Reason, not panic should be the response of management to the question of AIDS in the workplace. Except in an extremely restrictive sense in a narrow range of occupations, AIDS is not an occupational disease. There are, however, important isues that must be discussed if concern over AIDS in the general workplace is to be dealt with in a rational way. This chapter is written to provide essential information at a level of understanding suitable for sharing with managers and workers.
Firstly, it is important to be clear on the meaning of important terms. The medical condition AIDS (acquired immunodeficiency syndrome) is a terminal illness with no presently known cure. It is caused by the human immunodeficiency virus (HIV) which attacks the body's immune system and commonly also the central nervous system. The virus attacks the cells responsible for maintaining immunity and actually invades their genetic material permanently. As a result, the body's defense mechanisms can no longer fend off certain disease-causing organisms and some rare cancers which normally would be easily repelled. It is these so-called opportunistic infections and cancers which cause the affected person'sdeath. AIDS-related complex (ARC) is a medical condition also caused by HIV infection and is characterized by swollen lymph nodes and systemic symptoms. Unfortunately, many other diseases resemble ARC although AIDS itself is characteristic in its history and signs. About 20% of persons infected with HIV will develop ARC in five years; of them 15% develop AIDS itself in 5 years. It is not known whether everyone infected with HIV will ultimately develop ARC or AIDS over the years or only a fraction of those exposed.
HIV is not easy to transmit. In the workplace, there are only a few unusual situations where a risk of becoming infected might plausibly exist. These are in the health care professions where nurses or laboratory personnel handle blood from infected people. An injury such as a needlestick with actual injection of some amount of blood or prolonged contact of contaminated blood with an open wound on the body of the worker may allow the virus to enter the worker's bloodstream directly. Both circumstances are known to have actually occurred but both situations are extremely unusual and are completely preventable by the use of sensible guidelines now in force at all hospitals and laboratories. Otherwise, HIV spreads from one person to another only through sexual contact (by vaginal secretions and especially semen) and direct entry into a person's blood (such as sharing IV needles or during the pregnancy of an infected mother, when the fetus and neonate are at risk). The virus must actually enter the bloodstream of the recipient before infection can occur; contact with normal skin is not enough. It does not spread like the common cold or with the relative ease of other sexually transmitted diseases. It is not even spread as easily as other viruses, such as hepatitis B, for which existing guidelines have been proven effective. The fact that HIV could be spread by blood and certain blood products led to further tragedy when patients who received blood transfusions and hemophiliacs who received blood products became infected as a result of contaminated blood from infected donors. In North America, this problem now has been practically eliminated by screening of each blood donation but this was not available until 1985. It should be apparent therefore that if entry of a quantity of virus into the blood of the recipient is necessary to establish an infection, HIV cannot be spread by casual contact, by mere proximity to an infected person or by touching.
Since the AIDS virus is not spread by casual contact or by contaminated food, only those occupations which come into contact with blood, semen and vaginal secretions present a problem of potential infection. The health professions already know how to deal with highly infectious material. Barbers, morticians, policemen, prison guards, and ambulance attendants and others in those professions who could conceivably come into contact with blood may wish to take simple precautions but using standard hygienic practices will keep the risk extremely low. For one thing, HIV is a very fragile virus outside the protected environment of the body. It survives for only a short time exposed to air and dry conditions and can be killed by virtually any disinfectant, including common household bleach and by soap and water. There is no evidence or likelihood, for example, that sharing a respirator or face mask could transmit HIV. Concern over the possibility that respirators and face masks might spread HIV has emerged time and again among workers who fear that it could happen. Since this groundless fear could cause a worker to fail to use personal protective equipment under hazardous conditions or in an emergency, it is a dangerous falsehood.
AIDS is spread primarily by unsafe sexual practices and by sharing needles, as commonly occurs among drug users during illicit intravenous drug use. Such practices obviously have no place in the legitimate workplace. What workers and their managers do on their own time may place them at risk if they engage in risky behavior such as unprotected sexual intercourse, especially by the anal route. So what are the issues for the workplace?
In the general workplace the risk of spreading or contacting HIV infection is virtually nil. The important issues, therefore, include the need for fair employment practices for people with AIDS or HIV-infected persons so they are neither feared nor discriminated against. An AIDS awareness program in the workplace would ensure that employees learn the facts about the disease, especially what to do about preventing its spread.
When the virus enters the body, it stimulates a slow and ineffective immune reaction. This immune reaction usually produces specific antibodies (small bits of protein that attack elements of the virus in a vain effort to destroy it). These antibodies appear weeks to months after initial infection. Although they do not appear to protect the person against any of the effects of the virus and do not stop the virus from being produced and shed by the body, they do provide a convenient marker to indicate whether a person has been infected in the past. Because only 95% of persons infected with HIV develop these antibodies, the test is not absolutely reliable in detecting viral infection.
Since AIDS is not transferred through normal everyday casual contct, there is no need in the general workplace to routinely identify an HIV-antibody positive (infected) person or even a person with AIDS. Most of the estimated 1.0 to 1.5 million Americans infected with HIV (and antibody-positive) are unaware and are in normal health. There is no place for mandatory mass screening of workers for the HIV antibody. Since the screening test is not perfect, a certain small percentage of positive results are false; actions or diagnoses based on an unsubstantiated screening test lead to serious legal and ethical problems. The only justification for doing any sort of medical test in the workplace would be to help answer the question "Is the person in a particular job a hazard to self or others?" This does not apply to the otherwise healthy and fit applicant who may or may not be antibody positive; antibody status does not answer the question. Routine HIV antibody testing in the general workplace cannot be justified on the basis of a need to exclude AIDS patients or HIV antibody-positive persons because they are a hazard to others and there is likewise no basis for excluding healthy HIV antibody-positive persons on the basis of their being unable to do the job.
AIDS is a serious disease, and it affects individual workers in much the same way as any other chronic, debilitating, and eventually fatal disorder with the addition of the problem of discrimination against the person with AIDS and the potentially high cost of medical care and hospitalization. It should be considered as part of the employer's policy on medical leave and disability like any other serious disorder. A separate AIDS policy should not be needed and tends to perpetuate the idea that people with AIDS should be singled out.
During a fitness-to-work determination (Chapter 18), the health of the worker is evaluated according to the requirements of the working conditions of the job. If a person is clearly ill, or if for some reason the examining occupational health professional suspects they are dealing with an AIDS or an ARC patient, a test for HIV antibody might be considered as part of a medical evaluation but not as a routine screening test. The consent of the patient would then be needed, as would appropriate counselling before and after the test. In this situation it is important to know the medical diagnosis because a person with AIDS may be at risk of catching infections from others. This is a serious consideration in many jobs because the immune system of the AIDS patient appears to be unable to handle many common infections. Also, the prognosis may be such that the worker could not reasonably be expected to master a job or complete an assignment. However, a person with AIDS should not be handled differently from any other sufferer of a serious disease. Human rights codes protect the person with AIDS by declaring that discrimination for physical disability is not permitted. An employed AIDS sufferer enjoys the same protection from wrongful dismissal for health reasons as anyone else. On the other hand, if during a preplacement evaluation someone was discovered to be an AIDS sufferer, again because of an objective clinical concern but not a "shotgun" screening program of every applicant, that person could legitimately be declared unfit for the position if the working conditions were unsuitable or too hazardous for them. The status of a person infected with HIV but not symptomatic with AIDS is not as well defined under the law but logic and ethics suggest that such persons should be accorded the same protection.
The Surgeon-General of the United States, Dr. C. Everett Koop, has said that "AIDS should be treated at the worksite just like any other disease. Employers have an obligation to provide information on how AIDS is spread and how AIDS is not spread." Certainly it makes sense for an employer to educate employees to prevent the emergence of problems and misunderstandings and for their own protection. An AIDS awareness program that draws on the many resources now in the community should be extended to the workplace. The objective of such a program is to help educate workers so that they will be able to make reasoned individual decisions on the appropriate health-related behavior. It is not to present management's views on morality and personal conduct. AIDS is a serious epidemic and preventing its further spread is the responsibility of all in positions of influence and authority. The AIDS awareness program will also serve to put the situation into perspective by reassuring workers that they have no real risk of contracting or becoming infected with HIV in their workplace.
The emergence and rapid spread of AIDS and the discovery of HIV and the transmissable cause resulted in fear and much anxiety. This is now a time for correction, reasonable adaptation, and accommodation. Except in workplaces where there is a real risk of exposure to contaminated body fluids, a specific AIDS policy is simply not necessary and has the unfortunate effect of setting the disease apart and unintentionally promoting discrimination. What is necessary is a fair program of determining fitness to work in which AIDS is treated objectively and an AIDS awareness program for the general education of workers.
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