HIV and AIDS
in the Workplace
Since the early 1980s, more than 790,000 cases of AIDS and
457,000 AIDS deaths have been reported to the U.S. Centers for
Disease Control and Prevention (CDC).1 It is
estimated that between 650,000 and 900,000 Americans are
currently infected with HIV. Worldwide, an estimated 22 million
people have died of AIDS, and more than 40 million are infected.
During 2000 alone, AIDS caused the deaths of an estimated 3
million people, and 5.3 million became newly infected.2
Of the total cumulative AIDS cases in the U.S., approximately 85
percent have occurred in persons aged 25-49, substantially
impacting the American workplace. One in six large U.S.
worksites (>50 employees) and one in 15 small U.S. worksites
(<50 employees) have had an employee or employees with HIV
infection or AIDS.3
In addition to the sheer number of young people affected, the
profound impact of AIDS upon the American workplace and the
special attention garnered by the disease have stemmed from a
wide range of sensitive medical, social, and political issues.
From the onset of the epidemic, AIDS struck disproportionately
members of certain stigmatized groups, such as gay men and
intravenous drug abusers, adding layers of complexity to
workplace confidentiality and discrimination concerns. Because
it is an infectious illness, widespread ignorance regarding
disease transmission, particularly during the early years of the
epidemic, led to an increased risk of ostracism at work. The
episodic nature of an illness marked by recurrent opportunistic
infections also presented difficulties to both employers and to
those infected individuals trying to remain occupationally
productive. Today, as more AIDS patients benefit from highly
effective antiretroviral therapy, their re-integration into the
workplace adds yet another layer of complexity.
Occupational and environmental medicine (OEM) physicians,
uniquely positioned as medical professionals responsive to both
employees and employers, play a pivotal role in addressing
issues of HIV infection and AIDS in the workplace. This
guideline of the American College of Occupational and
Environmental Medicine (ACOEM) addresses general issues of HIV
and AIDS in the workplace, including the role of the OEM
physician within the context of the Americans with Disabilities
Act of 1990 and the Family and Medical Leave Act of 1993. In
addition, workplace issues specific to the health care industry,
including the infected health care worker, exposure prevention,
and prophylactic therapy are addressed.
ADA and FMLA
AIDS and HIV infection are considered disabilities under the
Americans with Disabilities Act (ADA) of 1990.4-7 The
Act applies to all employers with at least 15 employees working
at least 20 weeks in the current or preceding calendar year, and
expands upon the protections of the Federal Rehabilitation Act
of 1973, which applied only to workplaces receiving federal
funding.8 Under ADA, discrimination is prohibited in
all employment practices including recruitment, hiring,
promotion, training, layoffs, pay, firing, job assignments,
leave, and benefits. Only individuals who are qualified for a
particular job and who can perform the job, with or without
reasonable accommodation, are protected. Because the act applies
to people with disabilities and perceived disabilities, ADA
protects not only those who are infected with HIV, but also
those who are perceived as such.9-10
The act requires that employers provide “reasonable
accommodation” for disabled employees. Reasonable accommodation
is a change or adjustment to a work environment that permits a
qualified individual to participate in the job application
process, to perform the essential functions of the job, or to
enjoy the benefits and privileges of employment equal to those
enjoyed by employees without disabilities. Reasonable
accommodations must be provided only for known physical or
mental limitations resulting from a disability.
If an individual with HIV infection or AIDS is temporarily
unable to perform the essential functions of the job, she/he may
come under the protection of the Family and Medical Leave Act
(FMLA) of 1993.11 This legislation applies to
employees with at least one year of service (>1,250 work hours
during the year) at a workplace with 50 or more employees within
a 75-mile radius. Under FMLA, HIV infection and AIDS are
considered “serious health conditions,” which may qualify the
affected individual for up to 12 weeks of unpaid leave per
12-month period. FMLA also provides unpaid leave for employees
who must care for a spouse, child, or parent with a serious
medical condition, including HIV infection and AIDS. Employees
may be required to provide advanced notice when the leave is
“foreseeable,” and employers may require medical certification
to support a request for leave, as well as second or third
medical opinions at the employer’s expense.
In order for individuals with HIV infection or AIDS to invoke
the protections of either Act, the disclosure of medical
information to the employer may be required. (Employers are not
required to provide reasonable accommodation under ADA nor
unpaid medical leave under FMLA if they are not informed that a
disability or serious medical condition exists.) If an employee
makes an employer aware of AIDS, HIV infection, or any other
disability or serious medical condition, the law requires that
that information be held in strict confidence, and that it be
maintained in a separate, locked file which is not part of the
personnel file. The handling of sensitive medical information,
as well as the complexities of designing reasonable
accommodations and evaluating the appropriateness of FMLA
leaves, is a process in which OEM physicians should play an
- During the preplacement medical
examination the OEM physician should inquire whether the
newly hired employee is able to perform the essential
functions of the job, and whether any accommodations are
necessary. The physician should be familiar with both the
employee’s job description and the circumstances under which
the employee will work. The decision to disclose HIV status
is the prerogative of the HIV-positive individual, and the
OEM physician should not inquire regarding HIV status, nor
should HIV serological screening be undertaken as part of a
- For employees reporting HIV infection
or AIDS under ADA, reasonable accommodations might include
modifying physical facilities to enhance access,
restructuring jobs, changing schedules, or transferring
marginal functions to another employee. The goal of
accommodations in the general workplace is to address the
medical needs of the affected employee, not to establish
unnecessary precautions against HIV transmission to other
workers. The special case of an HIV-infected healthcare
worker is addressed in the next section. The OEM physician
should work with administrative and supervisory personnel
during the design and implementation process of workplace
accommodations, as well as with the primary healthcare
provider of the employee, to make certain that
accommodations are appropriately implemented. Consistent
with the ACOEM Position on the Confidentiality of Medical
Information in the Workplace, 12,13the OEM
physician should not reveal to managerial/supervisory staff
the employee’s health condition, only the necessary work
- More broadly, the OEM physician should
be intimately involved in the development of institutional
policies addressing AIDS and HIV in the workplace, assuring
that at a minimum such policies encompass the requirements
of ADA and FMLA, and that they are appropriate from medical
and infection control perspectives.
- The OEM physician should assume a
leadership role in the design and implementation of
workplace educational programs around HIV infection and
AIDS, making certain that such programs educate employees
about the following: 1) HIV transmission and prevention; 2)
non-discrimination; and 3) the ADA and FMLA. Depending upon
the specific workplace, employees should also be educated
about the Standard (Universal) Precautions and the OSHA
Bloodborne Pathogen Standard. The OEM physician should also
serve as a resource to provide advice as needed to both
employers and employees about HIV infection and AIDS, and be
prepared to respond to an HIV- or AIDS-related medical
problem with appropriate triage or care.
The HIV-infected Health Care Worker
Of adults reported with AIDS in the United States through June
30, 2000, 22,618 have been employed in health care, representing
5.1 percent of the 445,380 AIDS cases reported to CDC for whom
occupational information was known.14 Of those
infected, 57 were documented by CDC to have acquired their
infections on the job, and another 138 may have acquired HIV
from their job. Health care workers with HIV infection or AIDS
enjoy the same protections under the ADA and FMLA as do
employees in other industries. However, because some healthcare
workers perform medical procedures in which there is a small
risk of viral transmission to patients, they are subject to
Since the onset of the AIDS epidemic there have been two
instances in which health care workers transmitted HIV to
patients. The first was a well-publicized case in which a
Florida dentist transmitted HIV to six patients in his practice.15-19
More recently, a French orthopedic surgeon who likely became
infected on the job in 1983 transmitted HIV to a patient on whom
he performed a 10-hour surgical procedure in 1992.20
Of the 982 other patients who underwent procedures with the same
surgeon, serological testing revealed no other transmissions.21
Numerous serological surveys of patients treated by other
HIV-positive healthcare workers, including dentists, surgeons,
obstetricians, and other physicians, have revealed no other
transmissions of HIV from healthcare workers to patients.22-26
In contrast, more than 350 patients have become infected with
hepatitis B following procedures by hepatitis B-infected health
care workers.27,28 Transmissions have taken place
during dental procedures prior to widespread use of examining
gloves, and during vaginal hysterectomies, major pelvic
surgeries, and cardiac surgeries, and nearly all transmissions
were linked to hepatitis B e-antigen-positive healthcare
providers. Clusters in which hepatitis C was transmitted from
healthcare providers to patients have been recently reported.29,30
The CDC has estimated that the risk for transmission of HIV or
hepatitis B lies between 1/42,000 and 1/420,000.31
On July 12, 1991, the CDC issued guidelines addressing HIV
and hepatitis B infection of health care workers, particularly
among those who performed certain “exposure prone” procedures.32
The guidelines stated that infected health care workers who
adhere to universal precautions and who do not perform invasive
procedures pose no risk for transmitting HIV or hepatitis B to
patients, but that those who perform certain exposure prone
procedures pose a small risk for transmitting hepatitis B or
HIV. Exposure-prone procedures were characterized as those in
which a needle tip was digitally palpated in a body cavity, or
those in which a health care worker’s fingers and a needle or
other sharp instrument or object are simultaneously present in a
poorly visualized or highly confined anatomic site. Initial
efforts to develop standard lists of procedures meeting these
criteria were abandoned shortly after the guidelines were
The guidelines stated further that health care workers
performing exposure-prone procedures should know their HIV
antibody status, and if non-immune to hepatitis B, their
hepatitis B surface antigen and hepatitis B e-antigen status.
Health care workers infected with HIV or hepatitis B (and
e-antigen positive) were further instructed not to perform
exposure-prone procedures unless they had sought counsel from an
expert review panel and been advised under what circumstances,
if any, they might continue to perform these procedures. Such
circumstances would include notifying prospective patients of
the health care worker’s seropositivity before they underwent
exposure-prone invasive procedures. Mandatory testing of health
care workers for HIV antibody, hepatitis B surface antigen or
hepatitis B e-antigen was not recommended.
Several court decisions have rejected health care workers’
discrimination claims regarding forced alterations of medical
practice.33 The Fifth Circuit Court of Appeals held
in 1994 that a hospital did not violate the Rehabilitation Act
of 1973 in reassigning an HIV-positive surgical assistant to a
position as procurement assistant in a purchasing department.34
A New Jersey court held that a hospital’s policy of restricting
an HIV-infected surgeon’s staff privileges was substantially
justified by a reasonable probability of harm to the patient.35
A U.S. District Court found in favor of a hospital which
suspended, then reinstated a surgeon’s privileges contingent on
his informing patients of his HIV status before he performed an
A number of professional organizations also responded to the
July 12, 1991, guidelines. The Society for Healthcare
Epidemiology of America (SHEA) distinguished the very low
potential for transmission of hepatitis C and HIV from the
somewhat higher potential for transmission from a hepatitis B
e-antigen positive health care worker performing invasive
procedures. SHEA also stated that patients should not be
informed of a surgeon’s serological status unless a clear
exposure had taken place.38
The American College of Physicians (ACP) and the Infectious
Disease Society of America (IDSA) generally reflected the CDC
Guidelines, but stressed the need for case by case evaluations
of practice restrictions and the ethical obligations of
individual physicians.39 The American College of
Surgeons (ACS) distinguished between HIV and hepatitis B,
stating that HIV-infected surgeons should be allowed to continue
to practice and perform invasive procedures unless there were
clear evidence that a significant risk of transmission existed,
but that surgeons who were hepatitis B e-antigen positive should
seek counsel from an unbiased expert review panel.40,41
In contrast, the American Academy of Orthopedic Surgeons
(AAOS) stated that HIV-infected orthopedic surgeons should not
perform invasive surgical procedures where there is substantial
risk that the patient will come into contact with the surgeon’s
blood. AAOS was the only professional organization which sought
to define “exposure-prone” procedures, characterizing them as
those of long duration involving blind probing or use of
internal fixation devices or implanted wires.42 The
American Hospital (AHA) stated that if an expert panel has
already made a determination that a health care worker poses no
reasonable risk to a patient, disclosure of the health care
worker’s infection status unnecessarily invades the health care
worker’s privacy. AHA stated further that providing patients
with the HIV status of their caregivers is unacceptable.43
In consideration of the minimal additional evidence for
transmission of HIV from health care workers to patients in the
10 years since CDC’s Guidelines were issued, ACOEM makes the
following position statement with regard to the HIV-infected
health care worker:
- The HIV-infected health care worker
should practice standard (universal) precautions at all
times. Health care workers who perform invasive procedures
should know their own HIV status. HIV-infected health care
workers who carry out invasive procedures should double
glove during all procedures and minimize to the extent
possible digital palpation of needle tips and blind probing
in poorly visualized or highly confined anatomic sites.
- Based on the accumulated evidence,
ACOEM does not consider that any invasive medical procedure
has distinguished itself as “exposure-prone” with respect to
HIV transmission from health care worker to patient. Hence,
ACOEM finds no basis to otherwise restrict the practice of
health care workers infected with HIV who perform invasive
procedures, and does not support notification of patients of
a health care worker’s HIV status unless an exposure has
- ACOEM does not support notification of
patients of a health care worker’s serological status with
respect to HIV unless an exposure has taken place.
HIV Exposure Prevention:
On November 6, 2000, President Clinton signed federal
legislation, the Needlestick Safety and Prevention Act, to amend
the OSHA Bloodborne Pathogens Standard (29 CFR 1910.1030).44
On January 18, 2001, the Final Rule appeared in the Federal
Register with a scheduled implementation date 90 days following
publication.45 The amendment requires that employers
review and update their Exposure Control Plans required under
the Bloodborne Pathogens Standard to “reflect changes in
technology that eliminate or reduce exposure to bloodborne
pathogens,” and “document consideration and implementation of
appropriate commercially available and effective safer medical
devices designed to eliminate or minimize occupational
exposure.” In addition, employers are required to establish and
maintain a sharps injury log to record percutaneous injuries
from contaminated sharps. The log must be maintained in such a
manner as to protect the confidentiality of the injured employee
and it must contain information regarding: 1) the type and brand
of device involved in the incident; 2) the department or work
area where the exposure incident occurred; and 3) an explanation
of how the incident occurred. Employers must also solicit input
from non-managerial employees responsible for direct patient
care to assist in identifying, evaluating, and selecting
effective safety devices and work practice controls.
The Needlestick Safety and Prevention Act was the federal
government’s response to a substantial body of evidence that
safer medical devices are associated with reductions in
percutaneous injuries among health care workers. Significant
reductions in injury rates among health care workers have been
demonstrated for phlebotomy devices with engineered safety
features and for needleless intravenous delivery systems.46-49
Several studies have documented reduction in percutaneous injury
rates among operating room staff following implementation of
blunt needles for certain procedures.50-52 In
addition, a number of studies have demonstrated the benefit of
educational programs addressing safe use of phlebotomy equipment
and safe methods of operating room instrument usage.53-58
- ACOEM enthusiastically embraces the
amended Bloodborne Pathogen Standard as an effective piece
of legislation to reduce percutaneous injuries and the risk
of bloodborne pathogen transmission to health care workers.
- OEM physicians in practice settings
where employees have potential bloodborne exposures should
involve themselves substantially in workplace education
efforts addressing bloodborne pathogen exposure reduction.
Such educational programs should address standard
(universal) precautions, proper usage of specific medical
devices, and procedures for immediate exposure triage.
- OEM physicians should take a
leadership role in identifying and implementing safety
devices in the workplace, conducting institutional reviews
of sharps injury logs to determine the circumstances under
which exposures occur, and working with other professionals
in the healthcare setting toward effective solutions.
Acute Exposure to HIV
On June 7, 1996, the U.S. Public Health Service (USPHS)
published provisional recommendations for chemoprophylaxis after
occupational exposure to HIV, which were made final May 15,1998,
and updated June 29,2001.59,60,82 The USPHS
recommendations were based primarily upon a case-control study
of health care workers who seroconverted following HIV-positive
blood exposures, a clinical trial of zidovudine administration
to HIV-positive pregnant women, and a number of animal studies
of antiretroviral prophylaxis. The case-control study assessed
risk factors for seroconversion in 33 health care workers who
became HIV positive following bloodborne occupational exposure
to HIV.61,62 Compared to a control group who did not
seroconvert, cases were significantly less likely to have used
anti-retroviral prophylactic medication (zidovudine) when
adjusted for other HIV transmission risk factors. The second
study cited in support of the guidelines was the AIDS Clinical
Trials Group protocol 076, in which zidovudine was administered
to HIV-positive pregnant women.63,64 The trial was
halted due to the markedly lower transmission of HIV to the
fetus in the treated vs. the placebo group (7.6 percent
transmission in treatment group, 22.6 percent transmission in
placebo group, p<0.001). Viral load testing at a later date
revealed that a relatively small proportion of the difference
could be attributed to reduction in maternal viral load,
suggesting that zidovudine may have acted prophylactically in
the fetus.65 Animal studies have shown mixed results,
but generally have demonstrated a greater effect when
medications were administered immediately following exposure.66-69
The current guidelines stratify exposed health care workers
into risk levels based on source patient characteristics and
nature of exposure. Combination therapy with antiretroviral
agents is tailored to risk level and probable patterns of
resistance in the source patient virus.
Several authors have reported on the experiences of large
medical centers in implementing the USPHS Guidelines, pointing
out a number of challenges for the OEM physician practicing in
such settings. More often than not, the HIV status of the
patient to whom the health care worker is exposed is not known
at the time exposure occurs. Because of frequent logistic
difficulties in obtaining blood from the source patient, many
health care workers receive prophylaxis as a precautionary step
while awaiting source patient HIV testing. Most such individuals
are later demonstrated to have been exposed to HIV-negative
source patients, and are treated for fewer than four days.70,71
However, despite the importance of source patient serological
testing, some authors have reported that it is obtained in only
about 50 percent of cases.72,73
Because prophylactic medications should be administered as
rapidly as possible, emergency departments are often relied upon
to carry out the initial evaluations of exposed health care
workers on nights and weekends when on-site occupational health
clinics are not open. This requires both familiarity of
emergency department clinicians with the USPHS Guidelines and
concerted efforts to coordinate follow-up testing, treatment,
and counseling. Coordination of exposure evaluation and
treatment by the OEM physician is even more challenging when
occupational health clinics serve exposed personnel who do not
work within the hospital environment, (e.g., police officers,
firefighters, and nursing home employees), or when they serve
health care workers employed in HIV-endemic areas of the
developing world where antiretroviral medications may not be
immediately available in the event of exposure.74
Although the USPHS Guidelines are based on best evidence to
date, ACOEM recognizes that issues remain to be resolved
regarding whether and to what degree combination antiretroviral
therapy may benefit HIV-exposed health care workers. To date,
epidemiological studies of prophylaxis in healthcare workers
have evaluated only the effect of zidovudine.61,62 A
recent study revealed possible benefit of combination
antiretroviral therapy following potential non-occupational
exposure to HIV through sexual contact or injection drug use.75
Although none of 401 participants taking post-exposure
prophylaxis became infected with HIV, it is not known how many
study participants were actually exposed to HIV. Laboratory
studies of health care workers exposed to HIV also leave
unanswered questions. It has been shown that individuals exposed
to HIV who do not seroconvert may develop markers of T-cell
mediated response to the virus,76-78 but that
HIV-exposed health care workers treated with antiretroviral
prophylaxis are less likely to develop the response.79
It is not known whether that indicates non-viability of the
virus in the setting of early prophylactic therapy. To date,
there have been 22 cases of HIV seroconversion among health care
workers despite use of prophylaxis, and 6 of those cases were
administered combination therapy.80 The side effects
of antiretroviral prophylaxis also cannot be ignored. The recent
report of an HIV-exposed health care worker who suffered
fulminant hepatic failure requiring liver transplantation
following antiretroviral prophylaxis with a nevirapine-containing
regimen strikes a particularly cautionary note.81
Because a randomized, placebo-controlled clinical trial of
antiretroviral prophylaxis is not likely to take place, judgment
regarding the efficacy of currently recommended prophylactic
regimens awaits the accumulation of sufficient numbers of
exposed subjects for additional retrospective studies to be
- OEM physicians who treat health care
workers or other individuals with potential for exposure to
bloodborne pathogens should thoroughly familiarize
themselves with current CDC guidelines for evaluation and
treatment of such exposures.
- OEM physicians should ensure that
workplaces for which they have responsibility provide
training for employees addressing immediate steps to take in
the event of a potential bloodborne pathogen exposure.
Medical coverage should be available 24 hours/day to
evaluate and treat exposures, assess exposure risk, provide
counseling, and administer post-exposure prophylaxis where
appropriate. OEM physicians who treat exposures should be
familiar with the pharmacologic action, toxicities and drug
interactions of antiretroviral medications.
- OEM physicians who treat workers with
potential for exposure to bloodborne pathogens should be
aware of possible drug resistance in the viral strains to
which their patients are exposed, and combination
antiretroviral therapeutic regimens should be designed
appropriately. When exposure occurs to a source patient who
may harbor resistant virus (based on that patient’s clinical
course, history of antiretroviral medication use, or
patterns of viral resistance in a community), expert advice
should be sought from an infectious disease physician,
ideally one familiar with the source patient’s clinical
course. Initial therapy, however, should not be delayed
while an ideal therapeutic regimen is designed, and the OEM
physician should strive to initiate prophylactic treatment
as soon as possible following exposure.
- Although it has been recommended in
the past that prophylaxis should begin within 1-2 hours
following exposure, the time period after which initiation
of prophylaxis is no longer indicated has not been
established. When an exposed individual does not seek
evaluation and treatment until many hours after exposure,
initiation of prophylaxis may still be indicated, even if
the interval since exposure exceeds 36 hours.
- Because the HIV serology of a source
patient is often not known at the time of exposure, the OEM
physician should base initiation of prophylaxis on an
assessment of the likelihood of source patient HIV
positivity. Testing of the source patient’s blood should be
accomplished as quickly as possible and applicable state
laws regarding that process should be followed. A rapid HIV
assay, which can provide a result within hours, is
recommended in order to minimize the amount of medication
taken by individuals exposed to HIV-negative patients. Once
the source patient is established to be HIV-negative,
prophylaxis should be discontinued.
- Individuals exposed to HIV-positive
source patients and prescribed antiretrovirals should be
monitored for the specific side effects associated with
those medications, and prophylaxis should be administered
for a 4-week period. Serological follow-up to determine
whether HIV seroconversion has taken place should be carried
out at 6 weeks, 3 months, and 6 months following exposure.
ELISA testing is currently considered to be the test of
choice for such monitoring. If an individual is exposed to
both HIV and hepatitis C, and becomes infected with
hepatitis C, monitoring for HIV seroconversion should be
extended to 12 months, due to a possible delay of HIV
seroconversion in hepatitis C-infected individuals.83
Since the onset of the HIV epidemic, AIDS and HIV infection have
presented tremendous challenges to infected individuals seeking
to remain productive in the workplace, to employers coping with
the special needs of such individuals, and to physicians who
treat and counsel exposed or infected personnel. OEM physicians
should strive to ensure that employers are familiar with
legislation and guidelines protecting the rights of infected
employees, and support rational workplace policies applying to
employees with HIV infection or AIDS. Where there is potential
for occupational HIV exposure, OEM physicians should assure that
adequate training around exposure prevention, triage, and
treatment is provided. OEM physicians who treat individuals with
occupational HIV exposures should involve themselves in
institutional efforts to prevent exposures through use of safer
devices and procedures, and should assure that immediate and
adequate clinical evaluation of exposures is available at all
This ACOEM guideline was prepared by Mark Russi, MD, chair of
the College’s Infectious Diseases Committee under the auspices
of the Council on Scientific Affairs. It was peer-reviewed by
the committee and council and was approved by the ACOEM Board of
Directors on October 12, 2001. Dr Russi is Associate Professor
of Medicine at Yale-New Haven Hospital in New Haven, Conn.
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