Article
It's not what you know but who else knows it.
Sexually transmitted diseases can be extraordinarily divisive. Some will talk freely about the disease process, some will stay silent and some will put aside the scientific discussion and simply react to the situation from their own perspective. Those charged with a role in public health may well react differently from those with a moral agenda, but for those living with the disease the reaction tends to be isolating, unless there is an effective cure at hand to control the spread.
When HIV and AIDS were first recognized as a ‘new’ sexually transmitted disease some 30 years ago, there was no cure and the precautionary restriction of infected healthcare workers (HCW) in the UK was introduced to stop the spread of disease in situations where the infected blood of a clinician might pass to a patient during an exposure-prone procedure (EPP); different categories of risk are recognized. Sadly, the massive transmission of HIV to haemophiliacs who received transfusions of infected blood products arose prior to the introduction of screening of donated blood, which eventually benefited from the same precautionary logic.
The fact that the spread of HIV was rarely recorded in a healthcare setting from clinician to patient over the ensuing three decades is a tribute to minimally traumatic medical interventions, combined with good infection control and the low risk associated with some of the procedures that had been classified as exposure-prone. Apart from the Acer case,1 which provoked criminal overtones, dental transmission has never been recorded.
That low risk, together with the improved standards of infection control and the introduction of combination anti-retroviral therapy (cART) for people living with HIV, meant that the precautionary approach of the last 20 years could be reviewed. Indeed, not to do so would have been both unscientific and an infringement of the Human Rights of the HCWs who were unable to practise their chosen profession.
Readers of Dental Update will already be familiar with the benefits of articles that review the latest evidence base. In this way we can all benefit from the research of a wide spectrum of experts in a given field. The trick, as the editor will know, lies in getting access to those individuals before consolidating their opinions into a consensus view.
When it comes to HIV and dentistry, there is just one forum to approach, but it only meets every four years or so. Fortunately, I was given an opportunity to ask them to consider the evidence base associated with the risk of transmission from HIV positive oral healthcare workers working in a dental setting. As a result, the 6th World Workshop on Oral Health and Disease in AIDS unanimously agreed a consensus statement in April 2009, known as the Beijing Declaration.2 The proceedings of the Workshop and the references were peer reviewed and published in Advances in Dental Research.3 In the intervening years, the three committees advising the Department of Health in the UK have discussed the situation affecting UK healthcare workers with blood-borne disease and, in 2011, the Department of Health announced that it was proposing a change in the regulations affecting HIV positive doctors and dentists.
The Chief Medical Officer, Professor Dame Sally Davies, has now confirmed the removal of restrictions on healthcare workers (HCW) with HIV practising exposure-prone procedures (EPPs) with effect from February 2014 and subject to the conditions published on the Public Health England website.4
All HCWs with HIV who wish to perform EPPs must:
In addition, they need to be registered on a confidential national register. The web-based register, managed by Public Health England, will be available from April 2014. Without that consensus agreement to point to, it would have taken a lot longer to obtain clearance for HIV positive HCWs who wished to continue working once it was safe to do so. But to avoid this article seeming too self-promoting, I have to acknowledge the financial support of Dental Protection in facilitating the lobbying that has occupied the last few years, as well as their legal expertise that was used to take a legal challenge to the Department of Health. A certain Chief Dental Officer once told me that without Dental Protection's input the issue would not have moved up the list of priorities as it did.
Finally, there is a particularly special dentist who bravely agreed to be named in the legal challenge that DPL mounted. Although that identity remains confidential, I want to make my thanks very public.