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R.R.
Frerichs Posting
Internal disagreements often make it difficult for organizations or
groups to focus on common goals. One clear example is HIV antibody testing,
which some support but others feel is controversial and should only be
done in special circumstances. In the debate on individual rights to avoid
disclosure versus community rights to avoid further transmission, the broad
goal of HIV control is often overlooked. Even defining criteria for HIV
antibody testing has met with resistance, as people prefer to think about
other topics that are less contentious and easier to resolve. Nevertheless
testing issue will not go away, especially for countries like India, Myanmar,
Thailand, Cambodia and parts of China and Vietnam where HIV is becoming
increasingly common. Such countries must develop coherent testing policies
if the epidemic is to be controlled.
Earlier I wrote to SEA-AIDS of the need to develop mechanisms for testing
of pregnant women, so that efforts can be made to avoid mother-to-child
transmission. Now in the current issue of the New England J of Medicine (i.e., NEJM
1997; 337, 1485-1490, 1542-1543) comes another reason for testing in countries
where HIV is common. The case-control study of health care workers focuses
on factors that contribute to the spread of HIV to health care workers
from their HIV infected patients. The CDC-led team reported that there
are four main factors associated with HIV transmission from patient to
care giver:
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deep injury, injury with a device on which the source patient's blood was
visible,
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a procedure involving a needle that had been in a source patient's artery
or vein, and
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exposure to a source patient who died of AIDS within two months after the
incident.
Most relevant to this posting, they found that zidovudine (AZT) prophylaxis
is apparently protective, in that the case subjects (i.e., health care
workers who became HIV infected) were five times less likely to have received
zidovudine following exposure than control subjects (i.e., health care
workers who did not become infected). This suggests that after inadvertent contact with the blood of HIV infected
patients, immediate AZT use may reduce HIV transmission by up to 80%.
So how is a doctor or nurse to know that AZT should be immediately used?
If they regularly treat themselves with AZT after every contact with blood,
regardless of the HIV status of their patients, then both cost and viral
resistance will become complicating factors.
Conversely if they routine test all patients at admission with newer
rapid tests, they will know who to manage with greater care, and when to
use prophylactic AZT if accidents happen.
Medium to high HIV prevalence
is what justifies routine HIV testing at hospital admission. Thus such
testing would likely not be considered in countries where HIV is uncommon.
What do health professionals in higher prevalence countries think about
routine HIV testing of hospitalized patients? Is some level of accidental
transmission from patient to physician or nurse acceptable, so as not to
jeopardize patients' rights to have HIV status remain free from disclosure?
Do patients who come into a hospital setting have such rights or is protection
of hospital personnel of greater importance?
Please share your criteria
for deciding if routine testing in medical settings is justified.
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