w DEPARTMENTS

Debra Hardy Havens, BS, RN, FNP Washington Representative for NAPNAP

Capitol Associates, Inc. Washington, DC

9 Update on AIDS/HIV n

T his past year, numerous activities have occurred around the acquired immunodeficiency syndrome (AIDS)/human immunodeficiency virus (HIV) issue. In the latter half of the first session of the 102nd Con- gress, the AIDS /HIV issue was debated and considered a number of times. In large part, the debate was initiated by media and public attention received regarding the likely transmission of HIV from a Florida dentist to several patients. This gave rise to considerable anxiety in the general public-even though medical evidence indicates the risk of transmission from health profes- sionals to their patients is low.

n BACKGROUND

AIDS is a bloodborne and sexually transmitted disease caused by the HIV, which compromises the immune system of its victims, rendering them susceptible to in- fections. The disease is fatal to most victims within 2 years of clinical mainfestation. Although HIV infection has been seen as difficult to transmit in health care set- tings, the possibility of this occurrence resulted in guide- lines being issued by the Centers for Disease Control (CDC; CDC, 1987; CDC, 1991). Until 1990, no cases of transmission by a health care worker (HCW) to a patient had been officially documented. In 1990, CDC reported a case “consistent with transmission of HIV to a patient during an invasive dental procedure (CDC, 1990). After investigation of this report, CDC con- cluded that the facts “strongly suggested that HIV was transmitted to five of the approximately 850” patients who were tested of the dentist in question (CDC, 1991).

The precise mode of transmission to the five patients remains a mystery. The dental practice opened in 198 1. Medical records indicate that the dentist’s first reported positive HIV test occurred in late 1986 and that he was diagnosed with AIDS in September 1987. Each of the five patients had invasive procedures performed by the dentist after he had been diagnosed with AIDS. All five of the patients have denied having sex with the dentist, and none received general anesthesic. Of the 14 em-

94

ployees in the dental office, eight have been tested for exposure to HIV. All eight tested negative, including the dental hygienists. The practice closed in 1989, and the dentist died in September 1990. Less than one half of the dentist’s estimated 2000 patients are known to have been tested, despite the fact that certified letters have been mailed to each patient in the practice. Inves- tigators speculate that those who have not yet been tested are deliberately choosing not to find out if they are infected.

These five Florida cases are the only patients who are known to have acquired HIV from an HCW in a health care setting. In two studies of patients in the practices of a surgeon and a surgical resident who had AIDS, all patients tested were negative for HIV infection (Porter Cruickshank, Gentle, Robinson, & Gill, 1990; Arm- strong, Miner, & Wolfe, 1987). In another study, pa- tients of a surgeon with AIDS were offered HIV testing. Of the 1340 patients contacted, 616 were tested. The HIV test results for 615 were negative; the one patient who was HIV positive was a known intravenous drug user. Although his HIV status at the time of surgery was unknown, he had been diagnosed with an AIDS- related infection and, therefore, probably became in- fected by a contaminated needle before the surgery (Mishu, Shaffner, & Horan, 1990). In a study of 143 patients treated by a dental student with HIV infection, all tested negative for exposure to HIV (Comer, Myers, Steadman, Carter, Rissing, & Tedesco, 1991).

CDC has reopened its investigation into the practice of the dentist in Florida and is considering whether the dentist might have deliberately injected some of his pa- tients with HIV (Altman, 1991). Other factors being examined include the infection control procedures used by the dental practice. The dentist occasionally had his teeth cleaned by his hygienists. The office did not have a written policy for cleaning dental instruments and did not consistently adhere to the recommended guidelines to prevent transmission of HIV. Therefore the possi- bility exists that the virus could have been passed from the dentist to the patients through contaminated dental

JOURNAL OF PEDIATRIC HEALTH CARE

Journal of Pediatric Health Care Legislative News 95

equipment. This mode of transmission is considered to be unlikely, however, because HIV does not survive in the environment for long periods of time and has not been shown to be resistant to heat or chemical germi- cides. CDC issued its first guidelines to prevent the transmission of AIDS in the health care setting in No- vember 1987 and has issued several updates since that initial publication. Professional organizations have also issued their own guidelines.

On July 12, 1991, as a result of the cluster of cases in Florida, CDC released its revised guidelines. Previous CDC guidelines did not make recommendations re- garding HCWs with HIV and did not indicate which invasive procedures may pose an increased risk to the patient. The new guidelines recommend that HCWs who perform exposure-prone procedures should be tested for HIV. Exposure-prone procedures (EPPs) are defined as “the simultaneous presence of the health care worker’s fingers and a needle or other sharp instrument or object in a poorly visualized or highly confined an- atomic site (CDC, 1991).

EPPS were to be identified by professional health care organizations (medical, surgical, dental, nursing, and institutions). CDC, at the time of this writing, does not recommend restricting HIV-infected HCWs from performing invasive procedures that are not exposure prone and is not recommending mandatory HIV testing of HCWs. Analysts speculate that the guidelines will make HIV testing of HCWs essentially compulsory be- cause of insurance and liability considerations.

During late 1991, CDC has been working on this issue in collaboration with professional health care groups. On November 4, 1991, CDC met with the professional health care groups, including the nursing organizations, to develop a list of EPPs. Most of the health care groups have adamantly opposed the devel- opment of such a list. Originally, CDC intended to publish an EPP list in the Federal Rgister sometime mid-November 1991. .Because of the lack of coopera- tion and opposition of the professional health care groups, CDC is reevaluating whether or not such a list will be developed. However, CDC is expected to pub- lish something through a Federal Register notice some- time in January 1992.

n LEGISLATIVE SUMMARY

This past summer, the Senate passed two amendments to appropriations bills that took divergent approaches to the issue. This situation caused great concern and interest by the professional health care groups. They were concerned about mandatory testing of health care workers and about ensuring both the confidentiality of these results and nondiscrimination, based on the test results.

The first amendment (No. 734), offered by Senator Jesse Helms (R-NC) on July 181991, essentially would have required that all HCWs who perform or who are involved with invasive medical procedures and know that they are HIV positive inform their patients. To fail to do so would be a criminal act with a minimum penalty of 10 years in prison and a $10,000 fine. This amend- ment was agreed to by the Senate by a vote of 81 to 18. Because the Helms amendment would have applied to any procedure that involved an invasive physical con- tact, it went beyond the CDC guidelines, which do not recommend restricting HCWs who were HIV infected from performing invasive procedures that were not ex- posure prone. Some argued that this approach would discourage HCWs from being tested because it only applied to those who knew they were infected with HIV. This amendment was dropped by the House and Senate conferees during the conference.

The second amendment (no. 78 l), sponsored by Senator Robert Dole (R-KS), required the states to adopt the July 12, 1991, CDC guidelines of HIV-in- fected HCWs within 1 year or risk losing their federal public health service funds. The Dole amendment re- quires the appropriate state licensing agency to disci- pline HCWs who do not comply with the guidelines. The amendment was agreed to in the Senate by a unan- imous vote of 99-O. This amendment was included as a provision in th e SC year 1992 Treasury, Postal Ser- fi al vice, and General Government Appropriations bill, which has been signed into law.

Another amendment offered by Senator Helms to the Commerce, Justice, and State Appropriations bill would have allowed testing of patients to protect HCWs. During Senate consideration of the bill, the amendment was agreed to by a voice vote but was later dropped from the bill during the House and Senate conference on the appropriations bill.

In addition, on June 26,1991, Rep. Bill Dannemeyer (R-CA) introduced H.R. 2788, the “Kimberly Bergalis Patient and Health Provider Protection Act of 1991.” This bill would direct the Secretary of Health and Hu- man Services to specify medical and dental procedures that HCWs who are HIV infected should not perform. The HCW would be prohibited from performing the procedure except in cases in which the patient is in- formed that the HCW is HIV infected, is informed of the risk posed by HIV in the context of the procedure, and provides written consent to the HCW to perform the procedure. The bill mandates that HCWs perform- ing such procedures will be tested regularly, with the testing frequency to be determined by the Secretary. The bill also provides for nonconsensual HIV testing of patients by HCWs. H.R. 2788 differs from CDC’s guidelines, which do not recommend mandatory testing

96 Legislative News Volume 6, Number 2

March-April 1992

of HCWs. The bill is criticized as being expensive to implement; the cost at one 350-bed hospital has been estimated at $860,000 for the first year (Geberding, 1991).

Several hearings by the House Energy and Com- merce Subcommittee on Health and the Environment have been held on this issue, and no further action has occurred. Congressman Dannemeyer is expected to con- tinue to press ahead in the next session of Congress on this matter.

Lastly, on another appropriations bill, the fiscal year 1992 Appropriations for the Departments of Labor, Health, and Human Services and Education, the fol- lowing provision was adopted and enacted into law:

Notwithstanding any other provision of law, on or before December 1, 1991, the Secretary of La- bor, acting under the Occupational Safety and Health Act of 1970, shall promulgate a final oc- cupational health standard concerning occupa- tional exposure to bloodborne pathogens. The fi- nal standards shall be based on the proposed stan- dard as published in the Federal Register on May 30, 1989 (54 FR 23042), concerning occupa- tional exposures to the heaptitis B virus, the hu- man immunodeficiency virus and other blood- borne pathogens. Nothing in the Act shall be construed to require the Secretary of Labor (acting through OSHA) to revise the employment accident reporting reg- ulations published at 20 CFR 1094.8.

n REGULATORY ACTION

As mandated by law, the Occupational Safety and Health Administration (OSHA) issued its final stan- dards on December 6, 1991, on bloodborne pathogens, which will provide guidance to all employers and em- ployees who could be “reasonably anticipated” as a re- sult of performing their job duties to face contact with blood and other potentially infectious materials (OSHA, 1991). Such pathogens include HIV that causes AIDS and the hepatitis B virus. The bloodborne standard will become effective on March 6, 1992 (Fed- eral Register, 199 1) .

Meeting the requirements of this standard is not an option. The standard will cover employees who may reasonably anticipate coming into contact with human blood and other potentially infectious materials in the performance of their jobs. It will require employers to establish the following procedures:

n a written exposure control plan; n identification of workers with occupational expo-

sure to blood and other potentially infectious ma- terial;

n engineering controls, such as puncture-resistant containers used for needles;

. work practices, such as handwashing; l appropriate personal protective equipment, such as

gowns/gloves; = requirements for procedures, such as housekeeping

decontamination procedures; n labels, warning signs, and training. In addition, the standard requires employers to offer,

at their expense, voluntary hepatitis B vaccinations to all employees with occupational exposure. The standard also prescribes appropriate medical follow-up and counseling after an exposure incident. Employees who choose not to accept the vaccine must sign a dec- lination form, but they may be vaccinated at a later date, if they change their minds.

As of December 2, 1991, OSHA is issuing a series of fact sheets highlighting individual requirements of the standard, a booklet outlining the provisions of the standard, and specialized booklets targeted for acute care facilities, dental offices, emergency responders, and long-term care facilities. A videotape explaining the standard to health care workers will also be available.

Because this information is important, all nurse prac- titioners and their colleagues must be aware of these standards, must practice according to these standards, and must assist in implementing the standards into your practices. Details and specific information on the OSHA standard on bloodborne pathogens can be obtained by contacting:

Mr. James F. Foster OSHA

U.S. Department of Labor Office of Public Affairs

Room N3647 200 Constitution Avenue, N.W.

Washington, DC 20210 (202) 523-8151

n SUMMARY

Associated with the AIDS epidemic are some of the most difficult policy dilemmas society faces. The issues surrounding HIV are complex and involve legal, med- ical, ethical, and practice issues. In addition, many policy issues have received and will continue to receive atten- tion-education, public health measures, health care delivery and financing issues, legal issues, state laws and regulations, labor and employment issues, and inter- national concerns. The debate will most certainly con- tinue to heat up.

To contribute positively to the public policy debate, nurse practitioners must become knowledgeable about the disease- including its epidemiology- and examine

Journal of Pediatric Health Care Legislative News 97

their own practices, feelings, and attitudes regarding this deadly disease.

Comer, R.W., Myers, D.R., Steadman, CD., Carter, M.J., l&sing, J.P., & Tedesco, F.J. (1991). Management considerations for an HIV positive dental student. Journal ofDentalEducation, 55, 187- 191.

REFERENCES

Ahman, Lawrence K. (1991, July 30). An AIDS puzzle: What went wrong in dentist’s office? New York Times, p. C3.

Armstrong, F.P., Miner, J.C., St Wolfe, W.H. (1987). Investigation of a health care worker with symptomatic human immunodefi- ciencv virus infection: An epidemiological approach. Military Mediiine, 152, 414-418.

Centers for Disease Control. (1987). Recommendations for pre- venting transmission in HIV health care settings. Mmbidity and Mortahy Weekly Report, 36, 305.

Geberding, J.L. (1991). Expected costs of implementing a mandatory HIV and hepatitis B virus testing and restriction program for health care workers performing invasive procedures. Infection Con- trol Hospital Epidemiology, 12, 443447.

Mishu, B., Shaffner, W., & Horan, J.M. (1990). A surgeon with AIDS: Lack of evidence of transmission to patients. Journal of the

American Medical Association, 264, 467-470. Occupation Safety and Health Administration. (1991). Fact sheet,

OSHA bloodbornepatbo~ensJina1 standard, summay~ of kpy provisions, December 2, 1991.

Centers for Disease Control. ( 1990). Possible transmission of human Porter, J.D., Cruickshank, J.G., Gentle, P.H., Robinson, R.G., & immunodeficiency virus to a patient during invasive dental pro- Gill, O.N. (1990). Management of patients treated by a surgeon cedure. Morbidity and Mortality Weekly Rep&, 39, 489-491. with HIV infection. Lancer, 335, 113-114.

Centers for Disease Control. (1991). Recommendations for pre- Occupational exposure to bloodbome pathogens. Department of La- venting transmission of human immunodeficiency virus and hep- bor, Occupational Safety & Health Administration, 29 CFR Part atitis B virus to patients during exposure-prone invasive proce- 1910.1030 (1991, December 6) Federal Register, pp. 64004- dures Morbidity and Mortality Weekly Report, 40. 64182.