Ethical aspects of operating on seropositive patients.

Infection with blood-borne pathogens has long been recognised as an occupational risk for healthcare workers (HCWs), particularly surgeons and anaesthetists whose work often involves breaching the cutaneous or mucosal barrier, exposing them to blood and other body fluids and putting them at risk of acquiring HIV or other blood-borne infections (1). However, in spite of these risks, systems to protect HCWs are not in place.

More than 5% of patients with AIDS require surgical procedures, most commonly in cases of peritonitis, non Hodgkin’s lymphoma, Kaposi’s sarcoma, and appendicitis, and in situations requiring splenectomies or in deliveries requiring a caesarean section.

Exposure to an infected needle, blood or body secretions carries a risk of infection with Hepatitis B (9-30 % with a single percutaneous exposure), Hepatitis C (1-10 % with a single percutaneous exposure), or HIV (0.3 % with a single percutaneous exposure; 0.09% with a mucous membrane splash to the eye, or oro-nasal exposure) (2)

Despite following ‘universal precautions’, accidental exposure may occur while performing invasive procedures and handling body fluids. Our ART centre has more than 9,800 seropositive patients registered, and over five years, more than 60 HCWs here have been given post exposure prophylaxis (PEP) (2).

The risk of occupational transmission of HIV, HBV or HCV is likely to rise among HCWs in resource-poor settings where universal precautions are not practised and patients may not disclose their test reports even if they know their positive status.

Certain policies must be followed strictly regarding management of positive patients.

1. Immediately after exposure, the HCW should notify the designated supervisor for help in completing the incident report.
2. The patient’s blood should be tested for HIV, HBV and HCV (after pre and post test counselling) even if a patient refuses consent, and the results should be kept confidential.
3. Five doses of PEP should be kept in the operating theatre (OT) to be administered within two hours of exposure, routinely, without any panic or delay.
4. If an HCW tests positive, s/he should be allowed to continue working in a different area and receive a special benefit package to cover expenses for treatment, disability and possible loss of life.

Certain general policies must be followed. HCWs with a positive status for HIV and HBV should not work in an OT, or in any department where blood-to-blood contact is likely, to avoid the chances of transmission of blood-borne infections to patients. Although this is not a legal requirement, HCWs must be encouraged to know their HIV status. They should also be vaccinated against HBV and the records maintained confidentially

All OT staff should have a good understanding of risk of contracting infection in the theatre. Simultaneously, special ventilation systems for OTs must be used, and all standard precautions regarding patient preparation, use of protective kits and waste disposal must be implemented.

When operating on known positive cases, separate theatres should be maintained if possible. If not, a minimum of experienced staff should be deployed, excluding students and trainees. Surgical techniques may also be modified to minimise the use of sharp instruments.

No surgery should be postponed on grounds of HIV or HBV positivity test reports. But post-exposure prophylaxis should be available for all HCWs working in the OT, irrespective of their designation. If the patient is seropositive and on ART, his/her viral load and CD-4 count should be retested for better post-operative management. If the patient is diagnosed preoperatively, then after surgery, s/he should be advised to get registered in an ART centre. There may be delayed wound healing in such situations. ART should be re-evaluated and HIV co-infection should be ruled out.

While HCWs must be educated about the protocols to be followed, the importance of being tested when exposed, accepting a positive finding, reporting to superiors, and following up treatment till completion cannot be overemphasised. This applies particularly to new recruits who may be enthusiastic and incautious. There is a considerable lack of awareness among medical and dental postgraduate residents about PEP (3) against accidental exposure to HIV, suggesting a need for training and awareness programmes.