(HIV and HBV) for DDS Clients
August 1997
PURPOSE:
The purpose of this advisory is to provide standardized guidelines and procedures which reduce individuals' risks of exposure to and infection with bloodborne pathogens such as hepatitis virus and human immunodeficiency virus (HIV). Additionally, this advisory details procedures which ensure compliance with State and Federal law.
APPLICABILITY:
* This advisory applies to all individuals of the department who are under the care and treatment of the Commissioner.
The department recognizes the special need to work with facilities which it does not fund or license to ensure the thorough understanding and implementation of medical advisories.
* This advisory does not apply to employees. Procedures for DDS employees are detailed in DDS Personnel Directives and in regional OSHA Exposure Control Plans. Private agency employees should refer to agency personnel policies.
DEFINITIONS:
AIDS:
Acquired immunodeficiency syndrome is the result of a progression of infection with Human Immunodeficiency Virus (HIV) which destroys the body's immune (defense) system and permits usually controllable infections and malignancies to invade the body, leading eventually to death. (See Attachment A for Centers of Disease Control and Prevention (CDC) definition and information on AIDS surveillance data)
Bloodborne Pathogens:
Pathogenic micro-organisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to hepatitis B & C (HBV & HCV) and human immunodeficiency virus (HIV).
Confidential HIV Related Information :
Any information pertaining to an individual concerning whether a person has been counseled regarding HIV infections, has been the subject of an HIV related test, or has HIV infection, HIV related illness, or AIDS or information which identifies or reasonably could identify a person as having one or more of such conditions, including information pertaining to such individual's partners.
Direct Sexual Contact:
Anal, vaginal, and/or oral sexual intercourse, with anal intercourse posing the highest risk and oral intercourse posing less risk in regards to possible HIV or HBV infection.
Hepatitis B & C Virus:
Hepatitis B Virus and Hepatitis C Virus (and Hepatitis D which only occurs in conjunction with Hepatitis B), are the two major types of hepatitis virus which are transmitted via blood and blood products. Hepatitis A and E virus, transmitted via the fecal/oral route from infected food (mollusks), water and fecal material from infected individuals, are not discussed in this advisory.
HIV Antibody Positive:
An individual with positive ELISA blood test (or other screening tests) and a positive confirmatory immunofluorescent antibody (IFA) or Western Blot blood test, demonstrating presence of past infection with the human immunodeficiency virus (HIV).
NOTE: It takes between two weeks and six months after infection, for HIV antibodies to develop (i.e. the "window period"). A person can transmit HIV any time after infection, including during the window period.
Potentially Infectious Body Fluids:
Blood, semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, pericardial fluid, peritoneal fluid, amniotic fluid, saliva in dental procedures, and any body fluid that is visibly contaminated with blood.
Significant Exposure Incident:
A parenteral (e.g. IV, under the skin, intramuscular) exposure such as a needlestick or cut, or mucous membrane exposure such as a splash to the eye or mouth, to blood or a cutaneous exposure (skin) involving large amounts of blood or prolonged contact with blood, especially when the skin is chapped, abraded, or afflicted with dermatitis. CGS 19a-581(14) (See Attachment B)
Connecticut Regulations of State Agencies Section 19a-589-1 (o) (See Attachment C) further defines significant exposure as:
- contact between the mucous membranes (e.g. mouth & eyes) and at least one of the following: blood, a body fluid containing visible amounts of blood, cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, amniotic fluid;
- contact through the skin (such as contact through an open wound or cut or by means of a needlestick or puncture wound injury) with at least one of the [body fluids listed above];
- contact of skin, especially when the exposed skin is chapped, abraded or afflicted with dermatitis or the contact is prolonged or involving an extensive area, with at least one of the [body fluids listed above and];
- sexual assault (involving anal, vaginal or oral intercourse) on a worker in the course of his or her occupational duties.
As defined in Connecticut Regulations of State Agencies Section 19a-589-1 (p), a significant exposure does not include:
- exposure to urine, feces, sputum, nasal secretions, saliva, sweat, tears, or vomitus, unless the fluid in question contains visible amounts of blood;
- human bites or scratches, unless there is direct blood to blood or blood to mucous membrane contact; and
- any exposure that would otherwise constitute a significant exposure, if the person exposed already has HIV infection.
Universal Precautions:
Infection control procedures for handling blood and other potentially infectious body fluids as defined by the Centers of Disease Control (CDC) which assumes that all of these body fluids are potentially infectious.
DISCUSSION:
I. INFECTION CONTROL
It is essential that protection against exposure to the body fluids and other pathogens of all individuals be consistently carried out. Basic infection control practices, combined with properly applied procedures which limit contact with body fluids, especially blood, semen, and vaginal fluids, can prevent the transmission of bloodborne diseases such as hepatitis and human immunodeficiency virus (HIV). Please refer to regional/training school or agency policies and procedures for specific infection control information.
A. Universal Body Fluid Precautions
Universal body fluid precautions is an approach to infection control which considers everyone's blood and other body fluids listed above, as potentially infectious. Use of these precautions will:
- minimize the likelihood of transmission of bloodborne viruses such as HIV and Hepatitis B & C;
- minimize the likelihood of transmission of infectious agents found in other body fluids, such as shigella, hepatitis A, salmonella, giardia, and other viral agents that may cause gastroenteritis;
- encourage consistency in infection control practices; and
- increase confidentiality for individuals who are infectious since the same precautions are used for everyone.
B. Mode of Transmission
1. Hepatitis B (HBV) and Hepatitis C (HCV)
a. Hepatitis B is primarily transmitted by:
- direct sexual contract with an infected person;
- shared hypodermic needles or syringes contaminated with blood of an infected person; and/or
- transfusions of contaminated blood or blood products.
b. Hepatitis C is most commonly transmitted by
- shared hypodermic needles or syringes; and/or
- transfusions of contaminated blood or blood products.
(In the USA, HCV is not generally transmitted via sexual contact.)
2. Human Immunodeficiency Virus (HIV)
a. Transmission of HIV is primarily limited to intimate contact with blood, semen or vaginal fluids via
- direct sexual contact with an infected person;
- shared hypodermic needles and syringes contaminated with the blood of an infected person;
- an infected mother to her unborn or newborn child; and/or
- transfusions of contaminated blood or blood products.
b. Transmission of HIV has occurred to health care workers who had extensive superficial skin contamination with HIV infected blood.
c. Although HIV has sometimes been found in low levels in saliva, tears, and urine of infected individuals, contact with these fluids poses a negligible risk of transmission because of the minimal concentration of the virus in these body fluids.
d. Extensive medical evidence indicates that there is no risk of transmission by casual or close, nonsexual or non blood-to-blood contact with an infected individual. HIV infection cannot occur by:
- touching an object handled by an infected person;
- eating food prepared or served by an infected person;
- touching, hugging or casual (cheek) kissing an infected person;
- using the same toilet seat; or
- saliva contact with another person's intact skin.
II. PLACEMENT DECISIONS
No person who meets criteria for DDS services or funding shall be excluded from participation solely on the basis of his or her HIV or HBV/HCV status. Placement decisions shall not result in unreasonable restriction for persons who are HIV positive or hepatitis B carriers. Such individuals shall not be routinely isolated or segregated. Hazards unique to the person shall be handled individually and the person shall be allowed the greatest degree of freedom within the parameters of good health practices.
A. Individuals whose HBV status is not known shall be tested and vaccinated if appropriate and as directed by the individual's physician.
B. Individuals shall not be tested for HIV as a part of a placement decision process. Testing shall be done only as recommended by the individual's physician for valid health reasons.
C. Decisions related to residence, participation in various activities, work or school, shall be based on an evaluation, conducted by health professionals, of the individual's health and communicability status.
D. Elements to be considered in the evaluation process include, but are not limited to:
1. the individual's sexual activity;
2. the individual's personal hygiene (incontinence, menstrual care, and other such considerations);
3. the presence of assaultive behavior;
4. the presence of open or oozing lesions; and
5. the presence of indwelling catheters, feeding tubes, tracheostomies, or other similar devices.
E. For decisions involving HIV antibody positive individuals, consent to release HIV related information shall be obtained from the individual or his or her legal guardian (see Section III, B, pp. 7-10). Such consents shall name each person who shall participate in the evaluation process. Persons receiving this information shall be identified based on a "need to know" and may include the individual's:
1. DDS regional health service director or training school medical director;
2. DDS case manager;
3. DDS regional or training school director; and
4. day and/or residential manager(s).
All parties involved shall comply with the CGS 19a-581 through 19a-590 regarding AIDS related testing, medical information, and confidentiality.
III. CONFIDENTIALITY
A. Hepatitis Confidentiality
Information regarding hepatitis shall be handled confidentially in the same manner as any other confidential medical information.
1. As with all medical information, hepatitis related information shall be released to the individual's health providers and to others on a need to know basis as determined by the person's IDT and only after obtaining the consent of the individual or his or her legal guardian.
2. All persons shall maintain strict confidentiality of an individual's medical information, including hepatitis status. Any person disclosing confidential information without legal consent shall be subject to disciplinary action.
B. HIV Confidentiality
Connecticut General Statutes Section 19a-581 through 19a-590 provide direction for areas such as consent for testing and disclosure of HIV related information. These statutes should be carefully reviewed and referenced whenever HIV testing is contemplated or when HIV related information is requested or received. (See Attachment B)
All parties shall maintain strict confidentiality as directed in the above mentioned statutes. Any person who discloses confidential HIV information including information regarding requests for testing, without legal consent as defined in statute shall be subject to disciplinary action.
Any person who willfully violates Connecticut law regarding confidential HIV information shall be "liable in a private cause of action for injuries suffered as a result of such violation." (CGS 19a-590).
1. Testing
a. Individuals shall NOT be routinely tested for HIV. If testing is indicated for valid health reasons as recommended by the individual's primary care physician, it shall be done in accordance with CGS 19a-582.
b. When HIV testing of an individual is requested by an employee due to a significant exposure incident, procedures presented in CGS 19a-582(d)(5) and DDS or agency personnel procedures shall be followed.
c. If an exposure incident occurs between two individuals who are individuals of the department, or an individual of the department and a non-DDDS employee, a procedure similar to the process detailed for an occupational exposure [CGS 19a-583 (7)] significant exposure incident shall occur as follows:
- The alleged exposure incident shall be reported to the appropriate manager and to the DDS regional health service director/STS medical director or designee, and shall be documented on a DDS incident report form within 48 hours, maintaining strict confidentiality.
- The DDS health service director/STS medical director shall ensure that an evaluation is conducted by a physician to determine whether the incident constitutes a significant exposure.
- If the event is determined to be a significant exposure, the DDS health service director or STS medical director shall assist in obtaining consent to test the alleged victim within 72 hours of the incident and if negative for HIV antibodies, shall assist in obtaining consent to test the alleged perpetrator.
- If an individual(s) (individual) involved is not competent to grant consent for testing and he or she does not have a legal guardian, a temporary medical guardian shall be obtained immediately.
- If the alleged perpetrator or his or her legal guardian refuses voluntary consent to test for HIV antibodies, the DDS health service director/STS medical director shall notify the central office director of health and clinical services.
- The director of health and clinical services shall seek advice from the Office of the Attorney General, notify appropriate individuals, make recommendations, and assist with further actions.
2. Release of Confidential HIV Information
a. As per CGS 19a-581(9), confidential HIV related information shall be released only with written authorization which is signed by the individual or his or her guardian on a document which:
- is dated;
- specifies to whom disclosure is authorized;
- states the purpose for the disclosure; and
- states the time period for which the release is to be effective.
b. HIV related information shall NOT be released as part of a general authorization for release of other medical information unless the authorization specifically indicates this dual function and complies with the consent requirements outlined above.
c. Employees who have direct or indirect knowledge regarding HIV related information for any individual, shall not disclose or discuss this information with anyone who has not been identified on the HIV consent document, even if the individual chooses to discuss this information with others. (Staff who have legally authorized knowledge of an individual's HIV status per section 2 (a) above, should counsel the individual regarding this concern.)
d. HIV related information shall be released to DDS licensing and IPR/UR inspectors and to the Department of Public Health (DPH) ICF inspectors as part of an official licensing or review process as authorized under CGS 19a-583(6). These inspectors shall be subject to the confidentiality standards in section c above.
3. Receipt and Maintenance of Confidential HIV Information
a. Regions and agencies shall develop policies and procedures for ensuring the confidentiality of HIV related information. This information may be kept in the individual's DMR health records or master file only if all persons who have access to such records are identified on an HIV release of information consent document.
b. If HIV information is maintained in separate health files, regional and agency policies shall indicate the process for sharing this information when medically necessary and shall make this information available to DMR and DPH inspectors during the inspection/review processes.
c. If written HIV information is obtained in error, it shall be returned to the source. The receiver shall be held to strict confidentiality and shall not release the information either verbally or in writing.
d. If HIV related information is given in error verbally, the person receiving this information shall inform the reporter that such confidential information may be shared only within the parameters defined in statute. The receiver shall direct the reporter to obtain legal consent prior to any further release of information and to release the information only to the parties identified on the consent form. The receiver shall be held to strict confidentiality and shall not release the information either verbally or in writing.
IV. EDUCATION and PROTECTION OF INDIVIDUALS
A. Individuals who are competent to consent, shall receive education and counseling regarding infectious diseases, including the risk for and prevention of sexually transmitted diseases such as HIV and hepatitis. Such training and/or counseling shall be addressed as part of the individual's overall plan of service based on the needs of the individual.
B. For cases in which individuals are adjudicated incompetent (not competent to consent) or have been assessed to lack the capacity to understand safe sex practices, the individual's interdisciplinary team (IDT) will make reasonable efforts to protect the individual from unwanted or unsafe sex. These efforts may include increased supervision, a change of roommates, or other actions as determined by the individual's IDT.
C. When HIV testing is recommended for an individual, the individual's IDT and/or other staff who have legal consent for HIV related information per Section 2 (a) above, shall ensure that education and counseling is provided prior to such testing as required by CGS 19a-582(c).
D. The individual's IDT members and/or other staff who have legal consent for knowledge of HIV status per Section 2 (a) above, shall provide or secure counseling for individuals who are HIV antibody positive and for their families, if families have been informed with the individual's written consent per CGS 19a-581(9).
V. TREATMENT of HEPATITIS and HIV INFECTIONS
Diagnosis, treatment, and follow-up care shall be provided as recommended by the individual's primary care physician with referral to specialists as appropriate.
Attachments: (Not all are available online - see Regional Contact)
Attachment A: CDC definition and information on AIDS surveillance data
Attachment B: CGS 19a-581(14)
Attachment C: Connecticut Regulations of State Agencies Section 19a-589-1 (o)