Positive practice

James M N Duffy and Simon Rackstraw document the challenges facing doctors who are HIV positive

No one knows how many doctors practising in the United Kingdom are HIV positive. The professional ramifications of being HIV positive become clear only when seen through an historical lens, because the medical profession has been notoriously bad at supporting ill doctors in the past.

The Department of Health and the General Medical Council's policy is to support disclosure with confidentiality and acceptance, allowing HIV positive doctors to continue their professional practice. Indeed, these rights are protected in British law, through the Disability Discrimination Act 2005. But the reality of ensuring that employers and colleagues do not discriminate against HIV positive doctors remains a challenge in medical practice.

Dangers of disclosure

The General Medical Council considers HIV infection to be a serious communicable disease because it can be transmitted from human to human and results in a serious life threatening illness. HIV positive doctors must, therefore, follow the council's guidance, as outlined in its Serious Communicable Disease publication.¹ The guidelines say that doctors must seek appropriate help and advice from a consultant specialising in occupational health, infectious diseases, or public health. They must not rely on their own assessment of risk.

Advice should be sought on how professional practice should be changed, and if current, previous, or future employers should be told. The situation has gained further complexity recently because disclosure to an employer is now mandatory to receive legal protection under the Disability Discrimination Act. Reaching the decision to make a disclosure to an employer can be emotionally challenging and is confounded by the scarcity of practical guidance for either the mechanism of the disclosure or the consequences.

Clinicians with HIV must change their professional practice to avoid "exposure prone procedures." These procedures are defined by the UK advisory panel for healthcare workers infected with blood borne viruses.² The panel defines these procedures as those that risk injury to the doctor that could expose the patient's open tissues to the doctor's blood. The panel describes many such procedures-for example, the insertion of chest drains in emergency trauma, the placement of portacaths, and open surgical procedures. Universal standards of infection control do not allow HIV positive doctors to do exposure prone procedures. These standards minimise the risk of blood borne infections and include the use of protective barriers, careful needle handling and disposal, hand washing, and disinfection of instruments. The panel's guidance promotes changes in practice in some medical specialties, such as general surgery, but has few implications in other specialties, such as pathology.

The ability of an HIV positive doctor to change his or her professional practice rather than risk dismissal is now protected by legislation in the UK.³ The Disability Discrimination Act classifies HIV infection as a disability. After disclosure to the employer, therefore, the employer has a legal duty to allow HIV positive doctors to make reasonable adjustments to practice by removing exposure prone procedures from their workload. It is a misconception that an HIV positive doctor's professional career ends when the diagnosis of infection is made. Education about this misconception to the wider medical community could help people at risk to pursue HIV testing, in line with GMC guidance. From next year UK medical students will not undergo screening for serious communicable disease, as experience of exposure prone procedures will no longer be a necessity for preregistration with the General Medical Council.

With changes in professional practice comes another dilemma surrounding wider disclosure. HIV positive doctors must modify their professional practice but are under no obligation to inform colleagues as to why. But colleagues who notice a change in practice or see unusual practice may question this or even assume the doctor is HIV positive. This often forces HIV positive doctors into wider disclosure, beyond the current legal necessity. Interviews with HIV positive doctors raise repeated concerns associated with wider disclosures; especially the maintenance of confidentiality, misconceptions of HIV transmission in healthcare settings, and the recent criminalisation of HIV transmission. Unfortunately, wider disclosure does not have the same safeguards in terms of confidentiality as disclosure in a doctor-patient relationship.

Prejudices

The reliance on colleagues to maintain confidentiality is essential. Unfortunately, HIV infection brings with it an undertone of "otherness," in terms of different behaviours, such as sexual orientation, promiscuous sexual activity, and illicit drug misuse as well as being from different places, such as sub-Saharan Africa.

HIV infection also reinforces previously held prejudices, such as racism and homophobia. Personal internal conflict can develop, therefore, between an ethically based professional and their own prejudices about other people. Unfortunately, all the doctors interviewed by us for this article found that their concerns about breaches of their confidentiality were well founded. These breaches included disclosure to members of staff beyond the immediate team and to the public.

Breaches of confidentiality are damaging because they eliminate the essential trust between colleagues in a team, leading to fragmentation and ineffective working. Breaches of confidentiality also undermine the confidence of the public, and of healthcare workers, in assurances about confidentiality while they are being treated as patients. These substantial difficulties about confidentiality are largely founded on a lack of understanding and a lack of acceptance of HIV positive colleagues.

Tolerance and acceptance

Acceptance of an HIV positive colleague may require someone to challenge their own stigmatising beliefs. When people act on prejudice, stigma turns into discrimination. Historically, doctors have cared for ill people but have been intolerant of their own ill health and that of their colleagues. This intolerance is based on misconceptions surrounding HIV infection and individual doctors' prejudice.

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Acceptance is key

The main misconception highlighted by our recent interviews was that of the possibility of transmission of HIV from an HIV positive doctor to a patient, in a healthcare setting. Absolutely no evidence supports this misconception. The evidence shows that the risk of HIV transmission is far greater from HIV positive patients to doctors, in healthcare settings. Worldwide, only three reports exist of transmission from HIV positive doctors to patients. These three reports were before the introduction of universal precautions or the changes to professional practice that HIV positive doctors now make.

In comparison, transmission from HIV positive patients to doctors has been reported in 106 cases worldwide, with five in the UK.² Non-acceptance of HIV positive colleagues is prevalent and manifests itself in many behaviours, such as rejection, denial, discrediting, disregarding, under-rating, and social distancing. These behaviours are unacceptable and unlawful for medical professionals. Doctors experiencing discrimination or poor treatment can seek recourse through local grievance policies, and, if required, through the provisions made by the Disability Discrimination Act. This act entitles HIV positive doctors to take unfavourable treatment and harassment to the employment tribunal system.

To stop the need for seeking recourse through grievance procedures, acceptance and tolerance towards HIV positive doctors needs to become part of the culture of the National Health Service. Education is key in changing this culture. The wider community urgently needs educating, specifically undergraduate medical students, who should then be followed up throughout their career. This education needs to make clear that the NHS is committed to preventing discrimination and stigmatisation of HIV positive doctors. For example, medical professionals need to be educated through written materials and workshops so that prejudices can be challenged and information relayed. Displaying HIV awareness and educational posters in staff and patient areas is effective in changing attitudes.⁴ The NHS must promote its policy and guidelines about its expectations that its staff treat HIV positive doctors fairly and in an accepting manner. A combination of these strategies would hopefully result in a change of culture within the NHS.

Moving forward

In the 1980s, sustained tabloid campaigns bullied HIV positive healthcare professionals out of the NHS. These campaigns reinforced prejudice and made HIV positive doctors even more reluctant to seek help. Hopefully the attitudes of the general population, and especially the medical profession, have changed since then. Progress has still to be made: HIV positive doctors need total acceptance and support within their healthcare teams. Without this, talented doctors with a wealth of knowledge and experience could leave the NHS.

Acceptance is the key in the fight against prejudice and discrimination, which HIV positive doctors face. All healthcare professionals need better education about the implications of HIV infection and transmission in the workplace. Improved education will help combat prejudices gleaned from the media miseducation of the risks of transmission from doctor to patients.

1. General Medical Council. Serious Communicable Disease. London: GMC, 1997.
2. HIV infected health care workers: guidance on management and patient notification. London: DoH, 2005.
3. Disability Discrimination Act 2005.
4. National AIDS Trust. HIV in healthcare. London: National AIDS Trust, 2004.