Should HIV Positive Nurses Be Allowed to Deliver Direct Patient Care

HIV Positive Nurses

The most profound effects of HIV are the stigma, discrimination and the psychological aspects of the disease and hence efforts to relieve these negative psychosocial perceptions are the most wanted. Evidence suggests that occupational infection of HIV from the HCW to the patient is very negligible while the odds of the patient infecting a HCW are much higher. However, the extent of discrimination of a HIV positive HCW is much higher creating severe health, economic and psychosocial consequences for the person. Healthcare policy makers should carefully evaluate the implications for various stakeholders before framing regulations pertaining to practice restrictions of HIV sero positive HCWs.

Introduction

HIV is a global epidemic that is causing significant strain on our already stretched health care system. Almost three decades later the search for a cure to HIV still continues to elude us. However, the vast amount of research over the last decade has considerably changed our view of HIV from being an untreatable and fatal disease to a chronic treatable condition. While we are focused on the prevention, therapeutic progress and the discrimination of HIV patients a new debate has arisen. The widespread concern about HIV positive workforce in the healthcare sector, particularly the nurses who are the primary caregivers and the potential dangers of infecting patients under their care. The healthcare sector in particular has been identified as the area where discrimination against HIV positive people is more pronounced. [Mahendra et.al (2007)] Fear of discrimination puts off health care workers (HCW) from screening themselves for HIV and thereby delaying their own treatment. Tarwirevi & Majako (2003) report that 77% of HCW were unwilling to test themselves for HIV. [Sadoh et.al, 2009] the recently conducted UK National AIDS Trust Study also reported that one fifth of the HIV positive HCW who reported their status felt they were discriminated in the workplace. A discussion of the pros and cons of having HIV positive nurses in direct care delivery will provide better insight into this important healthcare topic.

HIV Positive Nurses in healthcare

The issue of a healthcare worker being infected with HIV is a very complex one to deal with. As per the Americans with Disability Law (ADA) nurses and other healthcare workers with HIV should be protected from discrimination and permitted to work unless their disability or the infection limits their ability to perform competently. The ADA also states that if by suitable changes the risk of contamination is removed then the worker shall continue to perform. While the ANA deems it obligatory for the nurses to disclose their HIV status it also advocates that nurses with HIV should be allowed to continue their work in such a manner that there is no medically known risk for the patients under their care, while at the same time ensuring that their privacy privileges are not compromised. Thus HIV status of a Nurse or any other healthcare worker should not be a factor that automatically excludes them from providing patient care. [Susan J. Westrick, 2009] However, it is incumbent upon the HIV positive nurse to adhere strictly to the recommended 'Universal Precautions', to stay away from high risk areas of care delivery such as in a surgical or emergency setting where exposure to patients' blood is more common. In other words, nurses who are identified to be HIV positive should stay away from areas of nursing that involve invasive procedures. The stance of the ANA on HIV positive nurses is clearly expressed in its support for "policies that will ensure equitable practice guidelines for nursing practice by HIV-positive nurses, without undue limitation on scope of practice, and based on scientific and epidemiological information, respecting the rights and confidentiality of both patients and HIV-positive nurses" [Shaw Kathy, 2003]

It is also to be understood that the outlook on HIV has changed significantly over the years. As Garcia Jones, a professor at the Florida International University School of Nursing states, "Instead of viewing HIV as a fatal disease, it's now thought of more as a chronic condition.. This means that people are living with HIV, and they need to continue to work - not only as a means of financial support but also as 'therapy.'" [Susan, 2004]

The fact is that the improvements in anti-retroviral therapies have reduced the viral loads to undetectable levels that greatly reduce the risk of transmission. So there appears no cause for undue concern or worry when there is no scientific reason that a nurse providing care is a danger for the patient. Some nursing advocates such Lucy BradleySpringer, PhD, research nurse and ANAC president go to the other extreme by suggesting that, "It is safe for nurses with HIV to practice, even in surgery, if they use the reasonable precautions required of all nurses." [Susan, 2004] While this is a valid argument it is not ethically acceptable to risk a patient by letting a HIV infected HCW participate in invasive routines.

However, a HIV positive nurse who has disclosed his/her status should be allowed to continue their care provision so long as they are not in invasive or emergency care settings where there is a definite risk for the patient to contract the virus. Also when we are experiencing a national shortage of nurses with an already overworked nursing force it is important to support the HIV positive nurses as much as possible so that they can continue to provide nursing care in settings that exclude 'exposure prone procedures'. In the UK the National Aids Trust conducted an extensive survey in the NHS network and recommended, "At a time when the NHS is facing significant workforce capacity issues, it seems only sensible that, wherever possible, people with an HIV diagnosis should be supported and enabled to continue working." [Charlotte Santry]

The Culture of Stigmatization and the Dangers

The GIPA (Greater Involvement of People living with HIV / AIDS) principle calls for greater participation of HIV patients as an effective means to prevent, control and provide support services for people infected with HIV. " the key to successful treatment education and advocacy is remembering our own dignity as human beings and taking hold of the power of that truth. Taking care of our feelings is as important as understanding and treatment of the physical manifestations of this disease. We are our own cure..." [Odetoyinbo Morolake et.al (2009)] Thus the optimal self-care setting for an HIV patient would be to be as participative as possible in a social setting while continuing the treatment. However, the prevailing discriminatory climate only helps to increase the dangers. HIV status has clearly affected the healthcare workforce throughout the world, even in well-developed countries. As the International Council of Nursing stated, "stigma and discrimination block the march forward against HIV / AIDS, fueling the HIV / AIDS epidemic by creating a culture of secrecy, silence, ignorance, blame, shame and victimization.." {Sandie Gracia, 2004]

In a health care setting such a discriminatory environment often leads to avoidance of disclosure, which has dangerous outcomes for the patients. For instance, a HIV positive nurse may continue to work in a trauma care or in a surgical setting by withholding his/her status. The risk for unintentional infection is greater in these exposure prone settings. In this case the fear of discrimination or even loss of job only created a precarious situation for patients.

An extensive study from Nigeria analyzed the attitude of HCW on fellow nurses and doctors infected with HIV and their willingness to undergo HIV screening. This study involved 67 health care facilities in the Ogun State of Nigeria. Using a two-part semi-structured questionnaire the researchers gathered information pertaining to the attitudes of the subjects (randomly selected) towards their HIV positive HCWs as well as their willingness to take a HIV screening test. The questions basically assessed the willingness of the subjects to examine the vital signs, give injections, assist in the surgery of HIV infected patients while also gathering their responses to undergoing similar procedures from an HIV infected doctor or nurse. The results showed that HCWs were less inclined to accepting injections or having surgery assisted by HIV infected co worker than they were in offering similar services to HIV infected general public. While 72.5% and 71.3% of HCWs were prepared to give injections or set up infusion on HIV patients only 38.3% and 31.9% were willing to accept the same from HIV positive co-worker. This study clearly highlights the discriminatory tendency within the hospital staff. As Eleanor Briggs, the assistant director of the NAT (National AIDS Trust) says, "Stigma remains a real issue, there's still a lot of misunderstanding. You might expect people in a healthcare setting to be the most informed. We found that wasn't the case and people faced a range of negative responses." [Charlotte Santry, 2009]

Conclusion

The most profound effects of HIV are the stigma, discrimination and the psychological aspects of the disease and hence efforts to relieve these negative psychosocial perceptions are the most wanted. Evidence suggests that the occupational…