatment by an HIV-positive dentist [37,41].
However, if the new proposed guidelines for HCWs
with HIV do come into place, some of these restrictions
would be removed [28].
At present, when there is uncertainty about whether
an HCW can carry out EPPs, guidance may be obtained
from UKAP [26,27,37]. UKAP have also provided
advice on procedures pertaining to particular specialties and defined whether they consider them to constitute EPPs [26,27]. Their remit also involves provision
of advice regarding the necessity of patient notification
exercises when EPP has been carried out by an infected
HCW [37]. Only patients who have undergone category 3 (high risk) EPPs, where there is a distinct risk
of bleed-back, are traced, notified and offered testing,
in order to prevent unnecessary anxiety from being
imparted [37,39]. It is reassuring that although more
than 30 patient notification exercises involving HIVpositive HCWs have occurred in the UK (1988–2008),
with nearly 10 000 patients tested, no HIV transmissions
have been reported, although not all patients agreed to
testing, or could be contacted [28].
In exposure incidents where a risk of transmission to
a patient has occurred, not necessarily in the context of
an EPP, the HCW involved has a duty to cooperate fully
with those conducting the risk assessment, providing all
necessary information regarding their own infection status or risk behaviour [40]. Where the HCW’s HIV status
is unknown, testing should be offered but cannot occur
against their wishes, although EPPs can be restricted if
refused [40]. If the test (and other b
­ lood-borne virus
(BBV) testing) proves negative, there is no need to
inform the patient of the incident [40].
In comparison, the approach to infected HCWs in
other countries can differ, with some (e.g. France and
New Zealand) dealing with HIV-infected HCWs on
a case-by-case basis. Some other countries have no
policies, often because no infected HCWs have been
­
notified in that country. Others (e.g. Australia) restrict
infected HCWs from undertaking EPPs [28]. In the
USA, independent regulations apply for each state, some
completely restricting performance of invasive procedures (definition varies between states), while in others,
­consideration is made regarding the type of procedure,
an HCW’s skill and technique, their ability to adhere
to ­universal precautions, and their physical and mental
state, before a final decision is made regarding restrictions. Such decisions tend thereafter to be subject to
continual review and/or supervision of the HCW [42].
HIV testing of HCWs
Since March 2007, policies concerning HIV testing
of new UK National Health Service (NHS) HCWs
[30,31], aiming to decrease risk of HIV transmission
from staff to patients, have been in existence. New NHS
HCWs are defined as people with direct clinical patient
contact who are either new to the NHS, moving to (or
training within) a post involving EPPs, or are returning
to the NHS (dependent on activities engaged in while
absent from the NHS). Students on placement, visiting fellows and volunteer HCWs who carry out EPPs
are also included. Independent Health Care standards
state that such HCWs comply with the Department of
Health guidelines on HCWs infected with BBVs, and
this extends to HIV testing. Providers of temporary staff
to the NHS should also ensure that ­similar occupational
checks are made [30,31].
As part of standard health clearance checks, all new
HCWs should be offered HIV testing, although refusal or
testing positive would not restrict employment unless the
role involves EPPs. Where EPPs are involved, HIV testing
is required, preferably early in the appointments/admissions process. Declining a test, or testing positive in this
situation would mean EPP restriction, and if integral to
the position/training would mean ineligibility for the position [30,31]. In all cases pre-test discussion should be
carried out in a confidential environment, covering reasons for and benefits of testing, explaining whether it is
mandatory or not for employment, and how the result will
be given [43,44]. The HCW’s professional responsibilities
in relation to HIV should also be discussed [30,31].
Regardless of new HCW HIV testing policies, all
HCWs have ethical and legal duties to protect their
patients. Therefore, if an HCW suspects that they may
have been exposed to infection, even non-occupationally
and irrespective of circumstance, prompt, confidential
professional advice regarding whether testing is necessary must be sought. Failure to follow the advice would
breach duty of care, a continual obligation for the HCW
[26,27,45–48]. Such guidance is consistent with GMC,
GDC and Nursing and Midwifery Council guidance,
and extends to self-employed HCWs and health care
­students [26,27,45].
246 OCCUPATIONAL MEDICINE
Risks to the HIV-infected HCW
Risks are to some extent dependent on the health of
the HIV-infected HCW. Employment in a health care
setting may place them at risk of acquiring infections
from patients. This is particularly true for those exposed
to individuals with active pulmonary tuberculosis
and other infections that may be opportunistic in the
immunocompromised, and should be a consideration
when an occupational health physician advises on
suitability for particular posts [26,27]. This is not always
straightforward as HIV-infected HCWs may choose
to work in infectious diseases or HIV services, which
increases their risk of exposure to infections such as
tuberculosis. An HIV-infected HCW may be prepared
to accept the risk of acquiring opportunistic infections
through work, but the consequent risks to patients must
also be considered.
HIV infection within the military
Although many HIV-positive service personnel attend
local non-military HIV services, designated military
HIV medicine facilities are being further developed in
the UK. This is to ensure that individuals receive specialized guidance from a military occupational viewpoint,
so they can be best advised regarding the most suitable
placements and roles within the military. Annual clinical reviews at these facilities are planned; concerned
with the degree of limitation an individual’s HIV will
have on their role if deployed. Routine follow-up by local
non-military HIV services can however continue [49].
Despite the existence of such facilities for those who have
already joined, HIV seropositivity/AIDS is listed among
the many d
­ iseases that can prevent enlisting within the
British Army and the Royal Air Force, although the
precise reasons for such restrictions are not provided
[22,23]. Farther afield, the US Army has an extensive
HIV screening protocol. If an American soldier is found
to be infected with HIV, some restrictions apply, including no deployment/­assignment overseas [50].
Airline pilots and air traffic control
officers with HIV
According to UK CAA guidelines [51], there exist restrictions to HIV-positive pilots and air traffic control officers
in terms of classes of Joint Aviation Authorities certification that may be issued. Such restrictions exist to ensure
that illness/medication does not affect work capability/
judgment. Deviation from such restrictions may occur
for pilots, provided there are no symptoms/signs related
to HIV or its therapy, and there is a low risk of disease
progression/incapacitating events. However, there may be
limitations imposed allowing infected individuals to fly
only UK-registered aircraft. UK CAA guidelines detail
the various assessments that are required of infected pilots
and air traffic control officers, including HIV specialist,
neurology and neuropsychological reviews. In addition,
certificate holders are considered temporarily unfit to
work during times of antiretroviral therapy initiation,
modification or discontinuation. This can be reassessed
after a 2-month period. In particular, where efavirenz is
used, it is suggested that psychiatric and neurological
examination may be needed. Regulations may change
in 2012, when European Aviation Safety Agency rules
are implemented [51]. In the USA, the Federal Aviation
Administration’s protocol similarly stipulates the need
for regular medical and cognitive function assessments
for infected individuals [24].
Vaccination for employment purposes
Vaccination may sometimes be required for employment
purposes. Examples include hepatitis B vaccination for
HCWs, as well as travel vaccines for employees who
travel to certain countries as part of their work. While
hepatitis B immunization can be administered at any
CD4 count, it may fail to produce an adequate immune
response if administered when the CD4 count is low.
Measurement of hepatitis B surface antibody 6–8 weeks
after final vaccine dose is recommended. If <10 IU/l,
three further double-doses of vaccine should be offered
at monthly intervals. One further vaccine dose should be
offered if the level is between 10 and 100 IU/l [52].
Travel vaccination may be affected by HIV status
when considering yellow fever vaccination. As it is a live
vaccine, administration is contraindicated if CD4 counts
are lower than 200 cells/µl and should only be offered at
higher counts after a discussion concerning the risks and
the benefits. An exemption certificate should be given if
international travel requirements rather than true exposure risk are the only reasons to vaccinate. In addition,
administration to HIV-positive individuals aged over 60
is not advised. This is until there are more available data
concerning neurotropic and viscerotropic disease, which
are potential complications that are of higher incidence
in older recipients. If given, it should be administered
at least 2 weeks before travel, and the recipients should
be monitored closely. If it cannot be/is not given, it is
­preferable not to deploy the person to a yellow fever risk
area [52].
More vaccination information is available within the
‘British HIV Association guidelines for immunization of
HIV-infected adults 2008’ [52].
International work-related travel
Some countries have restrictions preventing HIVpositive foreign nationals from entering their country.
Therefore, some international work-related travel may
C. McGOLDRICK: HIV AND EMPLOYMENT 247
be affected, and international travel proved difficult for
27% of respondents in one survey [9]. Many countries,
including Saudi Arabia, United Arab Emirates, Russia
and Singapore, continue to restrict entry of HIV-infected
individuals, although similar restrictions enforced by the
USA were lifted on 4 January 2010. Some countries
may have waivers for certain situations [53]. It would
be discriminatory under the Equality Act 2010 to deny
career progression/employment because of inability to
travel to certain destinations, unless it can be clearly
justified why such a policy is essential for an employee’s
role or for the company [34].
occupational environments. Examples are shown in
Box 2 [40,55].
Employers’ responsibilities
Employers have legal duties to protect staff under
the Health and Safety at Work etc. Act 1974 and the
Management of Health and Safety at Work Regulations
1999. In addition, under the Control of Substances
Hazardous to Health Regulations 2002, there is a
legal duty to assess risk of infection for employees,
­implementing suitable precautions [55].
Previous occupational transmissions
Occupational and other exposures to
HIV infection
Percutaneous and mucocutaneous exposure
Needlestick injuries are percutaneous injuries from
­needles/other sharp materials, which may be contaminated by blood/body fluids [54]. If materials become
contaminated with such fluid, decontamination processes should be used as per local policies [55]. Apart
from blood, fluids that may pose a risk of HIV transmission include amniotic fluid, cerebrospinal fluid,
exudative/other fluid from burns/skin lesions, breast
milk, pericardial fluid, peritoneal fluid, pleural fluid,
saliva associated with dentistry, semen, synovial fluid,
unfixed human tissues and organs, vaginal secretions
or any other blood-stained fluid [40,54]. HIV may also
be transmitted through mucocutaneous exposure to
such materials through contamination of non-intact
skin, or potentially via human bites if the skin becomes
­broken [40,54]. There has also been a documented HIV
seroconversion in a police officer resulting from hand
wounds sustained after punching a man in the teeth
­during a bloody arrest [56].
Although needlestick injuries occur frequently within
civilian health care settings, they may also occur in other
Although universal precautions are advocated in health
care environments, and similar precautions in other work
environments [27,54,55], five documented cases of HIV
seroconversions among UK HCWs after specific exposure incidents have occurred (data published in 2008).
Another 23 were possibly occupationally acquired,
although 21 were probably contracted in countries of
high HIV prevalence, e.g. within Africa or the Indian
subcontinent [57,58]. Notably, of all UK exposures to
HIV-infected sources reported from 2005 to 2007, infection in the source was unknown at the time of the incident in 13% (41/316), highlighting the importance of
universal precaution adherence [58].
Precautions in various work environments
There are various other examples of precautions
that may be taken to reduce the risk of such injuries within many different occupational environments.
For example, within the waste and recycling industry,
good practice would be to provide gloves with a high
degree of puncture resistance (but these must not be
relied upon), puncture-resistant clothing, sharps boxes,
other sharp resistant containers (e.g. wheelie bins) and
tools to pick up needles (e.g. pincers) and to promote
Box 2. Occupational environments with potential HIV exposure risks
Civilian/other health care settings
Police force
Fire service
Rescue services
Custodial services
Voluntary aid agencies
Social services
Armed forces
Laboratories
Needle exchange services
Tattooing and piercing services
Sewage processing
Embalming and crematorium work
Mortuaries
Local authority services (e.g. street cleaning, public lavatory
­maintenance, refuse disposal)
Medical/dental equipment repair & decontamination
Beauticians
Hairdressing
Plumbing
Vehicle recovery and repair
Contact sports
248 OCCUPATIONAL MEDICINE
sweeping needles with dustpans and brushes to aid
­disposal [59].
For sewage workers who may potentially be
­percutaneously or mucocutaneously exposed (e.g. water
containing sanitary towels, condoms), risks are minimized due to HIV’s extreme dilution and poor survival in
­sewage (up to 12 h in non-chlorinated sewage) [60,61].
In respect of mortuary services, measures to minimize the risk of HIV transmission are also necessary.
Examples include wearing visors where there is a splash
risk at post-mortems. Where HIV is present, embalming
should also be avoided. This is because there is a potential risk of contact with blood when it is replaced with
a preservative solution using injection equipment. In
­addition, body bags should be used if there is a known
risk of HIV [62].
The UK Ministry of Defence Safety Handbook also
includes precautions to reduce occupational risk of BBV
acquisition for armed forces members. Although mainly
geared towards those within military health care environments, it also highlights the risk of HIV transmission from
blood transfusion for all military members, ­particularly
in countries of high HIV prevalence. It suggests ways
to minimize the risk of being transfused with contaminated blood and emphasizes the importance of carrying
­first-aid kits with sterile medical equipment [63].
Similarly, within the prison service, where inmate
HIV prevalence is higher than in the general population,
there exists a best practice framework, covering what to
do in incidents of potential exposure [64]. In terms of
the police force, a working group in Scotland considered whether an assailant of a police officer should be
subjected to mandatory HIV testing. However, this was
not advised, as at the time of testing, the person would
not yet have been convicted. By the time a conviction
occurred, this would represent too long a delay for testing to be beneficial, as at that stage HIV post-exposure
prophylaxis (PEP) initiation (see later) would no longer
be effective [65]. In Scotland, data were collected over
a period of 47–55 weeks in police forces and in the
Scottish Prison Service. One hundred and eight exposure incidents were reported, although most (74%) were
from spits, bites or splashes. Just over half were deliberate, and 84% occurred outside occupational health
working hours [66].
There may also be HIV exposure risks within
professional/semi-professional sport, due to potential
contact with blood from an infected person. The risk is
higher with contact and collision sports. The US Centers
for Disease Control say that with the exception of boxing,
overall the risk is low at less than one potential transmission
in 1 million games, although estimated risks reported
by others vary widely. The International Federation
of Associated Wrestling Styles and the International
Boxing Federation say that HIV testing is compulsory
for participants in their sports. Despite this, there have
been no definite reported transmissions in sport, with
one possible exception in a footballer from Italy, where
occupational transmission could not be ruled out.
Preventative measures that can be taken include providing
prompt and appropriate treatment for bleeding injuries,
using appropriate protective equipment such as mouth
protectors, covering wounds with occlusive dressings
and removing/cleaning contaminated equipment from
activity areas. In general, the decision to compete should
be personal to the individual with HIV. Other HIV risks
that may be encountered within sport include the sharing
of needles, e.g. for steroids, hormones and vitamins [67].
For teachers, there may be risks through blood spillage, bites or scratches from pupils, and guidelines are
available for such situations. The risks may be higher for
those working with pupils with special educational needs.
An additional risk may be posed if a teacher comes across
a discarded needle left by a trespasser [61,68]. Another
setting where there may be risk is that of ­workers who deal
with vehicles that are involved in road traffic ­accidents.
The hard and soft surfaces of damaged motor vehicles
may become contaminated following such i­ncidents,
although no documented HIV transmission has ever
occurred in a worker dealing with such an incident [61].
When there has been a potential exposure
In the event of a percutaneous injury, washing with soap/
water, avoiding antiseptics/skin washes and encouraging
bleeding are advised, while exposed mucous membranes
should be irrigated copiously with water including before
and after contact lens removal [40,54].
While the risk of HIV transmission is small, these
injuries can prove worrying for the workers concerned,
and therefore appropriate counselling is required
[40,54]. The approximate average risks of HIV transmission following some exposures to HIV-infected blood
are shown in Table 1 [40,58]. However, factors that
increase risk should be considered (Box 3)[40,57,58,69].
Encouragement should also be given to provide blood
at baseline for storage, which may be analysed later if
­subsequent tests detect HIV infection [40].
Employment and risks of sexual transmission
Sexual transmission of HIV may also be relevant in the
occupational health setting, considering that international
Table 1. Average risk to a health care worker of contracting HIV
from an HIV-positive source
Type of exposure
Estimated average risk of transmission (%)
Percutaneous
Mucocutaneous
Intact skin
0.3
<0.1
No risk
C. McGOLDRICK: HIV AND EMPLOYMENT 249
Box 3. Factors which may increase
risk of HIV transmission after
percutaneous injury
Deep injury
Hollow-bore needle
Visible blood on injurious device
Device had been placed in source’s artery/vein
Terminal/late stage HIV-related illness of source
High viral load of source (during seroconversion,
during later stages of infection)
travel features in some lines of work, e.g. the oil and gas
industry, armed forces and business travel. This may
involve travel to regions of high HIV prevalence where
there are even greater risks from casual sexual encounters than in the UK [70]. For example, much of the largescale oil and gas sector project activity occurs in less
developed countries where HIV is often of much higher
prevalence than in the UK. Such regions include West
Africa (e.g. Nigeria, Angola, Ghana and Cameroon) and
Asia (e.g. India, China, South-East Asia and East Russia)
[71]. It is recognized that many field-based workers are
at risk of HIV through sexual networking with commercial sex workers and settlers at oil locations. This is perhaps compounded by spending long periods away from
their usual sexual partners [71,72]. A pre-travel safer sex
message to such workers is ­therefore important [70].
Post-exposure prophylaxis
Background
The need for PEP using antiretroviral drugs should be
considered where there has been a significant risk of HIV
exposure. EAGA guidance in this matter (briefly summarized) can be used in both health care and non-health
care settings [40]. As antiretrovirals are not licensed for
this particular purpose, the recipient should be advised
of its off-label use, despite national UK guidelines recommending its provision [40,58]. Although zidovudine
monotherapy has been the only PEP regimen studied,
combination therapy with three drugs has been the consensus UK recommendation since 1997, extrapolated
from its greater efficacy when used in HIV treatment
[40]. This contrasts with guidance from the USA that
suggests that either two- or three-drug PEP regimens may
be used depending on the assessed level of risk of transmission from the incident [73]. But how does PEP work?
As animal models show viral dissemination after primary
HIV infection does not occur immediately, theoretically, there is a window where PEP may prevent infection
from becoming established [40]. Due to ethical considerations, no randomized controlled trials of its use have
been performed, and the recipient should be informed
of its unproven efficacy. Its recommendation is therefore
based on limited evidence from fairly weak studies. An
example includes a case–control study conducted in the
pre-HAART era on HCWs with occupational percutaneous exposure to HIV-infected blood. Those who seroconverted (33 individuals) were significantly less likely
than those who did not (665 individuals), to have taken
post-exposure zidovudine monotherapy (OR = 0.19;
95% CI = 0.06–0.52) [57,69].
If indicated, PEP should be given as soon as possible
(ideally within 1 h), earlier use being more effective.
However, it may be initiated up to 72 h later and is
recommended for 28 days [40,58]. Not all HIV-exposed
HCWs can tolerate a full 28-day course of PEP, although
tolerability has improved with the use of more modern
antiretrovirals. Protease inhibitors are particularly hard
to tolerate. However, every dose of PEP is likely to reduce
the risk. In occupational settings outside of the health
care environment, accident & emergency departments or
sexual health clinics would ordinarily provide the worker
with PEP or guide them to the appropriate place [55].
Ordinarily, the need for PEP’s continuation would be
decided in conjunction with a physician experienced in
HIV management, and any concerns regarding initiation
should be discussed with such a physician.
UK surveillance data show that early initiation is
achievable, PEP being received within 1 h in 37% (22/59)
of HCWs exposed to an HIV-positive source and within
24 h in 89% (53/59) [58]. In the UK (2000–07), 889
HCWs were occupationally exposed to HIV infection, of
which 700 (79%) initiated PEP [58]. There appear to be
no similar statistics published for occupational ­exposures
in non-health care environments.
When PEP should be considered
PEP should not be offered for exposures to low-risk
materials such as urine, vomit, faeces or saliva (unless
blood stained or associated with dentistry), irrespective of source HIV status. For high-risk materials, urgent
preliminary risk assessment should inform whether PEP
is indicated. It is generally offered when the source is
already known to be HIV positive or is considered at
high risk of infection. However, some potentially positive source patients may not disclose or be aware of their
risk. Where the source is unknown, e.g. injury from a discarded needle, judgement based on epidemiological likelihood of source HIV in that setting is necessary. PEP is
unlikely to be justified in the majority of exposures [40].
Antiretrovirals used
The recommended PEP starter pack regimen in the
UK consists of tenofovir, emtricitabine, and lopinavir
with ritonavir boosting, although local variations are
250 OCCUPATIONAL MEDICINE
acceptable [40]. Boosting refers to the pharmacokinetic
action of low-dose ritonavir (a protease inhibitor without
antiretroviral action at such doses), as a potent inhibitor
of cytochrome P450 3A4, used to boost lopinavir serum
concentration by inhibiting its metabolism [6]. Although
this regimen may be continued for the treatment period,
it may be modified by an HIV physician if source drug
resistance is known/suspected/discovered. However, this
must not delay standard regimen initiation. Vigilance for
adverse effects is also necessary [40].
HIV testing after exposure incidents
Post-exposure testing, like all HIV testing, should be with
fourth-generation combined antibody and antigen assays.
Testing for HIV RNA is not advised due to the high falsepositive rate. Testing should occur at least 12 weeks after
the incident or at least 12 weeks after PEP completion, if
given [40,44]. Where the person is already immunocompromised, develops an ­illness compatible with seroconversion or the source is co-infected with viral hepatitis,
follow-up may need to be longer [40,58]. During the
follow-up, modification of working practice is not necessary for HCWs performing EPPs, unless seroconversion
is confirmed [40]. Practising safer sex and avoiding blood
donation during the follow-up should nevertheless be
discussed [40,54]. If, through testing, a worker is found
to have acquired HIV, they should be referred to a physician involved in HIV ­management [54].
Financial help
In terms of financial help for individuals who contract
HIV by occupational means, there may be eligibility under
the Industrial Injuries Disablement Benefit Scheme if a
level of disablement has been established [27,40,54,74].
For HCWs, compensation may be available through the
NHS Injury Benefits Scheme or the Northern Ireland
Health and Personal Social Services Injury Benefits
Scheme if there is reduced earning ability as a result
of occupationally acquired infection [27,75]. Ill-health
retirement benefits under the NHS Pension Scheme
may be payable when permanent incapacity in performing duties occurs because of infection [27]. In other situations where transmission has not necessarily occurred
through the course of employment but affects the ability
to work, other sources of financial s­ upport may be available, e.g. the British Dental Association ­benevolent fund
for dentists [76].
Conclusions
HIV-positive individuals enjoy working within a variety
of occupational roles and are legally protected from
workplace discrimination by the Equality Act 2010.
Indeed, occupational disclosure of HIV status should be
treated confidentially. Some workplace accommodations
may be considered, including time off for clinic
attendances, although often HIV status does not interfere
greatly with work. For the particular circumstance of
HIV-infected HCWs, for patient protection reasons,
involvement in EPPs is currently restricted, but the
regulations concerning this are likely to change soon. In
addition, there is now a policy to offer HIV testing to all
new HCWs, with this being mandatory for those involved
in EPPs. In addition, there are also some employment
restrictions within the military and aeronautical industries.
Other issues relating to employment that may need to
be considered include those of work-related vaccination
of HIV-positive employees and some international
travel restrictions that prevent travel to some countries.
Prevention of HIV transmission to the worker in various
working environments is another consideration, and
PEP may be indicated after a potential HIV exposure. If
occupational transmission of HIV does occur, financial
help may be available.
While there is an abundance of information in this area,
there is also a paucity of information on some aspects of
this topic. Suggestions for future research include assessing the feasibility/acceptability of offering confidential
HIV testing for those returning from work-related travel
to high-risk countries, assessing whether HAART adherence is affected by shiftwork/erratic shift patterns and
establishing if any particular industries are particularly
problematic in terms of HIV-related discrimination.
Conflicts of interest
The author has received sponsorship to attend conferences/
meetings from the following companies that produce antiretroviral drugs – Bristol-Myers Squibb, GlaxoSmithKline, Janssen
and Pfizer.
References
1. Health Protection Agency. HIV in the United Kingdom:
2010 report. Health Protect Rep 2010;4:1–13.
2. Antiretroviral therapy cohort collaboration. Life expectancy of individuals on combination antiretroviral therapy in high-income countries: a collaborative analysis of
14 cohort studies. Lancet 2008;372:293–299.
3. Palella FJ, Delaney KM, Moorman AC et al. Declining
morbidity and mortality among patients with advanced
human immunodeficiency virus infection. N Engl J Med
1998;338:853–860.
4. British HIV Association. Standards for HIV Clinical Care.
2007. http://www.bhiva.org/documents/Guidelines/Stand­
ards/StandardsHIVClinicalCare.pdf (29 January 2012,
date last accessed).
5. De Clercq E. Antiretroviral drugs. Curr Opin Pharmacol
2010;10:507–515.
C. McGOLDRICK: HIV AND EMPLOYMENT 251
6. Wamke D, Barreto J, Temesgen Z. Antiretroviral drugs.
J Clin Pharmacol 2007;47:1570–1579.
7. Goldman DP, Bao Y. Effective HIV treatment and the
employment of HIV+ adults. Health Serv Res 2004;39:
1691–1712.
8. Rodger A, Brecker N, Bhagani S et al. Attitudes and barriers to employment in HIV-positive patients. Occup Med
(Lond) 2010;60:423–429.
9. National AIDS Trust. Working with HIV A Summary of
NAT’s HIV - Employment Research. 2009. http://www.nat.
org.uk/Media%20library/Files/Policy/Our%20thinking/
Employment%20summary%20report%20-%20FINAL%20
August%202009.pdf (29 January 2012, date last accessed).
10. Blalock AC, McDaniel JS, Farber EW. Effect of employment on quality of life and psychological functioning in
patients with HIV/AIDS. Psychosomatics 2002;43:400–404.
11. Conyers LM. Expanding understanding of HIV/AIDS and
employment: perspectives of focus groups. Rehabil Couns
Bull 2004;48:5–18.
12. Pence BW, Barroso J, Harmon JL, Leserman J, Salahuddin
N, Hammill BG. Chronicity and remission of fatigue in
patients with established HIV infection. AIDS Patient Care
STDs 2009;23:239–244.
13. van Gorp WG, Rabkin JG, Ferrando SJ et al.
Neuropsychiatric predictors of return to work in HIV/
AIDS. J Int Neuropsychol Soc 2007;13:80–89.
14. Timmons JC, Fesko SL. The impact, meaning and challenges of work: perspectives of individuals with HIV/AIDS.
Health Soc Work 2004;29:137–144.
15. Fumaz CR, Muñoz-Moreno JA, Moltó J et al. Long-term
neuropsychiatric disorders on efavirenz-based approaches:
quality of life, psychologic issues, and adherence. J Acquir
Immune Defic Syndr 2005;38:560–565.
16. Gorman AA, Foley JM, Ettenhofer ML, Hinkin CH, van
Gorp WG. Functional consequences of HIV-associated
neuropsychological impairment. Neuropsychol Rev 2009;
19:186–203.
17. Fogarty AS, Zablotska I, Rawstorne P, Prestage G,
Kippax SC. Factors distinguishing employed from
unemployed people in the Positive Health Study. AIDS
2007;21:S37–S42.
18. Rabkin JG, McElhiney M, Ferrando SJ, van Gorp WG, Lin
SH. Predictors of employment of men with HIV/AIDS: a
longitudinal study. Psychosom Med 2004;66:72–78.
19. Martin DJ, Arns PG, Batterham PJ, Afifi AA, Steckart
MJ. Workforce reentry for people with HIV/AIDS: intervention effects and predictors of success. Work 2006;
27:221–233.
20. Ibrahim F, Anderson J, Bukutu C, Elford J. Social and economic hardship among people living with HIV in London.
HIV Med 2008;9:616–624.
21. Braveman B, Levin M, Kielhofner G, Finlayson M. HIV/
AIDS and return to work: a literature review one-decade
post-introduction of combination therapy (HAART). Work
2006;27:295–303.
22. British Army. Medical Conditions. http://www.army.mod.uk/
join/20157.aspx (5 June 2011, date last accessed).
23. Royal Air Force. Medical Conditions That Preclude Entry. http://
www.raf.mod.uk/careers/rafcms/mediafiles/8AC4A6D0_
5056_A318_A8628AA28D2D8DAE.pdf (5 June 2011, date
last accessed).
24. Federal Aviation Administration. Guide for Aviation
Medical Examiners. http://www.faa.gov/about/office_org/­
headquarters_offices/avs/offices/aam/ame/guide/dec_cons/
disease_prot/hiv/ (20 September 2011, date last accessed).
25. Directgov. Disability and the Equality Act 2010. http://www.
direct.gov.uk/en/DisabledPeople/RightsAndObligations/
DisabilityRights/DG_4001068 (27 February 2011, date
last accessed).
26. Scottish Executive Health Department. HIV Infected
Health Care Workers – Guidance on Management and Patient
Notification. 2005. http://www.scotland.gov.uk/Resource/
Doc/57346/0016315.pdf (1 February 2012, date last
accessed).
27. Department of Health. HIV Infected Health Care Workers Guidance on Management and Patient Notification. 2005.
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digi­
tal­assets/@dh/@en/documents/digitalasset/dh_4116416.
pdf (1 February 2012, date last accessed).
28. Expert Advisory Group on AIDS, UK Advisory Panel for
Healthcare Workers Infected with Blood-borne Viruses,
Advisory Group on Hepatitis. Management of HIV-Infected
Healthcare Workers: The Report of the Tripartite Working
Group. 2011. http://www.dh.gov.uk/prod_consum_dh/
gro­u ps/dh_digitalassets/documents/digitalasset/dh_
131574.pdf (30 January 2012, date last accessed).
29. General Medical Council. Confidentiality. 2009. http://www.
gmc-uk.org/static/documents/content/Confidentiality_
0910.pdf (30 January 2012, date last accessed).
30. Department of Health. Health Clearance for Tuberculosis,
Hepatitis B, Hepatitis C and HIV: New Healthcare Workers.
2007. http://www.dh.gov.uk/prod_consum_dh/groups/dh_
digitalassets/@dh/@en/documents/digitalasset/dh_
074981.pdf (30 January 2012, date last accessed).
31. Healthier Scotland (Scottish Government). Health
Clearance for Tuberculosis, Hepatitis B, Hepatitis C and HIV
for New Healthcare Workers with Direct Clinical Contact with
Patients. 2008. http://www.scotland.gov.uk/Resource/Doc/
221201/0059484.pdf (30 January 2012, date last accessed).
32. Burki T. Discrimination against people with HIV persists in
China. Lancet 2011;377:286–287.
33. Dray-Spira R, Gueguen A, Lert F. Disease severity, selfreported experience of workplace discrimination and
employment loss during the course of chronic HIV disease: differences according to gender and education. Occup
Environ Med 2008;65:112–119.
34. National AIDS Trust. Advice for Employers HIV@ Work.
2010. http://www.nat.org.uk/Media%20library/Files/Pol­
icy/2010/HIV-Work-employers.pdf (1 February 2012, date
last accessed).
35. Gazzard BG, Anderson J, Babiker A et al. British HIV
Association guidelines for the treatment of HIV-1-infected
adults with antiretroviral therapy 2008. HIV Med 2008;
9:563–608.
36. El-Sadr WM, Lundgren JD, Neaton JD et al. CD4+ count–
guided interruption of antiretroviral treatment. N Engl
J Med 2006;355:2283–2296.
37. United Kingdom Advisory Panel for Healthcare Workers
Infected with Bloodborne Viruses. Second Report (1st April
2004 to 31st December 2006). http://www.hpa.org.uk/webc/
HPAwebFile/HPAweb_C/1228291495165 (9 May 2012,
date last accessed).
252 OCCUPATIONAL MEDICINE
38. Bell DM, Shapiro CN, Culver DH. Risk of hepatitis B and
human immunodeficiency virus transmission to a patient
from an infected surgeon due to percutaneous injury during an invasive procedure: estimates based on a model.
Infect Agents Dis 1992;1:263–269.
39. United Kingdom Advisory Panel for Healthcare Workers
Infected with Bloodborne Viruses. Third Report - 1st January
2007 to 31st December 2010. http://www.hpa.org.uk/webc/
HPAwebFile/HPAweb_C/1317132071281 (30 January
2012, date last accessed).
40. Department of Health. HIV Post-Exposure Prophylaxis –
Guidance from the UK Chief Medical Officers’ Expert Advisory
Group on AIDS. 2008. http://www.dh.gov.uk/prod_consum_
dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_089997.pdf (30 January 2012, date last accessed).
41. Author Unknown. Fit to sweep roads. Br Dent J 2007;
202:54.
42. The Center for HIV Law & Policy. Guidelines for HIVPositive Health CareWorkers 2008. http://hivlawandpolicy.org/
resources/view/167 (1 February 2012, date last accessed).
43. Salkeld LR, McGeehan SJ, Chaudhuri E, Kerslake IM.
HIV testing of junior doctors: exploring their experiences,
perspectives and accounts. J Med Ethics 2009;35:402–406.
44. British HIV Association, British Association of Sexual
Health and HIV, British Infection Society. UK National
Guidelines for HIV Testing 2008. http://www.bhiva.org/
documents/Guidelines/Testing/GlinesHIVTest08.pdf
(30 January 2012, date last accessed).
45. General Medical Council. Good Medical Practice. 2006.
http://www.gmc-uk.org/static/documents/content/GMP_
0910.pdf (30 January 2012, date last accessed).
46. Health Professions Council. Guidance on Health and
Character: A Guide for Applicants and Registrants on How We
Consider Information They Declare. 2009. http://www.hpc-uk.
org/assets/documents/10002C17Guidanceonhealthandcha
racter.pdf (25 January 2012, date last accessed).
47. General Dental Council. Standards for Dental Profession­
als. 2005. http://www.gdc-uk.org/Newsandpublications/
Publications/Publications/StandardsforDentalProfession­
als[1].pdf (25 January 2012, date last accessed).
48. Nursing & Midwifery Council. Human Immunodeficiency
Virus (HIV). http://www.nmc-uk.org/Nurses-and-midwives/
Advice-by-topic/A/Advice/Human-ImmunodeficiencyVirus-HIV/ (25 January 2012, date last accessed).
49. Thomas LM. Centralisation of military HIV and sexual
health services to Birmingham Heartlands Hospital, Letter
to all UK NHS Trusts, HIV, Sexual Health and Infectious
Diseases Societies 2011.
50. Department of the Army. Identification, Surveillance,
and Administration of Personnel Infected with Human
Immunodeficiency Virus (HIV). 2005. http://img.thebody.
com/press/2005/hiv_army_regs.pdf (2 February 2012, date
last accessed).
51. UK Civil Aviation Authority. UK CAA Guidelines for
Providing JAA Class 1 and 2 and European Class 3 Aeromedical
Certificates to HIV Seropositive Applicants. 2010. http://www.
caa.co.uk/docs/49/20100329HIVGuidelinesForJAAEuro­
Cl3Certification.pdf (30 January 2012, date last accessed).
52. Geretti AM, Brook G, Cameron C et al. British HIV
Association guidelines for immunization of HIV-infected
adults 2008. HIV Med 2008;9:795–848.
53. Deutsche AIDS-Hilfe e.V., European AIDS Treatment
Group, International AIDS Society. The Global Database on
HIV-Specific Travel & Residence Restrictions. www.hivtravel.
org (18 February 2011, date last accessed).
54. UK Health Departments. Recommendations of the Expert
Advisory Group on AIDS and the Advisory Group on Hepatitis.
Guidance for Clinical Health Care Workers - Protection against
Infection with Blood-Borne Viruses. 1998. http://www.dh.gov.
uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/
documents/digitalasset/dh_4014474.pdf (30 January 2012,
date last accessed).
55. Health and Safety Executive. Bloodborne Viruses in the
Workplace - Guidance for Employers and Employees. 2011.
http://www.hse.gov.uk/pubns/indg342.pdf (28 January
2012, date last accessed).
56. Abel S, Ce’saire R, Cales-Quist D, Be’ra O, Sobesky G,
Cabjé A. Occupational transmission of human immunodeficiency virus and hepatitis C virus after a punch. Clin
Infect Dis 2000;31:1494–1495.
57. Tomkins S, Ncube F. Occupational Transmission of
HIV - Summary of Published Reports. Health Protection
Agency, 2005. http://www.hpa.org.uk/webc/HPAwebFile/
HPAweb_C/1194947320156 (30 January 2012, date last
accessed).
58. Health Protection Agency, National Public Health Service for
Wales, Health Protection Scotland. Eye of the Needle: United
Kingdom Surveillance of Significant Occupational Exposures to
Bloodborne Viruses in Healthcare Workers. 2008. http://www.
hpa.org.uk/webc/HPAwebFile/HPAweb_C/1227688128096
(30 January 2012, date last accessed).
59. Health and Safety Executive. Handling Needles in the Waste
and Recycling Industry. 2007. http://www.hse.gov.uk/pubns/
waste19.pdf (30 January 2012, date last accessed).
60. Garvey D. Exposure to biohazards an emerging concern
for construction workers in sewer lines and wastewater
treatment plants. Prof Saf 2005;50:26–31.
61. Health and Safety Executive. Advisory Committee on
Dangerous Pathogens: Protection against Blood-Borne Infections
in the Workplace HIV and Hepatitis. 2008. http://www.hse.
gov.uk/biosafety/diseases/bbv.pdf (2 February 2012, date
last accessed).
62. Health and Safety Executive. Controlling the Risks of Infection
at Work from Human Remains: A Guide for Those Involved in
Funeral Services (Including Embalmers) and Those Involved
in Exhumation. 2005. http://www.hse.gov.uk/pubns/web01.
pdf (30 January 2012, date last accessed).
63. Ministry of Defence. Leaflet 31 - Blood BorneViruses (Previously
HIV and AIDS), Joint Service Publication 375 - MoD Health
& Safety Handbook:Volume 2. 2007. http://www.mod.uk/NR/
rdonlyres/03C6C0AE-F461-48F2-95C4-B9259856A174/0/
leaf_31.pdf (2 February 2012, date last accessed).
64. Department of Health, National AIDS Trust. Tackling Blood
Borne Viruses in Prison: A Framework for Best Practice in the
UK. 2011. http://www.nat.org.uk/media/Files/Policy/2011/
NATBlood%20Borne%20VirusesPrisonsMay2011-1.pdf
(29 January 2012, date last accessed).
65. Scottish Executive. Working Group to Address the Needs of
Those Potentially Exposed to a Blood-Borne Virus. First Report:
Advice to the Scottish Executive on Mandatory Blood Testing.
2006. http://www.scotland.gov.uk/Resource/Doc/1101/
0022892.pdf (2 February 2012, date last accessed).
C. McGOLDRICK: HIV AND EMPLOYMENT 253
66. Taylor A, Roy K, Cullen B, Gow J, Dunleavy K. An
Evaluation of Post-Incident Management of Police and Prison
Service Staff Occupationally Exposed to Blood and/or Body
Fluids. Scottish Government Social Research, 2009.
http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/
1240899128519 (1 February 2012, date last accessed).
67. Kordi R, Wallace W. Blood borne infections in sport:
risks of transmission, methods of prevention, and recommendations for hepatitis B vaccination. Br J Sports Med
2004;38:678–684.
68. Department of Health. Children in Need: HIV and Hepatitis and
BloodborneViruses. 2004. http://www.dh.gov.uk/prod_­consum_
dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/
dh_4093512.pdf (2 January 2012, date last accessed).
69. Cardo DM, Culver DH, Ciesielski CA et al. A case-control
study of HIV seroconversion in health care workers after percutaneous exposure. N Engl J Med 1997;337:1485–1490.
70. Foreman M. Combat AIDS: HIV and the World’s Armed
Forces. London: Healthlink Worldwide, 2002.
71. Melville J, Panse S, Kovacs G, Hancock T, Neumann R.
The Global Business Coalition on HIV/AIDS, Tuberculosis
and Malaria (GBC): HIV, TB & Malaria Management &
Prevention in the Oil & Gas Supply Chain. New York: Booz
& Company Inc., 2010.
72. Faleyimu B, Ubuane L, Ogunniyi S, Faleyimu A, Aremo G.
Sexual networking and AIDS education at the workplace
and the community: the case of oil locations in Nigeria.
Cochrane Colloquium Abstracts Journal 2000; PA25.
73. Panlilio AL, Cardo DM, Grohskopf LA, Heneine W, Ross
CS. Updated U.S. Public Health Service guidelines for
the management of occupational exposures to HIV and
recommendations for postexposure prophylaxis. MMWR
Morb Mortal Wkly Rep 2005;54:1–17.
74. Department for Work and Pensions. Industrial Injuries
Disablement Benefit. http://www.dwp.gov.uk/healthcareprofessional/benefits-and-services/industrial-injuries-­
disablement/ (28 January 2012, date last accessed).
75. NHS Professionals. Scheme Guide: NHS Injury Benefits
Scheme. 2009. http://www.nhsbsa.nhs.uk/IBS/Documents/
InjuryBenefitScheme/SDIB_(V2)_-_Online_07.2009.pdf
(25 January 2012, date last accessed).
76. McIntyre I. The caring face. Br Dent J 2007;202:54–55.
SOM ASM 2012
SOM on the Tyne: clearing the fog
18–21 June 2012—The Sage, Newcastle Upon Tyne
The SOM North East group is hosting the
2012 Annual Scientific Meeting of the Society of
Occupational Medicine at The Sage, Newcastle Upon
Tyne.
Speakers include
Professor Tom Kirkwood (Newcastle University)
Professor Sir John Burn (Newcastle University)
Professor Simon Folkard (University of Swansea)
Professor Paul Cullinan (Imperial College London)
Dr Lesley Rushton OBE (Imperial College London)
Professor Graham Devereux (University of Aberdeen)
Key topics are
•• Ageing and Work
•• Shiftwork
•• Future Developments in Occupational Health
•• Clinical Updates
More information is available at http://www.somasm.org.uk/index.asp