Report from IDSA: symposium on healthcare worker issues

Data on documented transmissions of HIV, HCV, and HBV from health care workers to patients are presented in a chart. Two well-known cases identifying the source of HIV transmission from a healthcare worker to a patient are discussed. CDC recommends against mandatory testing of health care employees and recommends that infected healthcare workers not be restricted unless they perform invasive medical procedures in a blind body cavity. Factors contributing to the risk of HIV transmission, the importance of universal precautions, and the status of post-exposure prophylaxis are discussed. HCV transmission from infected patients to healthcare workers was reviewed.     

AIDS/HIV counselling in occupational health

AIDS/HIV counselling will increasingly become part of the role of occupational health professionals. Issues that arise in the occupational setting include: occupational transmission, knowledge and attitudes, problems with family and friends, AIDS dementia, and uncertainty. Dilemmas can occur in relation to contamination incidents, HIV positive employees, or staff refusing to work because of fears of HIV/AIDS. It it easier to deal with the problems that arise if the issues have been thought through beforehand. Examples are given of problems that have occurred in a setting of occupational health in the British Health Service and their resolution is discussed.     

Prevention of HIV infection in adolescents and young adults

The prevention of HIV infection in school and university communities acquires great importance in adolescents and young adults where the risk of HIV infection is caused by age, occupation, location, and also adjoining relations with other groups of high incidence of infection, such as teachers and administrative employees. Adequate strategies for specific groups are needed. This paper focuses on the strategies developed at the National Autonomous University of Mexico. An interdisciplinary health commission for the prevention and control of AIDS was established to inform the student body. Other activities performed by this commission include providing medical and psychological attention for AIDS victims, as well as detecting and carrying out follow-up studies of infected students. Efforts in health education have also been made by training professors to include preventive measures against this disease as part of their subject matter. Specific, organized, and immediate action must be taken by health personnel and community organizations in order to prevent HIV infection in adolescents and young adults.     

Antiretroviral drug development: the challenge of cost and access

The global threat of HIV infection requires sustainable solutions driven by investments from both the public and the private sector. The pharmaceutical industry has supported research and development of antiretroviral therapies that have prolonged the lives of individuals infected with HIV. The medical need for new antiretroviral agents remains great, however, a consequence of the progressive evolution of viral resistance. In order to meet this ongoing challenge, investment into research and development needs to continue. These investment decisions are made relative to other pressing healthcare concerns and are based on assessments of the likelihood of technical success, the ability to define the clinical value of any new medicine, the patient's perception of medical need, and the ability of society to support the patient's access to those medicines. Any new antiretroviral therapy must be anticipated not only to work against future resistant strains but to work well with other agents as part of combination therapies. Those challenges are coupled with the need for systems that optimize patients' access to treatment, including the global regulatory process, reliable and quality manufacturing and distribution systems, and basic healthcare delivery infrastructure. Synergies generated from the contributions to HIV care by both the public and private sector will, in the long and the short run, lead to improvements in the health and well-being of individuals living with HIV.     

不同途径感染HIV人群的心理状态分析

综合近年来国内外对艾滋病病毒(HIV)感染者及艾滋病(AIDS)病人心理健康的研究,分别对有偿献血、吸毒和经性途径感染HIV人群的心理状态进行分类分析,由此得出不同传播途径感染HIV人群的心理感受和心理状态是不同的。有偿献血人群存在严重的抑郁、焦虑情绪障碍;吸毒人群存在较严重的强迫、敌对、焦虑、抑郁、精神病性问题,可能丧失生活信心,产生报复社会的情绪;女性性工作者人际关系敏感、强迫症、偏执等表现较为突出,有更强烈的社会支持的心理需求;男男性行为者会产生强烈的负罪感,感到焦虑,羞耻、难以适应,产生自杀念头。文章提出,要掌握不同途径感染HIV人群的心理特点,心理干预工作才能事半功倍,才能更好地提高HIV感染者及AIDS病人的生存质量。     

Back to the future: survival, uncertainty, and hope

The HIV/AIDS epidemic is compared to the World War II-era Holocaust during which millions of people were persecuted. Those infected and affected by HIV/AIDS are described as undergoing a form of post-traumatic stress disorder. People who provide physical, social, and mental health care services to HIV/AIDS clients are reminded to facilitate the participation in the emotional healing process and to allow time and space for grieving. Individuals and communities need rituals as a vehicle for the expression of their grief. Providers must keep issues of abandonment, respect, compassion, and living with uncertainty in the forefront. Individual successes in the lives of HIV/AIDS patients, such as return to work or school, should be acknowledged and celebrated.     

Mental health of carers of children affected by HIV attending community-based programmes in South Africa and Malawi

There is strong evidence that both adults and children infected with and affected by HIV have high levels of mental health burden. Yet there have been few studies investigating carer mental health outcomes in the context of HIV in Malawi and South Africa. The objective of this study was to assess the mental health of carers of children affected by HIV as a part of the Child Community Care study, which aims to generate evidence on the effectiveness of community-based organisation (CBO) services to improve child outcomes. In a cross-sectional study, we interviewed 952 carers of children (aged 4–13 years) attending 28 randomly selected CBOs funded by 11 major donors in South Africa and Malawi. Psychological morbidity was measured using the Shona Symptom Questionnaire and suicidal ideation was measured using an item from the Patient Health Questionnaire. Carers were asked about care-seeking for emotional problems. Overall, 28% of carers scored above the clinical cut-off for current psychological morbidity and 12.2% reported suicidal ideation. We used logistic regression models to test factors associated with poor outcomes. Household unemployment, living with a sick family member and perceived lack of support from the community were associated with both psychological morbidity and suicidal ideation in carers. Reported child food insecurity was also associated with psychological morbidity. In addition, carers living in South Africa were more likely to present with psychological morbidity and suicidal ideation than carers in Malawi. Rates of help-seeking for mental health problems were low. Carers of children affected by HIV are at risk for mental health problems as a result of HIV, socio-economic, care-giving and community factors. We call for increased recognition of the potential role of CBOs in providing mental health care and support for families as a means to improve equity in mental health care. Specifically, we highlight the need for increased training and supervision of staff at CBOs for children affected by HIV, and the inclusion of CBOs in broader efforts to improve population mental health outcomes.     

Preventing work disability among employees with rheumatoid arthritis: what medical professionals can learn from the patients' perspective

OBJECTIVE: To compare the perspectives of employees with rheumatoid arthritis (RA) with those of medical professionals regarding what persons with RA need to prevent work disability. METHODS: Concept mapping was conducted in a group session with 21 employees and by mail with 17 medical professionals. Each group was asked to formulate statements on what enables employees with RA to retain their jobs. Group members scored all statements for importance and clustered them into themes. Results were statistically aggregated at the group level. RESULTS: The concept mapping with employees yielded 59 statements, which were clustered into 7 themes. The 4 most important themes were employer support; understanding and acceptance of illness by employees themselves; suitable working conditions; and support from colleagues, health professionals, and the patient's organization. The concept mapping with medical professionals yielded 65 statements, which were clustered into 8 themes. The 6 most important themes were well-informed professionals who cooperate effectively; employees' coping capacities and commitment to work; financial regulations at the workplace; adequate social security provisions, medication, and therapy; a positive attitude on the part of employers and colleagues; and suitable working conditions. CONCLUSION: Factors that enable continued employment lie at different levels, including the psychosocial, practical, organizational, and social policy levels. Health professionals appear to underestimate factors that are important from the patient's perspective, especially support from employers. In discussing work with patients, health professionals need to address themes that are important from the patient's perspective.     

Practice of sumo kodhi among the Luo and implications for HIV transmission in western Kenya

This paper discusses the practice of sumo kodhi among the Luo ethnic group and its implications for spread of HIV in western Kenya. Sumo kodhi is a practice in which a woman arranges to have sex with a man other than her legitimate sexual partner (husband or levir/inheritor) to give birth to children with specific qualities she wants in them. Data were drawn from a 16-month ethnographic study on reproductive aspirations of women living with HIV/AIDS (WLWHA). The study found that WLWHA engaged in sumo kodhi as they believe they will get gender balanced, beautiful, and academically talented and healthy children who are free from HIV. The WLWHA targeted agnates of their husbands living in distant villages, former boyfriends (before marriage) and other men who were new in the area such as civil servants, employees in local institutions and businessmen who would not suspect their HIV status. These WLWHA kept their HIV status secret and exposed the targeted men to the risk of being infected with HIV. It can be deduced that having knowledge of HIV status does not always translate into taking action towards protecting sexual partner(s). Moreover, continued childbearing is not always as a result of unmet contraceptives needs. It is apparent from this study that social factors sometimes overrule health considerations. The study recommends that further research be conducted among other ethnic groups to gauge whether they also have a practice similar to sumo kodhi. Women living with HIV/AIDS should be involved in HIV/AIDS control and prevention strategies. There is also need for an intervention that would ensure that WLWHA meet their reproductive aspirations without putting their sexual partners at risk of contracting HIV.     

HIV-associated tuberculosis in developing countries: epidemiology and strategies for prevention.

The association between tuberculosis and HIV presents an immediate and grave public health and socioeconomic threat, particularly in the developing world. In early 1992 WHO estimated that approximately 4 million people had been infected with both Mycobacterium tuberculosis and HIV since the beginning of the pandemic; 95% of them were in developing countries. The association between tuberculosis and HIV is evident from the high incidence of tuberculosis, estimated at 5-8% per year, among HIV-infected persons, the high HIV seroprevalence among patients with tuberculosis, the high occurrence of tuberculosis among AIDS patients, and the coincidence of increased tuberculosis notifications with the spreading of the HIV epidemic in several African countries. The impact of the two epidemics on resource-poor countries has ominous social and medical implications, and the already overstretched health services now have to face a tremendously increasing tuberculosis problem. HIV infection worsens the tuberculosis situation by increasing reactivation of latent tuberculosis infection in dually infected persons as well as by favouring rapid progression of new infections in the HIV-infected. This also results in an increase of the risk of infection and a subsequent increase of cases in the general population. In order to respond to this urgent problem, the highest priority must be given to strengthening tuberculosis control programmes in the countries where they are poorly developed and where the prevalence of HIV and tuberculosis infections is high. Besides improving the cure rate by early diagnosis and prompt treatment of patients with tuberculosis, two major strategies that need consideration include BCG vaccination and preventive chemotherapy among HIV-infected individuals. The latter strategy is considered as the most critical intervention that would help to limit the expected increase in clinical tuberculosis from the pool of HIV and tuberculosis coinfected individuals. However, a number of issues need to be addressed urgently and before such an intervention can be implemented in the developing countries.     

Predictors of workplace sexual health policy at sex work establishments in the Philippines

Based on the literature, we identified manager and establishment characteristics that we hypothesized are related to workplace policies that support HIV protective behavior.We developed a sexual health policy index consisting of 11 items as our outcome variable. We utilized both bivariate and multivariate analysis of variance. The significant variables in our bivariate analyses (establishment type, number of employees, manager age, and membership in manager association) were entered into a multivariate regression model. The model was significant (p<.01), and predicted 42) of the variability in the development and management of a workplace sexual health policy supportive of condom use. The significant predictors were number of employees and establishment type. In addition to individually-focused CSW interventions, HIV prevention programs should target managers and establishment policies. Future HIV prevention programs may need to focus on helping smaller establishments, in particular those with less employees, to build capacity and develop sexual health policy guidelines.     

Pressure mounts for CDC to change guidelines for infected HCWs. Centers for Disease Control and Prevention

The Centers for Disease Control and Prevention (CDC) are currently reviewing the guidelines for handling HIV-positive health care workers (HCWs). The Advisory Committee on HIV and STD Prevention and the Hospital Infection Control Practices Advisory Committee are working together to change these recommendations based on problems arising under the present regulations. Worker's lack of confidentiality in disclosing their HIV status to patients, and ambiguous terminology stating that HCWs should not perform procedures that are exposure-prone, are among the problems that need to be addressed. Current practices have shown that health care personnel with HIV and hepatitis B (HBV) should be dealt with separately, and disclosure of HIV status should not be mandated because the risk of transmission to patients is very low. The group suggests that self-disclosure is warranted in specific cases, and may be mitigated by a supervisor who could oversee the worker's health condition. Additional recommendations include concentrating efforts on preventing injury to health care workers, studying transmission risks for hepatitis C, and analyzing the methods for preventing transmission. Results from a look-back study conducted by the CDC suggest that there is no data to demonstrate transmission between 53 HIV-positive health care providers and their 22,759 patients. The working group also recognizes the need for review panels, but feels that they should be decentralized to fit the needs of individual health care providers.     

Lung function abnormalities in HIV‐infected adults and children

Despite the advent of antiretroviral therapy (ART), the human immunodeficiency virus (HIV) epidemic remains a global health crisis with a high burden of respiratory disease among infected persons. While the early complications of the epidemic were dominated by opportunistic infections, improved survival has led to the emergence of non‐infectious conditions that are associated with chronic respiratory symptoms and pulmonary disability. Obstructive ventilatory defects and reduced diffusing capacity are common findings in adults, and the association between HIV and chronic obstructive pulmonary disease is increasingly recognized. There is synergism between viral factors, opportunistic infections, conventional influences like tobacco smoke and biomass fuel exposure, and potentially, the immunological effects of ART on the development of HIV‐associated chronic obstructive lung disease. Pulmonary function data for HIV‐infected infants and children are scarce, but shows that bronchiectasis and obliterative bronchiolitis with severe airflow limitation are major problems, particularly in the developing world. However, studies from these regions are sorely lacking. There is thus a major unmet need to understand the influences of chronic HIV infection on the lung in both adults and children, and to devise strategies to manage and prevent these diseases in HIV‐infected individuals. It is important for clinicians working with HIV‐infected individuals to have an appreciation of their effects on measurements of lung function. This review therefore summarizes the lung function abnormalities described in HIV‐positive adults and children, with an emphasis on obstructive lung disease, and examines potential pathogenic links between HIV and the development of chronic pulmonary disability.     

Supreme Court to rule on application of ADA

Four of eleven recent court cases cited the Centers for Disease Control and Prevention's (CDC) 1991 Federal guidelines governing the treatment of HIV-positive health care workers. These guidelines have helped define the scope of an infected worker's job responsibilities and restrictions and whether a worker has adhered to the outlined practices and precautions. Another key issue in the courts is whether the Americans with Disabilities Act (ADA) applies to individuals who are HIV-positive or hepatitis B-positive, and if these individuals are considered disabled. Two recent court rulings in cases showed that these individuals are disabled, yet could still perform their jobs. The courts are not as clear in cases involving health care employees, and need to determine how to define disability as it relates to HIV-positive patients. Currently, the Supreme Court is considering if asymptomatic HIV should be deemed a disability, particularly in light of the new combination therapies that enable many patients to continue working. Lawrence Gostin, a professor of law at Georgetown University Law Center and an advisor to the CDC, speculates that the Supreme Court will not make a blanket ruling, but will make decisions on an individual basis.     

Embedding HIV Mentoring Programs in HIV Research Networks

In Spain little research has focused on assessment of health indicators, both physical and psychological, in people living with HIV. The aim of this study is to evaluate a set of different indicators that allow us to identify psychological factors that may be influencing the quality of life of these people. The sample consist of 744 people infected with HIV aged between from 18 to 82 years (M = 43.04; SD = 9.43). Results show that factors such as self-esteem and leading a healthy lifestyle act as protectors in both, physical and mental health. On the other hand, financial problems, body disfigurement, and depressive mood could have harmful effects on both, physical and mental health. The structural model reveals depressed mood as the factor with greatest influence upon mental health, which in turn can be largely explained by factors such as the stress generated by HIV and personal autonomy. This work has allowed us to identify the vulnerability and protective factors that play a significant role in the physical and mental HRQOL of persons with HIV, providing guidelines for design and implementation of psychological intervention programs aimed to improve HRQOL in this population.     

Disclosure of diagnosis by parents and caregivers to children infected with HIV: prevalence associated factors and perceived barriers in Addis Ababa, Ethiopia

Vertical transmission of HIV from infected mothers to children is a common phenomenon. After the introduction of highly active antiretroviral treatment (HAART), most children live longer than before. Recently, HAART has become widely available to children living in sub-Saharan African countries, and this makes disclosure of HIV status an important issue. We conducted a cross-sectional survey involving 172 parents/caregivers of HIV-infected school-age children who had follow-up at the Pediatric Infectious Disease Clinic of the Yekatit 12 Hospital, Addis Ababa. Only 16.3% of HIV-infected schoolchildren knew their diagnosis. The child's age was the main predictor of disclosure (OR: -0.25; 95% CI: -0.35, -0.09; p<0.05). The main reason for nondisclosure was fear of negative emotional consequences for the child. More than half of the parent/caregivers agreed that they need to tell the children their diagnosis, but 86% reported that they needed health care providers to help them at the event. The low rate of disclosure found in this study shows the need for awareness creation and training of health professionals, and this should be supported by appropriate guidelines to be followed by health professionals working in pediatric ART clinics. Caregivers need to be provided with the necessary knowledge and skills on how to look after children who know their HIV status.     

Psychosocial and economic aspects of HIV/AIDS and counselling of caretakers of HIV-infected children in Uganda

The knowledge that her child is infected puts a heavy emotional burden on a mother. Despair or depression lead to difficulties in reacting to the options and advice given by health workers. The compliance of the mother also is largely dependent on her acceptance of the HIV status of the child. Additionally, the belief that the child might die any moment may cause her not to take proper care of the child anymore. Worries of the caretakers are frequently related to poverty. Counselling of caretakers at the health centre could and should be an important element in care for HIV-infected children. Psychological and material support and advice concerning HIV infection, proper childcare and material problems may empower the caretakers. This may lead to a better follow-up of the child by health care workers and to increased compliance of and better care by the caretaker, which will improve life and survival of an infected child.     

The Plight of Older Persons as Caregivers to People Infected/Affected by HIV/AIDS: Evidence from Uganda

This paper describes the challenges faced by elderly persons (50 years and above) in Uganda, as parents and/or relatives of persons infected by HIV and as caregivers of the infected relatives and their uninfected children. Little is known regarding these indirect impacts of HIV/AIDS on the elderly in sub-Saharan Africa. Yet, the elderly are most often the main caregivers of HIV-infected persons and their families. Data used in this study were obtained from focus group discussions and in-depth interviews conducted among elderly respondents in 10 rural and urban communities within two Ugandan districts, Luwero and Kamuli. Findings indicate that the elderly do provide care to patients with AIDS at the terminal stage of the illness-when patients most need constant care. In most cases, the challenge of caring for the sick patients is compounded by the responsibility to care for the children affected by HIV/AIDS, which also starts when their parents are still living, not when the children become orphans. This demanding work was reported to negatively affect the elderly in various dimensions (economic, emotional, physical, and nutritional), all of which impacts their health and well-being. The responsibility for day-to-day patient care is borne primarily by elderly females, who reported a higher rate of physical ailments than male respondents-perhaps an indication of their disproportionate contribution to the care responsibilities. Most of the elderly respondents interviewed have a lot of anxiety about their future health and well-being, which they attributed in most part to the HIV/AIDS epidemic. These challenges do appear to exacerbate the aging process of the elderly whose health and well-being are already affected by the poor resource base and weak health infrastructure in this setting.     

Using age‐specific mortality of HIV infected persons to predict Anti‐Retroviral Treatment need: a comparative analysis of data from five African population‐based cohort studies

Objectives To present a simple method for estimating population‐level anti‐retroviral therapy (ART) need that does not rely on knowledge of past HIV incidence. Methods A new approach to estimating ART need is developed based on calculating age‐specific proportions of HIV‐infected adults expected to die within a fixed number of years in the absence of treatment. Mortality data for HIV‐infected adults in the pre‐treatment era from five African HIV cohort studies were combined to construct a life table, starting at age 15, smoothed with a Weibull model. Assuming that ART should be made available to anyone expected to die within 3 years, conditional 3‐year survival probabilities were computed to represent proportions needing ART. The build‐up of ART need in a successful programme continuously recruiting infected adults into treatment as they age to within 3 years of expected death was represented by annually extending the conditional survival range. Results The Weibull model: survival probability in the infected state from age 15 = exp(?0.0073 × (age ? 15)^1.69) fitted the pooled age‐specific mortality data very closely. Initial treatment need for infected persons increased rapidly with age, from 15% at age 20–24 to 32% at age 40–44 and 42% at age 60–64. Overall need in the treatment of naïve population was 24%, doubling within 5 years in a programme continually recruiting patients entering the high‐risk period for dying. Conclusion A reasonable projection of treatment need in an ART naive population can be made based on the age and gender profile of HIV‐infected people.     

How stigmatizing is stigma in the life of people living with HIV: a study on HIV positive individuals from Chennai, South India

The nature and intensity of AIDS stigma are shaped by the social construction of the epidemic in different locales. Stigma therefore needs to be discussed in its cultural context. This clinic-based study aims at understanding stigma among 203 HIV positive individuals from Chennai, South India. The study throws light on the impact of stigma on the quality of life among these individuals. It also discusses the gender implications of stigma. This study brings out the findings that actual stigma experienced among those infected with HIV is much less (26%) as compared to the fear of being stigmatized or perceived stigma (97%). Internalizing of stigma was found to have a highly significant negative correlation with quality of life in the psychological domain and a significant negative correlation in the environmental domain. However individuals who did experience actual stigma seemed more determined to live and experience an above moderate quality of life. The implication of this study encourages HIV infected individuals to rise above stigma, avoid internalizing their stigmatized feelings and work toward a better quality of life. Health providers need to address these issues in their care for HIV infected individuals.