New research by the Journal of Medical Ethics questions whether routine HIV testing of healthcare workers is ethical and should continue.
It reveals that juniors are being inappropriately forced into having HIV tests. Doctors involved say they were unaware that they might need an HIV test as part of their pre-employment occupational health checks until they received the letter from their prospective employer.
They were not given any information about the HIV test or told why they needed to have it - prerequisites of giving informed consent to a procedure - either in this letter or when they actually had a blood sample taken.
It may be a relatively small study - of just 24 junior doctors in four NHS hospital trusts - but the findings are worrying. It suggests that trusts are treating new juniors with a lot less respect and trust than they would a patient.
In 2007, the Department of Health issued new guidance relating to health screening for doctors working in the UK.
It stipulated that all staff should be offered tests for the serious blood-borne viruses hepatitis B and C, HIV and TB to provide reassurance to patients that the healthcare community do not harbour communicable diseases and protect patients from infection.
But the research suggests there are two challenges to its justifiable continuance: firstly, whether it is ethical to screen healthcare workers and, secondly, how the HIV test is being offered.
On the ethics of screening, there have been no cases in the UK of HIV transmission from a healthcare worker to a patient. There have been only three documented cases of transmission worldwide.
The risk of transmission from healthcare workers to patients is in the order of 1 to 42,000; the risk of transmission from a patient to a doctor is 1 in 300. There are clearly few benefits for patients from screening healthcare workers.
On the issue of how the HIV test is being offered, the research shows there’s a lack of understanding by occupational health teams on the indications of the test and little understanding of the implications of a positive result.
Juniors felt they didn’t have the opportunity to ask questions before receiving the HIV test and had concerns over confidentiality. But, most disturbingly, they felt they were forced to have the test even though in the majority of cases it was not compulsory.
The DoH guidance makes it clear that the tests are not mandatory for doctors whose work does not expose them to these viruses, nor are they a prerequisite for employment.
One doctor in the study said: “The only discussion I had with somebody about the test was to say: “We’re going to test you for HIV. Is that OK?” and then being stabbed.”
Another said: “I wonder if they’d have sacked me if it was positive. No one really explained what would happen if it were positive either. Would my bosses have been told about it?”
Only three of the doctors were actually asked about the behaviours that would have increased their risk of acquiring HIV; none felt they had been at high risk.
Few were offered any follow up counselling or discussion, which would have been provided had they been ordinary patients. And most of the doctors did not feel they had the option to refuse the test; only four did so.
It’s a significant problem because each year thousands of junior doctors will be offered an HIV test as they enter their foundation year 1 or move between NHS trusts.
“The unacceptable way in which the HIV test has been offered has far-reaching implications for healthcare professionals already employed in the NHS and future generations of junior doctors and medical students,” says the research.
Research lead Dr Lee Salkeld, ST2 GP trainee at University Hospitals Bristol Foundation Trust, explains: “This is a worrying invasion of the individual healthcare worker’s privacy.
“Would it be reasonable to start introducing depression or alcohol-dependency questionnaires in occupational health checks? The DoH policy shows little regard for the thousands of healthcare workers who have to undergo a needless, stress-inducing, HIV test.”
He also suggests that the money spent on the “unnecessary” HIV testing of healthcare workers should be better utilised.
“This policy isn’t about patient safety, it’s about public reassurance. Time and money would be much better spent educating patients about the real risk of acquiring HIV from their surgeon and improving the safety of exposure-prone procedures,” says Salkeld.
The BMA says it will take on trusts that conduct the health screening of doctors poorly. Dr Andy Thornley, chairman of the BMA Junior Doctors Committee, says: “The behaviour by trusts reported here is outrageous and is tantamount to an assault on the doctors concerned.
“It is shameful that any employer can consider putting staff through such testing without appropriate informed consent. The NHS would not treat patients in this way and so why should it be acceptable treatment for doctors. We would ask any doctors who have experienced this kind of testing for blood borne viruses to contact askBMA to highlight the offending trusts.”
The research proffers two potential solutions. Dr Salkeld says: “Scrap the policy! It’s ineffective and poorly implemented. It fails to improve patient safety. And cost-effectiveness studies performed elsewhere do not recommend the routine HIV testing of healthcare workers.”
However, if the screening policy is retained, the research concludes that: “Many of the criticisms and concerns raised by the doctors could be readily addressed by the occupational health departments of NHS trusts.”
Salkeld explains: “The overwhelming suggestion from the participants in the study was more information about the indications and implications of the test. This can either be through better occupational health practice or uniform literature provided by the DoH.”
A Department of Health spokesperson responded: “National policies on healthcare workers infected with hepatitis B, hepatitis C or HIV are kept under review to take account of changes in the evidence base. We expect that the current review will be completed in late 2009/early 2010.”
