HIV: Reporting and risks

The article in this month’s issue by Drs Timothy Christie and Perry Kendall is an important one and should be required reading for every physician in BC. This is the first time that HIV has been designated a reportable disease through legislation. The decision to enshrine this requirement in law is commendable, but why did it take so long for HIV to join a list that includes things like measles, hepatitis, tuberculosis, and syphilis? Few of the infectious diseases on the reportable list kill people these days; they are primarily there because they pose a public health hazard. HIV, however, does kill people and has been a recognized as a global public health hazard for many years now. I have difficulty coming to terms with the knowledge that far too many years have passed during which epidemiologists, infectious disease specialists, and HIV workers have been warning anyone who would listen that HIV was already a pandemic of biblical proportions.

However, it seems that BC’s legislators have only become interested in enacting “reportable disease” legislation since it became clear that HIV even infects people who are not marginalized because of IV drug use and sexual orientation.

The numbers of people infected with HIV worldwide is staggering and this absolutely necessary legislation does a reasonably good job of negotiating through the minefield of confidentiality and Canadian Charter issues. I was particularly impressed with the inclusion of a non-nominal option whereby a physician who has knowledge of risk to a third party because of an “index case” refusing to inform a sexual partner can refer to a local medical health officer (MHO). The MHO can then do what is necessary to protect the person at risk.

There are a few gaps in the tracking equation, however, and I wonder how long it will take before there is a realization that there are still potential disasters out there that will keep the disease percolating in the community. It is clear that partners are pretty well covered, but relying on an index case to provide names of all past partners is a fairly big gap in contact case identification. One has to wonder how big this group might be (the BCCDC is pretty sure that these figure are not well known and only are alluded to in most published epidemiologic studies). The other big group is the obvious exposure risk to first responders such as police, firefighters, and ambulance and health care workers who are inadvertently exposed during their work in spite of normal contamination protection maneuvers. Can we allay the fears of these important individuals (and their sexual partners) by legislating mandatory testing of individuals whose body fluids come into contact with any first responder?

Finally, if the HIV status of these individuals is already possibly established and part of a database, can access to this important information be enshrined in future legislation? There is currently no legal way to access this information, and the unfortunate alternative is that first responders have to take a drug cocktail for a month or more while they and their families wait to see if they have been infected.

There have been no reported cases of first responders developing HIV from blood splashes (there are a few from mucous membrane exposures, but the numbers are very low). In addition, it is clear that even with mandatory testing there are problems because the contact may be a high-risk person who is negative but is tested during the nonreactive window and will test positive within a few months.

This legislation is a huge step for public health in this province and the people involved in the crafting of the document should be applauded. However, it is still a first step and there is work to be done in drafting future legislation that will, I hope, include better protection for the group of workers who are most likely to regularly come in to potentially hazardous contact with HIV-infected individuals.

—JAW