This guidance, recently added as an advice sheet to TRAVAX (www.travax.scot.nhs.uk), is not ‘official’ in any sense. If used as a basis for advising students, the advice should be confirmed by the medical school responsible, taking any local views or policies into account.
Estimated adults and children newly infected with HIV (WHO data for 2001)
About 14 000 new HIV infections a day occurred during 2001 and more than 95% were in developing countries. 2000 a day were in children under 15 years of age. About 80% of infections were in those aged 15-49 years, of whom almost 50% were women and 50% were 15–24 year olds.
When is a Medical student at risk?
All sexual and blood/blood or blood/body fluid exposures, anywhere, are potentially a risk. Individual risk is greater
- when the ‘donor’ has a high viral load
- early after infection
- when symptoms appear
- when patient is not on anti-retroviral treatment (HAART) and viraemia levels are very high.
Is the risk more in certain countries?
Yes – where more of the local population (especially patients in hospital) are infected due to
- local sexual practices
- contaminated blood transfusions
- poor hygiene with blood and body fluids
- re-using sharp equipment such as needles
- poor medical facilities and infection control knowledge/practice
- poor hygiene in wards and theatres (e.g. with dressings and disposal of soiled materials)
- re-using poorly cleaned equipment
- hastily arranged operations
- insufficient staff trained in infection control
What situation holds the greatest risk for students?
- Risk for the individual is always present – therefore ‘universal precautions’ must be routine practice
- However accidents occur despite the best intentions. Most occur when taking blood samples – i.e. venepuncture. They are more common with inexperience, when tired and when managing ‘difficult’ patients (e.g. in A&E departments), when in unfamiliar situations and using unfamiliar equipment.
- Risk is more during ‘blind’ or ‘bloody’ operations such as emergency surgery, orthopaedics, obstetrics (including Caesarean sections and episiotomies).
Therefore we advise:
- Universal precautions should always be observed (e.g. using gloves, not re-sheathing needles, covering skin breaks on the operator with waterproof plaster, having appropriate disposal containers immediately available and - in the social context - safe sex).
- Students going to high and moderate risk countries should not undertake any invasive procedures including blood sampling - this should obviate the need to carry out ‘post exposure prophylaxis’ (PEP).
If PEP is taken out this should be on the understanding that:
- the implications of infection are serious both personally and for career intentions, so if PEP is used the student should immediately arrange to return home for counselling.
- the effectiveness of PEP after exposure in a medical setting remains unclear and is substantially less than 100%. It must be started immediately after exposure and often causes side effects.