hospitals today

Human Immuno Deficiency Virus (HIV) Infection & Role of Hospitals

Ajaz Mustafa MD; GJ Qadri MD; NA Pandit MD.

Abstract :
Human Immuno Deficiency Virus (HIV) infection a dreaded scourage has far reaching consequences
on human lives. In a recent UN report it has been estimated that world has HIV infected population of about 40
million with almost half infected adults being women. Globally HIV is known to spread rapidly if it crosses 1%
prevalence in the adult population. It is reported that in India about 5.1 million were living with HIV in 2003 and
in states of Andhra Pradesh, Maharashtra, Karnataka and Nagaland, HIV prevalence has crossed the 1%
mark among pregnant women. It has been also reported that the sex workers and drug injectors are topping
among the high-risk group of patients in some Indian states. As per the estimates about 10% patients infected
with HIV are expected to be seriously ill requiring hospital in patient care and about 30-40% with symptoms
requiring care at the various ambulatory care facilities. Such a scenario puts among others, health care
professional/ workers at a higher risk of exposure to HIV infection from the patients seeking help from the
various health care institutions. In order avoid its consequent effects a multi disciplinary approach is required.
The modern hospital, a complex of multi purpose institution has varied functions which include the prevention
and treatment of diseases, the education of health professionals / workers and patients and conduct of bio-
socio and clinical research based on the community needs. Thus hospital in tackling the problem of HIV/ AIDS
need to have a policy statement focusing on the needs of HIV positive patients and on the specific risks of
providing care to such patients. The hospital are to provide infrastructure, trained manpower, and required
material and sound hospital practices that would facilitate prevention and control along with the treatment of
the patient. Hospital will also be required to ensure safe blood/ blood products transfusion, undertake various
information, education and communication activities regarding HIV risks, prevention strategy. The hospitals
need to initiate a clear policy regarding use of various disposables, sterilization and sound disinfectant and
antiseptics practices in the hospital settings. Without aggressive prevention efforts the menace of HIV/AIDS
will continue to spread thus every health care professional / workers has a role in identifying people at high risk,
offering education and counseling, encouraging testing and linking HIV positive patients with treatment and
social service. This is the most cost effective humane way to reduce the ill effects caused by the HIV / AIDS
disease and avoid a global disaster in the world especially in the South East Asia with India being no exception.
JK-Practitioner 2006;13(4):233-238
Authors affiliations: Nosocomial Infection is the single most important factor that
Ajaz Mustafa, Prof. GJ Qadri, adversely affects the performance and image of the hospital. The greatest
N.A. Pandit contribution to science has been to demonstrate, by sound laboratory and
Department of Hospital clinical research, a rational approach to understanding the causation of
infection based on Pasteurs demonstration of an unseen ambient
Administration Sher-i-Kashmir
microbiological world. His revolutionary approach emphasized that
Institute of Medical Sciences microorganisms must be prevented from entering a wound during or after
P.O. Box 27, Srinagar J&K operation and that if microorganisms were already present, they must be
prevented from spreading and Health Care Workers / Professional have a
Accepted for publication : crucial role to play in this regard.
May 2006 Hospital policy regarding AIDS should aid in fulfilling the basic
objectives and responsibilities of the hospital. The modern hospital is a
Correspondence complex, multipurpose institution, its functions include:
Dr. Ajaz Mustafa, The prevention and treatment of disease.
Asstt. Prof. Deptt. Of Hosp. The education of health workers / professionals
Administration. and patients.
Sher-i- Kashmir Institute of The conduct of clinical research.
Medical Sciences The most fundamental goal of the hospital is to benefit its patients.
P. O Box-27, Srinagar, J & K. This goal is grounded responsibilities to provide competent and considerate
health care and to protect patients from avoidable harm. In addition to
patients, the hospital bears responsibility to the health care workers and
employees who work within it from unnecessary risk of harm in the
performance of their duties.
Implications of HIV for hospitals: The unknown, apparently healthy HIV
infected is reporting to hospitals, clinics and other healthcare institutions for
various medical, surgical, gynecological and other ailments, just like any

JK- Practitioner Vol.13, No. 4, October-December 2006 233

hospitals today
other patient. With the present estimated prevalence and
keeping in view the patient load at different types of
hospitals, the following scenario is expected: -
Medical school/ state level hospitals with Out
Patient Department load of about 1000-2000 per
day on an average of 1-2 asymptomatic /
symptomatic HIV positive cases is being
unknowingly treated every day.
District hospitals with Out Patient Department
load of 3-4 hundred patients per day will have1or 2
seropositive patients per week.
Pregnant women: Statistical projections of HIV
prevalence in pregnant women, suggest that on an
average about 20,000 deliveries in seropositive
women take place every year of whom about 6000
deliver HIV infected babies (33%); thus health
care professionals would be conducting deliveries
of HIV positive women.
This load, as per projections, is going to increase
in the years to come, thus as a routine all hospitals,
Primary Health Centers and other healthcare
institutions need to implement infection control
procedures all the time.
Risk factors for occupational HIV infections: The risk for
occupational HIV was increased when:
The occupational exposure is deep as compared with
superficial (P<0.0001)
Blood is visible on the device causing the occupational
exposure (P=0.0014)
The device causing the exposure has been placed in a
source patients vein or artery (P=0.0028)
The patient dies within 60days of the exposure
(P=0.0011)
The exposed health care worker does not take
Zidovudine post exposure chemoprophylaxis
(P=0.0026)
(Risk factors for occupational HIV infection
identified in retrospective case control study in the USA,
UK and France. (CDC and Prevention)
HIV infection is transmitted via blood, semen, and
other body fluids; caring for HIV positive poses some risk to
health care workers / professionals who come in contact
with these body fluids. As the number of HIV positive
patients grow the risk of exposure increases. Transmission
of infection cannot occur, however, unless infected fluids
have some route of entrance into the body, such as a needle
prick, open wound, or mucous membrane exposure. Even
when these exposures do occur, the risk of infection is very
low. In a recent review of 5 published studies of a total of
770 HCP / HCW who accidentally received parenteral or
mucous membrane exposure to infected body fluids, only 3
persons were HIV seropositive and in only 1 of these
cases, involving deep intramuscularly injection of a
substantial quantity of blood was sero conversion
documented by blood samples obtained before and after the
event. This review concludes that the upper 95% confidence
limit for the risk of infection after accidental exposure to
HIV is 0.76% compared with a 12-17% risk of sero
conversion after accidental injection of blood or serum from
patients positive for Hepatitis B surface antigen.
Tuberculosis (TB) is the most common and most
234
deadly infection for HIV +ve individuals. According to the
CDC, people co-infected with HIV and TB are up to 800
times more likely to develop active TB disease during their
lifetime than people who are HIV negative. TB is the cause
of death for one of every three people with AIDS
worldwide. Spread of HIV has helped fuel TB epidemic.
The CDC recommended that all people infected with HIV
should be tested for TB, and if infected, should complete
treatment as soon as possible to prevent the onset of TB
disease.
The CDC estimates that approximately
one quarter of HIV positive people in the US are also
infected with HCV. Incidence is even higher among HIV
positive injection drug users (50-90%). The US public
health service guidelines recommended that all HIV
infected persons should be screened for HCV infection. The
CDC also recommends that susceptible co-infection
patients should receive Hepatitis A and Hepatitis B
vaccines. Their risk of developing either or both of these
viruses is increased by the co-infection. The risk of
developing HIV infection from a needle prick with infected
blood is about 1:300 without prompt antiretroviral
treatment. To prevent transmission of HIV to Health Care
Workers, the CDC recommends that post-exposure
prophylaxis (PEP) should begin within 1-2 hours after the
exposure (CDC 2001).
Care of HIV positive patients required exotic
technology or professionals with special expertise
unavailable at most hospitals, the care of such patients
might be an unreasonable burden for most hospitals to bear.
In fact, however such patients need hospital care for many
conditions of all kinds, and the nature of that care is often
not significantly different from that of other patients.
Refusing hospital care on the basis of HIV infection or
AIDS would be an unfair, callous, and unreasonable action.
Such a refusal would be as unfair as refusing care solely on
the basis of a patients race, sex, or religion. Therefore,
especially in view of the significant potential for
discrimination against HIV positive patients, hospitals
should clearly express their willingness to care for these
patients.
Number of AIDS patients grows rapidly over the
next few years, their exclusion from most low experience
hospitals would greatly exacerbate the already serious
burdens of AIDS care at high experience hospitals,
threatening the survival of these latter hospitals and
ultimately jeopardizing access to care for AIDS patients.
Rather than turning away AIDS patients, then, hospitals
with few AIDS patients should perhaps attempt to gain
more experience in caring for them, or at least provide
intensive education in the care of AIDS patients for their
personnel. Bennett et al suggests that policy makers
consider creating regional AIDS centers, which could be
especially valuable in pursuing clinical research on AIDS.
On establishment of HIV infection in a community
it is estimated that out of total infected patients 10% will be
seriously ill requiring hospital in-patient care. 30-40 % will
be symptomatic, requiring out patient care etc. with the
present available hospital beds about 7 lakh bed in
government sector (including ES1, PHC), there will be
acute shortage of hospital beds even for AIDS related cases.
JK- Practitioner Vol.13, No. 4, October-December 2006

A public maternity hospital need not care for non-obstetric
AIDS patients but should be willing to provide obstetrical
care for women with AIDS who need such care. A private
maternity hospital should also provide appropriate care for
a woman with AIDS who can afford that care. Presently
there is no law enacted to make it mandatory for private and
missionary hospitals, to treat HIV positive cases, (although
some private/ missionary hospitals on their own initiative
have decided to accept HIV patients for treatment, just like
any other patient). Further in view of chronic illness and
cost many patients will not be able to afford private hospital
treatment. Thereby HIV patients will use government
hospitals in India.
HIV Virus, relevant to its transmission in Health care
setting.
In view of the persistent, wide spread fear of
contracting AIDS, hospitals must make a strong effort to
educate and counsel their workers on the extent of their risk
and on techniques for risk reduction. Better understanding
of the situation can allay a great deal of fear and overcome
reluctance to care for HIV positive patients. After providing
appropriate education and counseling, therefore, hospitals
should also take action against employees who refuse to
take care for patients with the HIV infection.
HIV is transmitted through blood and blood
related body fluids / products (Serum, pus and
blood fractions), and through semen and vaginal
fluids. Infectious fluids also include other body
fluids with the above infectious fluids such as
bloody or purulent sputum, saliva, bloody feces,
urine etc.
HIV is not transmitted through Saliva, Urine,
tears, sweat and feces (so long as these are not
contaminated with infectious body fluids).
Breast milk is a route of transmission particularly
in a recently infected woman (mothers who were
sero negative before delivery, but accidentally
transfused HIV +ve blood during delivery).
HIV is an extremely fragile virus, inactivated by
drying within a few minutes on exposure to
atmosphere.
Relative infectivity and risks with HIV
o Exposure preventable.
o Prevalence of patients increasing.
o Virus titer 10 to 1000 per ml of blood.
o Infection risk with single exposure < 1%.
o Prevalence in HCP < 0.01 in USA.
o Mortality rate > 90%.
Still in spite of low infectivity less than 1% (HBV
10-13%) has succeeded in raising and unprecedented
awareness of infection control, which HBV did not.
HIV is readily inactivated by the most commonly
available disinfectants and by routine infection
control measures.
Intact skin is a complete barrier against HIV. Risk
of infection from needle injuries is less than 1%.
Prolonged direct contact of blood or splashes of
blood into open skin lesions, eyes, or mucous
membrane of nose or mouth also carries risk of
transmission (0.1%).
JK- Practitioner Vol.13, No. 4, October-December 2006
hospitals today
HIV transmission through aerosol inhalation has
not been documented so far. (Aerosol are not
released into the atmosphere in the course of
surgeries)
Risk of transmission from HIV infected HCP/
HCW to patient does exist. HIV infected surgeons
or any HCP should not be involved in invasive
procedures.
Prevention strategies to decrease risk of HIV infection.
Use of Standard Precautious or of other Isolation
Procedures designed to place effective barriers
between HCW/ HCP and blood or other body
fluids.
Educating new staff and retraining existing staff
regarding occupational risks for blood-borne
pathogen infection in the context of other
occupational risks present and prevalent in the
health care work place; making certain staff aware
of these risks.
Including information about all occupational risks
in biomedical training schools curricula.
Evaluating all procedures associated with
occupational risk for exposure to blood borne
pathogens (particularly those presenting risks for
trans coetaneous exposure), with the intent at
modifying the aspects of those procedures
associated with risks for occupational exposures.
Aggressive use of newly developed engineered
controls, including careful evaluation of safety
devices for safety, efficacy and cost-effectiveness;
implementation of those devices that meet these
tests.
Development of efficient, readily accessible, user-
friendly institutional post exposure management
systems, including the option for post exposure
antiretroviral chemoprophylaxis for documented
occupational HIV exposures (Beekmann et al).
Infection Control Practices:
Hospital Infection control Practices can reduce the
risk of exposure to HIV infected blood and body fluids.
Center for Diseases Control (1987) has recommended the
use of Barrier Precautious for all patients when contact with
blood or body fluids is anticipated, this approach, usually
referred to as Universal Precautious, has been endorsed
by the American Hospital Association (1987): Under
universal precautions, HCP/HCW should assume that the
blood and other body fluids from all patients are potentially
infectious, and therefore should follow infection control
precautious at all times and in all settings. Meticulous
adherence to universal precautious is recommended by
CDC for the care of all patients and mandated by
Occupational Safety and Health Administration (OSHA).
Standard Precautious is a newer term that hospitals and
other agencies are moving towards. It includes all
recommendations for Universal Precautious plus body
substances isolation (BSI) when other potentially infectious
material (OPIM) is present.
Universal Blood and Body Fluid Precautious/ Standard
235
hospitals today
Precaution:
Hand Washing
Barrier techniques to prevent contact of blood or
body fluids with skin or mucous membrane
includes
o Use of gloves
o Use of mask.
o Protective eye and face shields, when
appropriate.
o Gowns and Aprons.
o Compulsory use of fully buttoned up
aprons in labs.
Ban on mouth pipetting of blood / serum for tests.
Disinfection of soiled material / used instruments
/ soiled surfaces.
Hospital Waste Disposal.
Risk to HCW / HCP of HIV infection even after
accidental parenteral exposure is low the risk to other
patients from HIV +ve patients must be vanishly small since
the exposure of patients to the body fluids of other patients
in modern hospitals is rare and all but eliminated by
prescribed infection control practices such as hand washing
after patient contact. A potentially greater risks to non
infected patients would be contact with HIV +ve HCW /
HCP, though the degree of risk in this case presumably
would depend on the nature of such contact and especially
the potential for parenteral or mucous membrane exposure
to body fluids of the infected HCP. Documented case of
transmission of HIV infection from two HCP(a dentist and
an orthopedic surgeon) to patient.
Hands of the hospital personnel are by far the most
convenient vehicle for transmission of infection while the
hands of the carrier are frequently used to comfort and treat
the patients. The role of hands in cross infection is
paramount. The modest measure of hand washing is to
decontaminate hands off the transient organisms is most
often ignored, resulting in vulnerability of the patient in the
hospital to itrogenic nosocomial infection. The majority of
transient organisms are removed by mechanical action of
hand washing or chemical action of hand disinfection.
Nevertheless HCP/ HCW fail to wash their hands and still
fail to appreciate the importance of doing so.
Work practice controls can eliminate a substantial
fraction of occupational exposures to blood-borne
pathogens; modifying medical devices associated with
exposure risks can reduce risk further. Some of these
devices have been tailored to the needs of specific hospital
settings (e.g. the operating suite); other specific procedures
(e.g. phlebotomy) are associated with decreased risk of
cutaneous and / or percutaneous blood exposures:
A surgical repair assist device.
Blunt surgical needles.
Surgical finger guards and glove liners.
Phlebotomy equipment.
Needle-less intravenous administration systems.
Modified (e.g. self-capping) intravenous
catheters.
Developing a systematic approach to the
236
assessment of new safety devices has been suggested,
emphasizing the importance of creating a multidisciplinary
team, including the primary users of the devices, to assist in:
Performing the analysis;
Developing prevention strategies tailored to an
institutions specific needs;
Developing relevant criteria for assessment of the
design and performance of the device;
Objective testing of the devices in clinical settings;
Carefully analyzing performance and cost-
effectiveness before making a product selection.
Development of a process for the systematic
objective evaluation of these devices is crucial for
effective risk reduction at all health care
institutions.
Particular precautious during care of Sero Positive
individuals:
According to NACO, it is safer to care for HIV +ve
patients in the general ward, provided sterilization
and disinfection of invasive instruments/
equipments is being done. Gloves are not to be
used for routine patient.
Nurses/ HCW with cuts / injuries or dermatitis
should have water proof dressing on it. Preferably
they should not work with HIV patients as long as
broken skin on hand, and forearm or other
vulnerable areas are there.
Storage and transport of items used on sero-
positive cases should be separate, marked and kept
in puncture resistant containers, containing
appropriate disinfectant.
All spillage/ contamination/ soilage of blood and
body fluids should be flooded and soaked in 1%
bleach solution for 30 minutes.
Linen soiled with blood / OPIM be treated as
contaminated. Contaminated laundry must be
bagged at the location where it was used, and shall
not be sorted or rinsed in patient care areas. It must
be placed and transported in bags that are labeled
or colour coded (red). Laundry workers must wear
protective gloves.
The cotton and acrylic/ synthetic blanket are
preferred to woolen blankets since these can be
easily decontaminated when soiled and washing is
also cheap and easy. These can be handled like
linen. Contaminated soiled woolen blankets can
be decontaminated either by exposing to
formaldehyde vapours or autoclaving.
All infectious waste must be placed in closable,
leak proof containers or bags that are colour coded
(red) to prevent leakage during handling, storage
and transport, essentially decontamination and
safely rendering unfit for reuse.
Tags must be used until the identified hazard is
eliminated or the hazardous operation is
completed. Tags must contain a signal word or
symbol and a major message. The signal word
shall be BIOHAZARD or the biological hazard
symbol. All employees are informed about the
meaning of the various tags used throughout the
JK- Practitioner Vol.13, No. 4, October-December 2006

workplace and what special precautions are
necessary.
Electronic thermometers with disposable covers
do not need to be cleaned between users unless
visibly soiled. Glass thermometers should be
soaked in 70-90% ethyl alcohol for 30 minutes,
and then rinsed under a stream of warm water
between each use. Glass thermometers pose an
additional hazard because they contain mercury,
which is a potent neurotoxin.
Special care during surgery of HIV patients:
Reconsider the need for the surgery pros and cons,
wound healing etc.
Use of disposables as for as possible.
All non-disposables including tubings, suction
fluid bottles, humidifiers used, to be thoroughly
cleaned and disinfected, if not possible to clean
exposed interiors, such items should be discarded
after decontamination.
o Knife preferred to diathermy.
o Skin closed by clips, not sutures.
o Thorough cleaning with 1% bleach of
floor, walls, table sides, surgical light,
fans, trolleys, every other possible place
with 7% Lysol.
o Use of protective Barriers.
What should be done following an exposure?
Dont get panicky
Needle pricks and cuts should be washed with
soap and water.
Splashed to the nose, mouth or skin should be
flushed with water.
Eyes should be irrigated with clean water, saline or
sterile irrigates including contact lenses.
Do not put the pricked finger in mouth reflexly.
Report the exposure to concerned authority.
Treat the condition as an emergency preferably
within two hours.
Prevention & Risk reduction:
HIV/ AIDS are preventable. Screening of blood
and blood products for the HIV has reduced the risk of HIV
transmission with transfusion to 1:1,000,000. Following
universal precautious in health care has unquestionably
prevented thousands if not millions of cases of HIV/ AIDS.
hospitals today
According to the CDC, occupational exposure to HIV has
resulted in only 57 cases of HIV sero conversion among
health care personnel in the U.S. between 1985 and June
2001. Thats the good news. Virus is transmitted through
behaviours that many people find pleasurable-sexual
activity and injection drug use prevention can be difficult,
but not impossible. Stigma and discrimination are the
major obstacles to effective HIV/ AIDS prevention and
care. Fear of discrimination may prevent people from
seeking treatment for AIDS or from acknowledging their
HIV status publicly. People with, or suspected of having,
HIV may be turned away from health care services, denied
housing and employment, shunned by their friends and
colleagues, turned down for insurance coverage or refused
entry into foreign countries. In some cases they may be
evicted from home by there families, divorced by their
spouses, and suffer physical violence or even murder. The
stigma attached to HIV/ AIDS may extend into the next
generation, placing an emotional burden on children who
may also be trying to cope with the death of their parents
from AIDS. Focus on stigma and discrimination; campaign
will encourage people to break the silence and the barriers
to effective HIV/ AIDS prevention and care.
Action Plan
1) Develop a sound and effective hospital infectious
control policy and monitor its implementation.
2) Health education to public/ patients and
attendants.
3) Awareness programmes for the hospital staff
including doctors, nurses and other health care
workers.
4) Hospital staff to assume that every patient is
potentially infectious.
5) Encourage use of Universal Precautions and
Standard Isolation Precautions.
6) Develops an effective method of reporting
exposure pricks/ cuts and implement the
recommended protocol to handle exposed staff.
7) Earmark a specific inpatient area with facilities of
barriers nursing for admitting the AIDS case with
TB.
8) Logistics to be made available to the staff treating
AIDS cases.
9) Safe and appropriate policy for hospital waste
from generation to final disposal.

Further Reading
1- Ajaz Mustafa, I A Bukhari, DK
Kakru, SA Tabish & GJ Qadri. JK
Practitioner Incidence of
Nosocomial Wound Infection in
Postoperative Patients at a Teaching
Hospital. Vol.1 No.11 (Jan.-March
2004) p-38-41.
2. Annas,George. Legal Risks and
Responsibilities of Physicians in the
AIDS Epidemic. Hastings Center
Report, USA 18, no.2 (1988): S26-
S32.
3. AORN Standards and
Recommendations Practices Denver,
Colo: Association of Operating
Room Nurses, Inc, (1999).
4- Bennett, Charles L., Jeffrey B.
Garfinkle, Sheldon Greenfield,
David Draper, William Rogers,
Christopher Matthews, and David E.
Kanouse. The Relation Between
Hospital Experience and In- Hospital
Mortality for Patients with AIDS-
Related PCP. Journal of the
American Medical Association, 261
(26 May 1989): 2975-79
5. Chamberland ME, Bell DM:
Human immunodeficiency virus
infection. In Bennett JV, Brachamn
PS (eds): hospital Infections, 4th ed.
Philadelphia: Lippincott-Raven
Publishers, (1998), pp 665-687.
6. Centers for Disease Control.(2001).
Exposure to blood: What health care
workers need to know.
Www.cdc.gov/ncidod/hip
7. Center for Disease Control and
Prevention Evaluation of blunt
suture needles in preventing
percutaneous injuries among health
care workers during gynecologic,
surgical procedures New York City,
(March 1993- June 1994). MMWR
Morb Mortal Wkly Rep (1997); 46:
25-9.

JK- Practitioner Vol.13, No. 4, October-December 2006 237

hospitals today
References
8- Centers for Disease Control
Recommendations for prevention of
HIV Transmission In Health Care
Settings. Morbidity and Mortality
We e k l y R e p o r t 3 6 ,
Supplement.No.2S (1987): 3S-18S.
9. Lot F, Seguier JC, Fegueux S, et al:
Probable transmission of HIV from
ortho pedic surgeon to a patient in
France. Annals of Intern Med
(1999); 130:1-6.
10. Mangrum A, Horan T, Pearson M,
Silver B, Jarvis W, and HICPAC:
CDC guideline for the prevention of
surgical site infection (1999). Infect
Control Hosp Epidemiol (1999); 20:
238
247-280.
11. Medical World News. USA AMA
Stresses Doctors Duty to AIDS
Patients. 28(14 December 1987):
40-41.
12. Occupational Safety and Health
Administration. Occupational
Exposure to Hepatitis B Virus and
Human Immunodeficiency Virus.
Federal register 52 (27 November
1987b): 45438-41.
13- Simmons B: Guidelines for
prevention of Surgical wound
infections. Infect Control (1982); 3:
188-196.
14. Ward JW, Deppe DA, Samson S, et
JK- Practitioner Vol.13, No. 4, October-December 2006
al, Human immunodeficiency virus
infection from blood donors who
later developed the acquired
immunodeficiency syndrome.
Annals Intern Med 1987; 106: 61-2.
15. Women are HIVs No. 1 targets.
Times of India New Delhi - June 14,
2005.
16- Woods IA, Leslie LF, Drake DB,
Edlich RF: Effect of puncture
resistant surgical gloves, finger
guards, glove liner on cutaneous
sensibility and surgical psychomotor
skills. J Biomod Mater Res (1996);
33:47-51.