Healthcare workers living with HIV in the UK

Healthcare workers with HIV in the UK will be permitted to carry out exposure-prone procedures from April next year, if they are taking HIV treatment, have regular medical monitoring and have an undetectable viral load.

An exposure-prone procedure is an operation or dental procedure that involves a risk of injury to the healthcare worker that could result in bleeding into the open tissue of a patient. This could present a risk of exposure to HIV.

All healthcare workers who carry out exposure-prone procedures have to have an HIV test. If they test positive for HIV, under current policy, they are not allowed to carry out such procedures.

However, a recent review of this policy and a public consultation concluded that the actual risk of HIV transmission from a healthcare worker to a patient was extremely small.

There’s never been a case of HIV transmission from a healthcare worker to a patient in the UK. Moreover, there is now a lot of evidence that people who are taking HIV treatment that suppresses viral load to undetectable levels are extremely unlikely to transmit HIV to someone else.

The UK Department of Health has therefore developed a new policy. This will allow HIV-positive healthcare workers to conduct exposure-prone procedures while also protecting the safety of patients.

But healthcare workers with HIV will have to meet a number of criteria:

• Notify their occupational health department that they wish to conduct exposure-prone procedures.
• Be taking HIV treatment and have an undetectable viral load (below 50 copies/ml).
• Have viral load monitoring every three months.
• If their viral load is between 50 and 200 copies/ml it should be retested. Individuals whose viral load remains between 50 and 200 copies/ml should have their permission to conduct exposure-prone procedures granted on a case-by-case basis.
• If their viral load increases above 200 copies/ml, the healthcare worker should stop carrying out exposure-prone procedures until their viral load again falls to below 200 copies/ml.

Several other countries already allow HIV-positive medical staff to conduct operations or work as dentists.

Self-testing for HIV to become legal in the UK

The Department of Health announced an important change to HIV testing policy for the United Kingdom last week. From April 2014, HIV self-testing kits approved by the Medicines and Healthcare Regulatory Authority will be available for sale to the public.

HIV organisations have welcomed the opportunity for self-testing, although there are concerns that some people who test positive may not then go on to access specialist HIV care. NHS advice will be that people should follow up a positive test result with a second test at a sexual health clinic or other testing centre to confirm the result.

There were some reports in the media that self-testing kits would be available free of charge through the NHS, but there is no commitment to this at present from the Department of Health.

Home sampling is already legal and available in the UK. This allows someone to take a blood or saliva sample at home and send it off for testing. Home-sampling kits supplied by Terrence Higgins Trust and Public Health England have been available since January 2013 for gay men and African people living in England.

The Mortimer Market Centre, one of London’s largest sexual health clinics, is due to begin distribution of home-sampling kits to gay and bisexual men leaving clubs in the Vauxhall area of south London from the August bank holiday weekend.

HIV/HCV co-infection and kidney disease

New research has shown that people with HIV who clear hepatitis C virus (HCV) co-infection have an increased risk of kidney disease.

Kidney disease is now an important cause of serious illness in people living with HIV, especially in those with hepatitis C co-infection. Researchers in Canada and the US wanted to explore the association between cleared and current hepatitis C infection and the risk of kidney disease.

Their study involved 63,000 people living with HIV who were divided into three groups according to their hepatitis C infection status:

• HIV mono-infection (i.e. only HIV, no hepatitis C).
• Hepatitis C antibodies, but no detectable hepatitis C virus (cleared infection).
• Hepatitis C antibodies and a detectable hepatitis C viral load (chronic infection).

The researchers compared rates of kidney disease between the three groups. All the study participants received care after the introduction of effective HIV treatment in 1996. Just over a third had an undetectable viral load and the average CD4 cell count was approximately 350 cells/mm³. Many of the participants had recognised risk factors for kidney disease such as high blood pressure and diabetes.

Compared to people with HIV mono-infection, individuals who had cleared hepatitis C and those with chronic hepatitis C were significantly more likely to develop serious kidney disease and to experience progression of kidney disease.

The association between cleared hepatitis C and an increased risk of kidney problems remained when the researchers took into account traditional risk factors.

They were surprised by their findings and couldn’t offer a ready explanation. However, they suggest that the increased risk found in people with previous hepatitis C infection could be due to the “effects from drug use, poorer control of HIV infection, lower socioeconomic status, or other unidentified factors”.

HIV and bone loss

A low CD4 cell count before starting HIV treatment is associated with an increased risk of bone loss during the early years of antiretroviral therapy, new research shows.

Infection with HIV is associated with low bone mineral density (BMD) and there is some evidence of an increased risk of fragility fractures. BMD continues to fall after HIV treatment is started. The reasons for this are uncertain. However, it has been suggested that immune restoration could be a cause.

Researchers in the US monitored BMD in approximately 800 people who started HIV treatment between 1998 and 2007.

BMD was checked using DEXA scans before starting HIV treatment and then 96 weeks after starting treatment.

BMD declined by an average of 2% during the course of the study.

However, people with a baseline CD4 cell count below 50 cells/mm³ lost 3% more BMD than people with a pre-treatment CD4 cell count above 500 cells/mm³.

Other risk factors for bone loss included being female, and having a lower body mass index (BMI) and higher viral load.

The researchers believe their research underlines the importance of starting HIV treatment promptly.