HIV and your elective

Medical staff from Medecins Sans Frontieres screen for malnutrition in east Africa. Would you go there for your elective?

As you plan your elective period, one aspect that fails to escape discussion is the risk posed to yourself while away, in particular that of HIV exposure,^w1 and fear may be detrimental to the experience.^w2 Many medical students choose to undertake their elective in regions of relatively high HIV prevalence^w3-w6 and are more likely to be exposed to infectious diseases than the average traveller because of the nature of their work.^w3 With careful planning, however, education about HIV/AIDS could form an integral part of the elective, leading to firsthand experience and knowledge to take into clinical practice.

Carrying out an elective in an HIV prevalent area could be beneficial, but understanding the risks and careful planning for their reduction are essential. Other infectious diseases that are ubiquitous in areas with high HIV prevalence are beyond the remit of this article but may well play a part in deciding where to take your elective.

Irrespective of the focus of an elective, HIV positive patients will form part of the patient population. HIV is a systemic disease that can present chronically and acutely, and initial diagnosis may be made in any specialty, provided the doctor has experienced of how it manifests. As the rate of HIV infection increases globally, all specialists will need to know how systemic HIV manifests.

The real risk

Carrying out an elective in areas where the prevalence of HIV/AIDS is high has risks associated, but the risk of transmission through occupational exposure is small (table).^w7-w8 Deeper injuries, larger needle size, visible contamination, and advanced state of the source’s disease—that is, large viral inocula—are factors that raise the probability of transmission.^w8-w10 In 2002 the number of occupationally acquired HIV infections documented among healthcare workers worldwide was 106 definite and 238 possible cases.^w11

Worldwide, the most common route of HIV transmission is through unprotected sexual activity.^w12 HIV is transmitted through blood, semen, vaginal secretions, and saliva. Most infections are acquired through genital-anal and genital-genital routes, however, oral-genital and oral-oral contact still carry risk, particularly in the presence of ulcers, gingivitis, and so on.^w13

Another, often unappreciated, risk is infection with HIV through hospital treatment. This includes, depending on location, the use of non-sterile needles by a doctor. Carrying a personal supply may be advisable should an acute event occur but is not always practical. The risk of acquiring HIV through the transfusion of infected blood is almost 100%,^w14 but screening and tests that make use of nucleic acid amplification in developed countries have reduced the risk to one in two million.^w15

Predicting the risk of HIV transmission through blood transfusion in poor settings is difficult, however, because location—the country, city, and hospital—will play a large part.^w16 A study of samples before transfusion in Kenya estimated that 2% of blood transfusions transmitted HIV.^w17 The World Health Organization estimates that about 5% of HIV infections are transmitted through unsafe transfusions.^w14

Efforts are being made to reduce the risk in poor countries, but two factors make the risk of transmission greater. Firstly the donor blood comes from a population with a greater HIV prevalence, and status may be unknown. Secondly, poor investment in blood banks results in less accurate virus screening than in rich countries.^w18

Limiting risk

Students must be educated and prepared for their elective to avoid putting themselves in danger and to avoid disregarding certain areas altogether because of these risks. As a report by the BMA says, assessing and preventing risk doesn’t mean limiting destination—but limiting risk by appropriate planning and management.^w19 It is important to recognise that although avoiding patients with HIV may be a simple option, we must learn to deal with HIV positive patients in a way that makes both parties comfortable.^w20 Exposure can be minimised with responsible behaviour, good clinical practice, and risk management (box and fig 1¹).^{w7 w10} To make the most of the elective and to have a safe and constructive experience, students may need to seek advice from occupational health centres, general practitioners, and their medical schools.

Fig 1 How to manage exposure to body fluids

Is this relevant?

In many areas of the world, rates of HIV/AIDS are much higher than in the United Kingdom (fig 2²).^{w21 w22} But up to 2004, 68 556 cases of HIV had been reported in the UK, and 21 010 of these patients developed AIDS. In 2004, 7258 new cases of HIV and 183 deaths from AIDS were reported.^w23 Wherever you work in the world, HIV/AIDS is a cause for occupational, social, and medical concern and should be a key part of the undergraduate curriculum. It is important that healthcare workers are aware of the prevalence, presentation, and risks so they can manage their patients and protect themselves.

Fig 2 Global prevalence of HIV infection^w22

An elective undertaken in any specialty in an area with high HIV prevalence is likely to provide experience of HIV presentation in that specialty and often of advanced stages of HIV infection. So it is possible to learn a great deal about the varied presentation of HIV while on elective.

Consider HIV research

HIV/AIDS is a growing international concern, and the elective offers a worthwhile opportunity to focus study on a disease that affects people worldwide. It would be detrimental if stigma and fear turned this into a deterrent to a potentially valuable elective. Exposure to more patients with HIV infection will provide greater contact with, and experience of, the variety of presentations and systemic complications. Systemic manifestations may not be completely documented, and if you are considering a research elective consider researching HIV in the remit of your chosen specialty.

Tomorrow’s doctors will benefit from more awareness of the diversity of HIV presentations, whatever your career or geographical choice, because these patients are not necessarily the ones who present in HIV clinics. By far the greatest risk of HIV transmission is associated with irresponsible social behaviour. Occupational risk is relatively small, and academic pursuit should be made with regard for personal safety.

We thank A Tilzey for advisory input on an earlier version of the manuscript.

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19. BMA Medical Students Committee. Clinical attachments in medicine in the 21st century: Standards for undergraduate education in the new millennium. 2003;12-13
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