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Consolidation of AMA House Policies on HIV/AIDS

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This report responds to Recommendation 7 in CSA Report 1 (I-01), Universal, Routine Screening of Pregnant Women for HIV Infection, which was adopted by the American Medical Association House of Delegates in December 2001. The recommendation asked: "That the American Medical Association (AMA) Council on Scientific Affairs prepare a report that will consolidate current AMA policy on HIV."

As stated in AMA Policy H-545.964 (AMA Policy Database), the purpose of policy consolidation is to make information on House policy more accessible and readable. Policy consolidation also will improve the organization of the AMA PolicyFinder program database. The purpose of policy consolidation does not include the establishment of new policy positions. Changes in AMA policy can only be accomplished through other types of reports or by resolutions that are submitted to the AMA House of Delegates.

This report consolidates 60 policies the PolicyFinder progam database into 32 policies.

In considering policies for consolidation, the Council employed the following approach:

  1. Search the current AMA Policy Database (search terms included acquired immune deficiency syndrome, AIDS, bloodborne infections, bloodborne pathogens, human immunodeficiency virus, HIV, sexually transmitted diseases, substance abuse).
  2. Identify outmoded and outdated policies.
  3. Group similar policies (or parts of policies) together into categories, with each category given a new policy title and number. To facilitate review and comparison, all pertinent AMA policies or policy elements reflected in the consolidation are cited in their entirety.
  4. Develop an appropriate title and number for each policy grouping.
  5. Edit the language of each proposed policy so that it is coherent and easily understood, without altering its meaning or intent.
  6. Recommend that the House adopt the consolidated policies on HIV/AIDS in their entirety and that the House rescind current AMA policies that are duplicative.

AMA Policy H-545.964 states that recommendations in a policy consolidation report cannot be amended and must be voted upon in their entirety.

RECOMMENDATIONS

As recommended by the Council on Scientific Affairs the following statements were adopted by the AMA House of Delegates at the 2003 AMA Annual Meeting as AMA policy on HIV/AIDS:

HIV/AIDS as a Global Public Health Priority

In view of the urgent need to curtail the transmission of HIV infection in every segment of the population, the AMA: (1) Strongly urges, as a public health priority, that federal agencies (in cooperation with medical and public health associations and state governments) develop and implement effective programs and strategies for the prevention and control of the HIV/AIDS epidemic; (2) supports adequate public and private funding for all aspects of the HIV/AIDS epidemic, including research, education, and patient care for the full spectrum of the disease. Public and private sector prevention and care efforts should be proportionate to the best available statistics on HIV incidence and prevalence rates; (3) will join national and international campaigns for the prevention of HIV disease and care of persons with this disease; (4) encourages cooperative efforts between state and local health agencies, with involvement of state and local medical societies, in the planning and delivery of state and community efforts directed at HIV testing, counseling, prevention, and care; (5) encourages community-centered HIV/AIDS prevention planning and programs as essential complements to less targeted media communication efforts; (6) in coordination with appropriate medical specialty societies, supports addressing the special issues of heterosexual HIV infection, the role of intravenous drugs and HIV infection in women, and initiatives to prevent the spread of HIV infection through prostitutes; (7) supports working with concerned groups to establish appropriate and uniform policies for neonates, school children, and pregnant adolescents with HIV/AIDS and AIDS-related conditions; and (8) supports increased availability of anti-retroviral drugs and drugs to prevent active tuberculosis infection to countries where HIV/AIDS is pandemic.

HIV/AIDS to be Considered as a Communicable and a Sexually Transmitted Disease

  1. The AMA supports the classification of HIV/AIDS as a communicable and a sexually transmitted disease and the control measures attendant to its classification;
  2. State and local health department systems, in cooperation with other concerned organizations, are the appropriate mechanisms for determining whether HIV infection will be designated a sexually transmitted or communicable disease in that state;
  3. All precautions to prevent the spread of the HIV virus from patient to physician or other health care worker and from physician or other health care worker to the patient should be treated in the same manner as any other communicable or infectious disease, consistent with good medical practice.

HIV Testing

General Considerations: (a) persons who suspect that they have been exposed to HIV should be tested so that appropriate treatment and counseling can begin for those who are seropositive; (b) HIV testing should be consistent with testing for other infections and communicable diseases; (c) HIV testing should be readily available to all who wish to be tested, including having available sites for confidential testing; (d) the physician's office and other medical settings are the preferred settings in which to provide HIV testing; and (e) physicians should work to make HIV counseling and testing more readily available in medical settings.

Informed Consent Before HIV Testing: (a) The AMA supports the standard that individuals should knowingly and willingly give consent before a voluntary HIV test is conducted, in a manner that is the least burdensome to the individual and to those administering the test. Physicians must be aware that most states have enacted laws requiring informed consent before HIV testing; (b) informed consent should include the following information: (i) patient option to receive more information and/or counseling before deciding whether or not to be tested and (ii) the patient should not be denied treatment if he or she refuses HIV testing, unless knowledge of HIV status is vital to provide appropriate treatment; in this instance, the physician may refer the patient to another physician for care; (c) it is the policy of the AMA to review the federal laws including the Veteran's Benefits and Services Act, which currently mandates prior written informed consent for HIV testing within the Veterans Administration hospital system, and subsequently to initiate and support amendments allowing for HIV testing without prior consent in the event that a health care provider is involved in accidental puncture injury or mucosal contact by fluids potentially infected with HIV in federally operated health care facilities; and (d) the AMA supports working with various state societies to delete legal requirements for consent to medically indicated HIV testing that are more extensive than requirements generally imposed for informed consent to medical care.

HIV Testing Without Explicit Consent: (a) explicit consent should not always be required prior to HIV testing. Physicians should be allowed, without explicit informed consent, and as indicated by their medical judgment, to perform diagnostic testing for determination of HIV status of patients suspected of having HIV infection; (b) general consent for treatment of patients in the hospital should be accepted as adequate consent for the performance of HIV testing; (c) model state and federal legislation should be developed to permit physicians, without explicit informed consent and as indicated by their medical judgment, to perform diagnostic testing for determination of HIV status of patients suspected of having HIV infection; and (d) the AMA will work with the Centers for Disease Control and Prevention, the American Hospital Association, the Federation, and other appropriate groups to draft and promote the adoption of model state legislation and hospital staff guidelines to allow HIV testing of a patient maintaining privacy, but without explicit consent, where a health care worker has been placed at risk by exposure to potentially infected body fluids; and to allow HIV testing, without any consent, where a health care worker has been placed at risk by exposure to body fluids of a deceased patient.

HIV Testing Procedures: (a) Appropriate medical organizations should establish rigorous proficiency testing and quality control procedures for HIV testing laboratories on a frequent and regular basis; (b) physicians and laboratories should review their procedures to assure that HIV testing conforms to standards that will produce the highest level of accuracy; (c) appropriate medical organizations should establish a standard that a second blood sample be taken and tested on all persons found to be seropositive or indeterminate for HIV antibodies on the first blood sample. This practice is also advised for any unexpected negative result; (d) appropriate medical organizations should establish a policy that results from a single unconfirmed positive ELISA test never be reported to the patient as a valid indication of HIV infection; (e) appropriate medical organizations should establish a policy that laboratories specify the HIV tests performed and the criteria used for positive, negative, and indeterminate Western blots or other confirmatory procedures; and (f) the AMA recommends that training for HIV blood test counselors encourage patients with an indeterminate Western blot to be advised that three-to-six-month follow-up specimens may need to be submitted to resolve their immune status. Because of the uncertain status of their contagiousness, it is prudent to counsel such patients as though they were seropositive until such time as the findings can be resolved.

Routine HIV Testing: (a) Routine HIV testing should include appropriately modified informed consent and modified pre-test and post-test counseling procedures; (b) hospitals, clinics and physicians may adopt routine HIV testing based on their local circumstances. Such a program is not a substitute for universal precautions. Local considerations may include (i) the likelihood that knowledge of a patient's serostatus will improve patient care and reduce HIV transmission risk; (ii) the prevalence of HIV in patients undergoing invasive procedures; (iii) the costs, liabilities and benefits; and (iv) alternative methods of patient care and staff protection available to the patient; and (c) state medical associations should review and seek modification of state laws that restrict the ability of hospitals and other medical facilities to initiate routine HIV testing programs.

Voluntary HIV Testing: (a) Voluntary HIV testing should be provided with informed consent for individuals who may have come into contact with the blood, semen, or vaginal secretions of an infected person in a manner that has been shown to transmit HIV infection. Such testing should be encouraged for patients for whom the physician's knowledge of the patient's serostatus would improve treatment. Voluntary HIV testing should be regularly provided for the following types of individuals who give an informed consent: (i) patients at sexually transmissible disease clinics; (ii) patients at drug abuse clinics; (iii) individuals who are from areas with a high incidence of AIDS or who engage in high-risk behavior and are seeking family planning services; and (iv) patients who are from areas with a high incidence of AIDS or who engage in high-risk behavior requiring surgical or other invasive procedures; and (b) the prevalence of HIV infection in the community should be considered in determining the likelihood of infection. If voluntary HIV testing is not sufficiently accepted, the hospital and medical staff may consider requiring HIV testing.

Mandatory HIV Testing: (a) The AMA opposes mandatory HIV testing of the general population; (b) mandatory testing for HIV infection is recommended for (i) all entrants into federal and state prisons; (ii) military personnel; (iii) donors of blood and blood fractions; breast milk; organs and other tissues intended for transplantation; and semen or ova for artificial conception; and (c) the AMA will review its policy on mandatory testing periodically to incorporate information from studies of the unintended consequences or unexpected benefits of HIV testing in special settings and circumstances.

HIV Test Counseling: (a) Pre-test and post-test voluntary counseling should be considered an integral and essential component of HIV testing. Full pre-test and post-test counseling procedures must be utilized for patients when HIV is the focus of the medical attention, when an individual presents to a physician with concerns about possible exposure to HIV, or when a history of high-risk behavior is present; (c) post-test information and interpretation must be given for negative HIV test results. All negative results should be provided in a confidential manner accompanied by information in the form of a simple verbal or written report on the meaning of the results and the offer, directly or by referral, of appropriate counseling; and (c) post-test counseling is required when HIV test results are positive. All positive results should be provided in a confidential face-to-face session by a professional properly trained in HIV post-test counseling and with sufficient time to address the patient's concerns about medical, social, and other consequences of HIV infection.

HIV Testing of Health Care Workers: (a) The AMA supports HIV testing of physicians, health care workers, and students in appropriate situations; (b) employers of health care workers should provide, at the employer's expense, serologic testing for HIV infection to all health care workers who have documented occupational exposure to HIV; (c) the AMA opposes HIV testing as a condition of hospital medical staff privileges; and (d) physicians and other health care workers who perform exposure-prone patient care procedures that pose a significant risk of transmission of HIV infection should voluntarily determine their serostatus at intervals appropriate to risk and/or act as if their serostatus were positive. The periodicity will vary according to locale and circumstances of the individual and the judgment should be made at the local level. Health care workers who test negative for HIV should voluntarily redetermine their HIV serostatus at an appropriate period of time after any significant occupational or personal exposure to HIV. Follow-up tests should occur after a time interval exceeding the length of the "antibody window."

Counseling and Testing of Pregnant Women for HIV: The AMA supports the position that there should be universal HIV testing of all pregnant women, with patient notification of the right of refusal, as a routine component of perinatal care, and that such testing should be accompanied by basic counseling and awareness of appropriate treatment, if necessary. Patient notification should be consistent with the principles of informed consent.

HIV Home Test Kits: (a) The AMA opposes Food and Drug Administration approval of HIV home test kits. However, the AMA does not oppose approval of HIV home collection test kits that are linked with proper laboratory testing and counseling services, provided their use does not impede public health efforts to control HIV disease; (b) standardized data should be collected by HIV home collection test kit manufacturers and reported to public health agencies; (c) a national study of HIV home collection test kit users should be performed to evaluate their experience with telephone counseling; and( d) a national interagency task force should be established, consisting of members from government agencies and the medical and public health communities, to monitor the marketing and use of HIV home collection test kits.

Patient Disclosure of HIV Seropositivity

The AMA encourages patients who are HIV seropositive to make their condition known to their physicians and other appropriate health care providers.

Maternal HIV Screening and Treatment to Reduce the Risk of Perinatal HIV Transmission

In view of the significance of the finding that treatment of HIV-infected pregnant women with appropriate antiretroviral therapy can reduce the risk of transmission of HIV to their infants, the AMA recommends the following statements: (1) Given the prevalence and distribution of HIV infection among women in the United States, the potential for effective early treatment of HIV infection in both women and their infants, and the significant reduction in perinatal HIV transmission with treatment of pregnant women with appropriate antiretroviral therapy, routine education about HIV infection and testing should be part of a comprehensive health care program for all women. The ideal would be for all women to know their HIV status before considering pregnancy. (2) Universal HIV testing of all pregnant women, with patient notification of the right of refusal, should be a routine component of perinatal care. Basic counseling on HIV prevention and treatment should also be provided to the patient, consistent with the principles of informed consent. (3) The final decision about accepting HIV testing is the responsibility of the woman. The decision to consent to or refuse an HIV test should be voluntary. When the choice is to reject testing, the patient’s refusal should be recorded. Test results should be confidential within the limits of existing law and the need to provide appropriate medical care for the woman and her infant. (4) To assure that the intended results are being achieved, the proportion of pregnant women who have accepted or rejected HIV testing and follow-up care should be monitored and reviewed periodically at the appropriate practice, program or institutional level. Programs in which the proportion of women accepting HIV testing is low should evaluate their methods to determine how they can achieve greater success. (5) Women who are not seen by a health care professional for prenatal care until late in pregnancy or after the onset of labor should be offered HIV testing at the earliest practical time, but not later than during the immediate postpartum period. (6) When HIV infection is documented in a pregnant woman, proper post-test counseling should be provided. The patient should be given an appropriate medical evaluation of the stage of infection and full information about the recommended management plan for her own health. Information should be provided about the potential for reducing the risk of perinatal transmission of HIV infection to her infant through the use of antiretroviral therapy, and about the potential but unknown long-term risks to herself and her infant from the treatment course. The final decision to accept or reject antiretroviral treatment recommended for herself and her infant is the right and responsibility of the woman. When the woman’s serostatus is either unknown or known to be positive, appropriate counseling should also be given regarding the risks associated with breast-feeding for both her own disease progression and disease transmission to the infant. (7) Appropriate medical treatment for HIV-infected pregnant women should be determined on an individual basis using the latest published Centers for Disease Control and Prevention recommendations. The most appropriate care should be available regardless of the stage of HIV infection or the time during gestation at which the woman presents for prenatal or intrapartum care. (8) To facilitate optimal medical care for women and their infants, HIV test results (both positive and negative) and associated management information should be available to the physicians taking care of both mother and infant. Ideally, this information will be included in the confidential medical records. Physicians providing care for a woman or her infant should obtain the appropriate consent and should notify the other involved physicians of the HIV status of and management information about the mother and infant, consistent with applicable state law. (9) Continued research into new interventions is essential to further reduce the perinatal transmission of HIV, particularly the use of rapid HIV testing for women presenting in labor and for women presenting in the prenatal setting who may not return for test results. The long-term effects of antiretroviral therapy during pregnancy and the intrapartum period for both women and their infants also must be evaluated. For both infected and uninfected infants exposed to perinatal antiretroviral treatment, long-term follow-up studies are needed to assess potential complications such as organ system toxicity, neurodevelopmental problems, pubertal development problems, reproductive capacity, and development of neoplasms. (10) Health care professionals should be educated about the benefits of universal HIV testing, with patient notification of the right of refusal, as a routine component of prenatal care, and barriers that may prevent implementation of universal HIV testing as a routine component of prenatal care should be addressed and removed. Federal funding for efforts to prevent perinatal HIV transmission, including both prenatal testing and appropriate care of HIV-infected women, should be maintained.

Neonatal Screening for HIV Infection

The AMA: (1) Urges the U.S. Public Health Service, other appropriate federal agencies, private researchers, and health care industries to continue to pursue research, development, and implementation of diagnostic tests and procedures for more accurate demonstration of HIV infection in the newborn; and supports the widespread use of such tests in early diagnosis; (2) favors giving consideration to rapid HIV testing of newborns, with maternal consent, when the maternal HIV status has not been determined during pregnancy or labor; and (3) supports voluntary, routine HIV testing of neonates in states with a high prevalence of HIV infection with maintenance of strict confidentiality. When treatment modalities with proven benefits for infected neonates are available, the AMA supports mandatory HIV testing of all newborns in high prevalence areas.

Breastfeeding and HIV Seropositive Women

The AMA believes that, where safe and alternative nutrition is widely available, HIV seropositive women should be counseled not to breastfeed and not to donate breast milk. HIV testing of all human milk donors should be mandatory, and milk from HIV-infected donors should not be used for human consumption.

HIV/AIDS Reporting, Confidentiality, and Notification

Reporting: The AMA strongly recommends that all states, territories, and the District of Columbia adopt a requirement for the confidential reportability of HIV seropositivity of all patients to appropriate public health authorities for the purpose of contact tracing and partner notification. Strict confidentiality must be maintained by each local and state public health authority.

Confidentiality: (a) The AMA supports uniform protection, at all levels of government, of the identity of those with HIV infection or disease, consistent with public health requirements; (b) patients should receive general information on the limits of confidentiality of medical records at the initial medical visit. Specific information on the limits of confidentiality should be provided before the patient receives HIV-related services or when the patient is counseled about HIV testing; (c) physicians should be able, without fear of legal sanction, to confidentially discuss a patient's HIV serostatus only with those other health care providers who need this information to properly plan and provide quality medical care to the patient; and (d) the AMA will continue to address, through the Council on Ethical and Judicial Affairs, the patient confidentiality and ethical issues raised by known HIV antibody-positive patients who refuse to inform their sexual partners or modify their behavior.

Contact Tracing and Partner Notification: The AMA: (a) Strongly recommends that states adopt a system for contact tracing and partner notification in each community that, while protecting to the greatest extent possible the confidentiality of patient information, provides clear guidelines for public health authorities who need to trace the unsuspecting sexual or needle-sharing partners of HIV-infected persons; (b) requests that states make provisions in any contact-tracing and notification program for adequate safeguards to protect the confidentiality of HIV-seropositive persons and their contacts, for counseling of the parties involved, and for the provision of information on counseling, testing, and treatment resources for partners who might be infected; (c) in collaboration with state medical societies, supports legislation on the physician's right to exercise ethical and clinical judgment regarding whether or not to warn unsuspecting and endangered sexual or needle-sharing partners of HIV-infected patients; and (d) promulgates the standard that a physician attempt to persuade an HIV-infected patient to cease all activities that endanger unsuspecting others and to inform those whom he/she might have infected. If such persuasion fails, the physician should pursue notification through means other than by reliance on the patient, such as by the Public Health Department or by the physician directly.

Discrimination Based on HIV Seropositivity

The AMA: (1) remains cognizant of and concerned about society's perception of, and discrimination against, HIV-positive people; (b) condemns any act, and opposes any legislation of categorical discrimination based on an individual's actual or imagined disease, including HIV infection; this includes Congressional mandates calling for the discharge of otherwise qualified individuals from the armed services solely because of their HIV seropositivity; (c) encourages vigorous enforcement of existing anti-discrimination statutes; incorporation of HIV in future federal legislation that addresses discrimination; and enactment and enforcement of state and local laws, ordinances, and regulations to penalize those who illegally discriminate against persons based on disease; and (d) encourages medical staff to work closely with hospital administration and governing bodies to establish appropriate policies regarding HIV-positive patients.

Prevention and Control of HIV and other Bloodborne Pathogens in Health Care Settings

  1. Employees of the health care system who might be at risk of contact with infected blood or other body fluids must be afforded all available and practical protection to assure a low level of personal risk of occupational infection. Universal precautions and all other applicable infection control measures must be understood and consistently used to safeguard the health of all personnel. Hospitals should establish procedures to ensure that these precautions are strictly enforced and that educational programs covering proper infection control procedures are available for all health care workers;
  2. The AMA uses the terminology "significant risk" in AMA policies, correspondence, and official actions when indicating the threshold of risk that is appropriate for restrictions on medical practice of physicians infected with bloodborne pathogens that can be transmitted to patients; and the AMA recommends that other medical associations, federal agencies, and courts also use the terminology "significant risk" consistently;
  3. Medical training should not unreasonably expose students, residents, and other health care workers to HIV infection from patients. Invasive techniques should be taught in situations where identified risks of HIV infection have been reduced as much as possible;
  4. Health care workers should be aware of the legal requirement to adhere to Occupational Safety and Health Administration regulations on bloodborne diseases. The AMA will monitor the impact of these regulations on physicians, physicians' offices, and health institutions;
  5. The AMA endorses and recommends adherence to the Centers for Disease Control and Prevention (CDC) guidelines for infection control and encourages institutions to develop recommendations to suit specific procedures and situations that may not be covered by currently published guidelines. In conjunction with other medical and public health organizations, the CDC should continue to review current policies for determination of occupational exposure to HIV so that they more accurately assess the true risk of seroconversion due to occupational exposure;
  6. The AMA recommends separate guidelines for HIV-infected and hepatitis B (HBV)-infected health care workers because of substantial differences in rates, risks, modes, and consequences of transmission;
  7. Health care employers whose employees or students in-training are at risk for occupational exposure to bloodborne pathogens should ensure that timely post-exposure counseling and prophylaxis, in accordance with relevant Public Health Services guidelines, are available to health care workers, including students, after an exposure;
  8. Medical schools and other health professions schools should develop payment systems for post-exposure chemoprophylaxis for students exposed to bloodborne pathogens in the course of their studies and training; a payment mechanism must be instituted to cover all necessary expenses of counseling, testing, and therapy for exposed health care workers, including students exposed while in clinical training;
  9. Health care employers whose employees or students in-training are at risk for occupational exposure to bloodborne pathogens should evaluate and make use of appropriate techniques and technologies, including safer medical devices, to prevent occupational exposure to bloodborne pathogens;
  10. The AMA will work with relevant federal agencies, medical societies, and public health organizations to study methods and recommend guidelines for institutions to allow immediate access to care and counseling for health care workers exposed to HIV;
  11. Ther AMA will explore the feasibility of developing a voluntary office visitation program to assess the policies, procedures, and education programs that are in place concerning prevention of HIV/HBV transmissions. This effort would include exploring the feasibility of developing minimal guidelines for physician offices.

Guidance for HIV-Infected Physicians and Other Health Care Workers

General Considerations: (a) A health care worker who performs invasive procedures and has reasonable cause to believe he/she is infected with HIV should determine his/her serostatus or act as if that serostatus is positive; and (b) as a general rule or until there is scientific information to the contrary, the HIV-infected health care worker should be permitted to provide health care services as long as there is no significant risk of patient infection and no compromise in physical or mental ability of the health care worker to perform the health care procedures.

Patient Care Duties: (a) A physician or other health care worker who performs exposure-prone procedures and becomes HIV-positive should disclose his/her serostatus to a state public health official or local review committee; (b) an HIV-infected physician or other health care worker should refrain from conducting exposure-prone procedures or perform such procedures with permission from the local review committee and the informed consent of the patient; and (c) when the scientific basis for patient protection policy decisions are unclear, HIV-infected physicians or other health care workers must err on the side of protecting patients.

Local Review Committee: (a) If an HIV-infected physician or other health care worker performs invasive medical procedures as a part of his/her duties, then the individual should request that an ad hoc committee be constituted to consider which activities can be continued without risk of infection to patients. Membership on the review committee should be flexible to meet various needs. It should include an infectious disease specialist familiar with HIV transmission risks, the pertinent hospital department chair, a hospital administrator, an epidemiologist, the infected health care worker's personal physician, the infected health care worker, and others as appropriate. Committee members should be unbiased and at least some of the members should be familiar with the performance of the infected health care worker. (b) This review committee may recommend to the appropriate authority restrictions upon the infected persons’ practice, if it believes there is a significant risk to patients' welfare. A confidential review system should be established by the committee to monitor the health care worker's fitness to engage in invasive health care activities. Any restrictions or modifications to health care activities that may affect patient safety should be determined by the committee based on current medical and scientific information. When determining practice limitations for HIV-positive physicians, the panel might consider: (i) morbidity and mortality experience of the physician in question; (ii) frequency with which the physician performs the following: procedures that have been associated with injuries to physicians in the course of surgery; procedures that are conducted in confined or difficult to visualize anatomical spaces; procedures where a physician's blood is likely to come in to contact with a patient's mucosal surfaces, open surgical wounds, or blood stream; and procedures that have been known to be involved in HBV transmission; ( c) Where restrictions, limitations, modifications, or a change in health care activities are recommended, the committee should do its utmost to assist the health care worker to obtain financial and social support for these changes. Consideration should be given to adapting programs for impaired health care workers to serve those who are HIV infected; (d) The committee should be empowered to monitor the HIV-infected physician or other health care worker for compliance with any practice limitations established by the committee, provide advice on the need to inform patients of the infected worker’s HIV status, monitor the infected person’s compliance with universal precautions, and assess the effects of the disease on clinical competency. Physicians and others who participate in making these decisions must be protected from legal challenges and personal legal responsibility; (e) Any HIV-infected health care worker who repeatedly violates local committee-imposed practice limitations and/or universal precautions should be reported to appropriate authorities, such as the state licensure board, for possible discipline; (f) If intra-institutional confidentiality cannot be assured, health care facilities should make arrangements with other organizations such as local or state medical societies to perform the functions of the ad hoc committee; and (g) HIV-infected health care workers not affiliated with a hospital may also use this procedure to form an ad hoc review committee.

Review Committee Liability: (a) State medical societies should be encouraged to survey hospitals and review their own coverage to determine whether existing liability insurance for those serving on peer review or Physicians Health Committees provides protection for those serving on review committees for HIV-infected physicians; and(b) the AMA should assist in the establishment of review committees by providing model state legislation that would afford committee members protection in state and federal courts and when they operate in good faith. Further, the AMA should prepare a protocol outlining how review committees would operate and further specify the definition of significant risk.

Confidentiality: (a) The AMA expresses its commitment to HIV-infected physicians concerning confidentiality of HIV serostatus, protection against discrimination, involvement in legislation affecting HIV-infected physicians, financial support through such means as insurance disability guidelines, and assistance with alternative careers through its Physician Health Program; (b) the AMA believes the confidentiality of the HIV-infected physician should be protected as with any HIV patient; and (c) knowledge of the health care worker's HIV serostatus should be restricted to those few professionals who have a medical need to know. Except for those with a need to know, all information on the serostatus of the health care worker must be held in the strictest confidence.

HIV-Infected Medical Students and Resident Physicians: (a) The AMA strongly supports indemnification of medical students and resident physicians infected with HIV as a result of contact with assigned patients. The AMA supports examining possible mechanisms to achieve the intent of this recommendation, realizing that the issues for medical students and resident physicians differ; and (b) an equivalent level and manner of health care provided to medical students, residents, and other employees with other medical conditions should be provided to those with HIV infection.

Liability Coverage for HIV-Infected Physicians: The AMA will continue the dialogue with liability insurance companies to monitor issues surrounding liability coverage for HIV-infected physicians and will establish guidelines for any collection or use of HIV serostatus data by professional liability carriers. Serostatus information should be treated with strict privacy and nondisclosure assurances. Discussions with liability insurance companies should include the position that to date there are no scientific grounds to require testing of physicians for HIV status.

Reporting of HIV- and HBV-Infected Physicians

The AMA opposes mandatory reporting of HIV- and HBV-infected physicians to state licensing boards until there is conclusive evidence that such infected physicians pose a significant risk to patients.

HIV-Infected Children

The AMA: (1) Supports day-care, preschool, and school attendance of HIV-infected children; (2) encourages the physician responsible for care of an HIV-infected child in a day-care, preschool, or school setting to receive information from the school on other infectious diseases in the environment and temporarily remove the HIV-infected child from a setting that might pose a threat to his/her health; and (c) encourages that HIV-infected children who are adopted or placed in a foster-care setting have access to special health care benefits to encourage adoption or foster-care.

HIV-Infected Aviation Pilots

The AMA urges the Federal Aviation Administration (FAA) to ensure: (1) that a pilot who has risk factors for HIV infection determine his/her serostatus and (2) that the serostatus of the HIV-infected pilot be kept confidential and shared only with those having a need to know this information for the treatment of the pilot or the safety of others. An HIV-infected pilot should confidentially make this status known to medical examiners of the FAA. On a case-by-case basis, guided by current scientific studies and an examination of the pilot, medical reviewers should determine the impact of the disease on the pilot's ability to safely perform his/her flight responsibilities. Certification or decertification of flight privileges should be based on the individualized medical assessment.

Medical Care of HIV-Infected Patients

Ethical Responsibilities of Physicians: The AMA believes that a physician may not ethically refuse to treat a patient whose condition is within the physician's current realm of competence solely because the patient is HIV seropositive. Persons who are seropositive should not be subjected to discrimination based on fear or prejudice. Physicians who are unable to provide the services required by HIV-infected patients should make referrals to those physicians or facilities equipped to provide such services. It is in the best interest of the patient for the physician to focus on treatment of the disease, rather than on making value judgments about how the disease was contracted.

General Considerations: The AMA: (a ) Encourages its constituent societies to facilitate the availability of physicians and health care services for HIV/AIDS patients; (b) advocates development of optimal care programs for HIV-positive and AIDS-symptomatic infants and their families. Such programs should include support systems to help parents care for these infants and simplified foster-care arrangements for children whose parents are unable to provide such care; (c) supports efforts to provide physicians with an awareness of the role that can be played in patient care by self-help and support groups for HIV-infected patients; and (d) will continue its efforts with the Social Security Administration to explore ways of educating physicians on the disability evaluation of HIV-infected patients.

Pharmacotherapy and HIV Infection: (a) Physicians should inquire of a patient with HIV infection whether the patient is taking unprescribed medications or drugs manufactured by a pharmaceutical company with an unfamiliar name. Appropriate action should be based on the circumstances, but the patient should be made aware of the possible ineffectiveness and complications of such medications; (b) The Food and Drug Administration, in consultation with other federal agencies, drug manufacturers, and health care associations, should continue to review ways to improve drug trials and the associated drug approval processing to expedite evaluations and expand the availability of drugs with demonstrated effectiveness to prevent HIV infection, treat any stage of HIV disease, and reduce symptom expression in HIV-infected persons (c) The AMA supports using its resources in cooperation with other health organizations and agencies to facilitate the distribution of information on available drug therapies for the prevention and treatment of HIV disease.

Tuberculosis Screening: Physicians should evaluate all HIV-positive patients for tuberculosis and all tuberculin-positive patients for HIV infection.

Sexual and Drug History: Physicians should take a sexual and substance abuse history, sufficient to identify the usual modes of HIV transmission, on every adolescent and adult patient, with a more comprehensive history taken when warranted.

Financing Care for HIV/AIDS Patients

The AMA: (1) Believes that current private insurance and existing public programs, coupled with a significant expansion of state risk pools, provide the best approach to assuring adequate access to health expense coverage for HIV-infected persons and persons with AIDS. However, as the disease patterns and costs become more defined, it may be necessary to reevaluate this conclusion. Continued study of this issue is imperative; (2) Supports the development of a clinical staging system based on severity of HIV disease as a replacement for the AIDS diagnosis as a basis for determining health, disability, and other benefits; (3) Supports increased funding for reimbursement and other incentives by public and private payors to encourage (a) expanded availability for therapies and interventions widely accepted by physicians as medically appropriate for the prevention and control of HIV disease and (b) for alternatives to in-patient care of persons with HIV disease, including intermediate care facilities, skilled nursing facilities, home care, residential hospice, home hospice, and other support systems; (4) Supports government funding of all medical services that are deemed appropriate by both the patient and physician for pregnant seropositive women lacking other sources of funding; (5) Supports broad improvements in and expansion of the Medicaid program as a means of providing increased coverage and financial protection for low-income AIDS patients; (6) Supports, and favors considering introduction of, legislation to modify the Medicaid program to provide for a yearly dollar increase in the federal share of payments made by states for care of all patients in proportion to the amount of increase in costs incurred by each state program for care of HIV-positive individuals and patients with AIDS over the preceding year; (7) Encourages the appropriate state medical societies to seek establishment in their jurisdictions of programs to pay the private insurance premiums from state and federal funds for needy persons with HIV and AIDS; and strongly supports full appropriation of the amounts authorized under the Ryan White CARE Act of 2000; (8) Supports consideration of an award recognition program for physicians who donate a portion of their professional time to testing and counseling HIV-infected patients who could not otherwise afford these services.

Health and Disability Coverage for Health Care Workers At Risk for HIV and Other Serious Infectious Diseases

Health Insurance: A currently held health insurance policy of a health care worker should not be terminated, coverage reduced or restricted, or premiums increased solely because of HIV infection.

Disability Coverage: (a) Each health care worker should consider the risks of exposure to infectious agents posed by his/her type of practice and the likely consequences of infection in terms of changes needed in that practice mode and select disability insurance coverage accordingly. The policy selected should contain a reasonable definition of "sickness" or "disability," an own-occupation clause, and guaranteed renewability, future insurability, and partial disability provisions; (b) In making determinations of disability, carriers should take into consideration the recommendations of the professional and institutional staff with whom an infected health care worker is associated, including the worker's own personal physician; (c) Since there are a variety of disability insurance coverages available and a diversity of practice modes, each health care professional should individually assess his/her risk of infection and that of his/her employees and select disability coverage accordingly.

HIV/AIDS Research

Information on the HIV Epidemic: The AMA: (a) Vigorously supports the need for adequate government funding for research, both basic and clinical, in relation to HIV/AIDS epidemic. Research on HIV should be prioritized, funded, and implemented in an expeditious manner consistent with appropriate scientific rigor, and the results of research should form the basis for future programs of prevention and treatment; (b) Requests the Secretary of the Department of Health and Human Services to make available information on HIV expenditures, services, programs, projects, and research of agencies under his/her jurisdiction and, to the extent possible, of all other federal agencies for purposes of study, analysis, and comment. The compilation should be sufficiently detailed that the nature of the expenditures can be readily determined; (c) Supports ongoing efforts of the Centers for Disease Control and Prevention to periodically monitor the incidence and prevalence of HIV infection in the U.S. population as a whole, as well as in groups of special interest such as adolescents and minorities; (d) Encourages federal and state agencies, in cooperation with medical societies and other interested organizations, to study and report means to increase access to quality care for women and children who are HIV-infected; (e) Encourages further research to assess the risk of HIV transmission in specific surgical techniques and how any such risk may be decreased; (f) Supports exploring ways to increase public awareness of the benefits of animal studies in HIV/AIDS research.

Lookback Studies: The AMA encourages the cooperation of the medical community and patients in scientifically sound look-back studies designed to further define the risk of HIV transmission from an infected physician to a patient and to determine if there is any scientific basis for the development of a list of exposure-prone procedures. A panel of experts should be assembled to translate available look-back information into a meaningful statement on the estimated true risk of transmission and the need, if any, for additional studies.

Community Research Initiatives: The AMA supports the objectives of community-based research to reduce HIV disease and encourages periodic review of progress toward these objectives.

HIV/AIDS Education and Training

Public Information and Awareness Campaigns: The AMA: (a) Supports development and implementation of HIV/AIDS health education programs in the United States by encouraging federal and state governments through policy statements and recommendations to take a stronger leadership role in ensuring interagency cooperation, private sector involvement, and the dispensing of funds based on real and measurable needs. This includes development and implementation of language- and culture-specific education programs and materials to inform minorities of risk behaviors associated with HIV infection; (b) Can be a catalyst to bring the communications industry, government officials, and the health care communities together to design and direct efforts for more effective and better targeted public awareness and information programs about HIV disease prevention through various public media, especially for those persons at increased risk of HIV infection; (c) Strongly urges the communications industry to develop voluntary guidelines for public service advertising regarding HIV/AIDS, in consultation with the health care community and government officials; (d) Encourages education of patients and the public about the limited risks of iatrogenic HIV transmission. Such education should include information about the route of transmission, the effectiveness of universal precautions, and the efforts of organized medicine to ensure that patient risk remains immeasurably small. This program should include public and health care worker education as appropriate and methods to manage patient concern about HIV transmission in medical settings. Statements on HIV disease, including efficacy of experimental therapies, should be based only on current scientific and medical studies; (e) Encourages and will assist physicians in providing accurate and current information on the prevention and treatment of HIV infection for their patients and communities; (f) Encourages religious organizations and social service organizations to implement HIV/AIDS education programs for those they serve.

HIV/AIDS Education in Schools: The AMA: (a) Endorses the education of elementary, secondary, and college students regarding basic knowledge of HIV infection, modes of transmission, and recommended risk reduction strategies; (b) Commends school administrations, boards of education, teachers, health educators, and all others who have helped implement HIV curricula in school systems and urges continuance of such efforts. Appropriate means must be found to provide HIV education for those who are not currently receiving such education through the school system, including individualized educational materials; (c) Supports efforts to obtain adequate funding from local, state, and national sources for the immediate development and implementation of HIV educational programs as part of comprehensive health education in the schools.

Education and Training Initiatives for Practicing Physicians and Other Health Care Workers: (a) The AMA supports continued efforts to work with other medical organizations, public health officials, universities, and others to foster the development and/or enhancement of programs to provide comprehensive information and training for primary care physicians, other front-line health workers (specifically including those in drug treatment and community health centers and correctional facilities), and auxiliaries focusing on basic knowledge of HIV infection, modes of transmission, and recommended risk reduction strategies. Such efforts should assure: (i) educational programs covering practical and didactic aspects of universal precautions and infectious control procedures be conducted for all health care workers, and especially for physicians who practice invasive procedures; (ii) an easily accessible method of receiving the most current authoritative information on HIV; (iii) readily available training in HIV counseling and education; (iv) continuing education and training on techniques related to nonjudgmental history taking of sexual practices and drug use; (v) identification of effective ways to change those behaviors that place a person at risk of HIV infection; (vi) a review of methods other than education and counseling that might be effective in preventing the spread of HIV; and (vii) special attention to reducing the spread of HIV among intravenous drug users; (b) Recognizing that it is unlikely that the care of HIV-infected persons will be provided entirely by specialists and referral centers, the AMA supports publishing information and offering training to encourage large numbers of physicians and other health care workers to become involved in the care of HIV-infected patients; (c) The AMA supports HIV/AIDS educational programs addressing home health care and the training of nonprofessional home care givers, with special attention to infection control; (d) The AMA encourages immediate publication of peer-reviewed reports of any case of HIV transmission from skin or mucous membrane exposure, and any case of a health care worker with occupation-related HIV infection; (e) The AMA supports the development and issuance of educational advisories for physicians, to assist them in halting the spread of HIV/AIDS by giving practical and medically sound advice to all individuals.

Medical Students and Resident Education and Training: The AMA: (a) Supports collaborating in a survey of medical schools and residency programs to review and report on HIV programs and policies; (b) Urges institutions and medical educators responsible for the education of medical students and resident physicians to assume the responsibility to ensure that: (i) the educational program includes attention to the basic and clinical sciences and to the related ethical and social issues associated with the current epidemic of HIV infection; (ii) the student and resident physician is instructed in practice techniques that will minimize the risk of acquiring infection from the care of patients with HIV infection; (iii) support systems are developed to assist students and resident physicians in coping with the difficulties associated with the study and treatment of patients with HIV infection; (iv) the variety of patient illnesses necessary for the educational experience is not distorted by a responsibility for caring for an excessive patient population with HIV infection; (iv) an institutional policy statement is in effect that addresses the role in medical education of a student or resident physician infected with HIV; (v) an institutional policy statement is in effect that addresses the responsibility of the institution to indemnify the student or resident physician who is infected with HIV as a result of contact with assigned patients; (c) Urges medical schools and teaching hospitals to disseminate to medical students and residents the Centers for Disease Control and Prevention guidelines delineating precautions to be observed in the care of patients with HIV/AIDS.

HIV/AIDS and Substance Abuse

The AMA: (1) Urges federal, state, and local governments to increase funding for drug treatment so that drug abusers have immediate access to appropriate care, regardless of ability to pay. Experts in the field agree that this is the most important step that can be taken to reduce the spread of HIV infection among intravenous drug abusers; (2) Advocates development of regulations and incentives to encourage retention of HIV-positive and AIDS-symptomatic patients in drug treatment programs so long as such placement is clinically appropriate; (3) Encourages the availability of opioid maintenance for persons addicted to opioids. Federal and state regulations governing opioid maintenance and treatment of drug dependent persons should be reevaluated to determine whether they meet the special needs of intravenous drug abusers, particularly those who are HIV infected or AIDS symptomatic. Federal and state regulations that are based on incomplete or inaccurate scientific and medical data that restrict or inhibit opioid maintenance therapy should be removed; (4) Urges development of educational, medical, and social support programs for intravenous drug abusers and their sexual or needle-sharing partners to reduce risk of HIV infection, as well as risk of other bloodborne and sexually transmissible diseases. Such efforts must target (a) pregnant intravenous drug abusers and those who may become pregnant to address the current and future health care needs of both mothers and newborns and (b) adolescent substance abusers, especially homeless, runaway, and detained adolescents who are seropositive or AIDS symptomatic and those whose lifestyles place them at risk for contracting HIV infection; (5) Encourages public authorities to employ vigorous efforts to reduce the risk of transmission of HIV infection through contact with debris found in shooting galleries and other places where drugs are injected, by identifying and barring access to or disinfecting such sites; (6) Will monitor and disseminate the results of current efforts to assess recovery rates, pinpoint effective strategies (including needle-exchange programs), collect ethnographic data, execute outcome evaluations, and track recidivism rates in programs aimed at reducing the spread of HIV infection among intravenous drug abusers; and (7) Will disseminate to the profession and the public credible, up-to-date information on HIV infection and substance abuse through its publications, conferences, and participation in appropriate forums and demonstration projects.

Sanctions for Willfully Infecting Others with HIV

The AMA requests that states provide sanctions for an HIV-infected individual who knowingly and willingly risks infecting an unsuspecting person when that person subsequently discovers his/her risk and makes a complaint to the authorities. Preemptive sanctions are not being endorsed by this recommendation.

HIV, Immigration, and Travel Restrictions

The AMA: (1) Supports enforcement of the public charge provision of the Immigration Reform Act of 1990 (PL 101-649); (2) Recommends that decisions on testing and exclusion of immigrants to the United States be made only by the U.S. Public Health Service, based on the best available medical, scientific, and public health information; (3) Supports keeping HIV infection on the list of communicable diseases of "Public Health Significance" for purposes of immigration law and supports excluding immigrants infected with HIV from settling permanently in the United States; (4) Recommends that non-immigrant travel into the United States not be restricted because of HIV status; (5) Recommends that confidential medical information, such as HIV status, not be indicated on a passport or visa document without a valid medical purpose.

HIV, Sexual Assault, and Violence

The AMA: (1) Urges that any legislative vehicle to establish a national HIV reporting mechanism include adequate safeguards to identify, screen, and protect victims of domestic violence who may either be HIV-positive or a contact of an HIV-positive individual; and (2) Believes that HIV testing should be offered to all victims of sexual assault, that these victims should be encouraged to be retested in six months if the initial test is negative, and that strict confidentiality of test results be maintained.

Blood Bank Look-Back Programs

The AMA supports the concept of blood bank look-back recipient notification programs as a means of protecting patients and reducing the possible spread of infections.

Safety of Blood Donations and Transfusions

The AMA: (1) Supports working with blood banking organizations to educate prospective donors about the safety of blood donation and blood transfusion; (2) Supports the use of its publications to help physicians inform patients that donating blood does not expose the donor to the risk of HIV/AIDS; (3) Encourages physicians to inform high-risk patients of the value of self-deferral from blood and blood product donations; and (4) Supports providing educational information to physicians on alternatives to transfusion.

Research on Drug Abusing Populations

The AMA encourages federal and state agencies to support research to: (1) Determine the number and demographic characteristics of the drug abusing population, with particular emphasis on intravenous drug users and the characteristics and conditions under which intravenous drug equipment is shared; and (2) develop effective strategies for preventing the initiation of intravenous drug use and for the treatment of intravenous drug users.

Human Sexuality Education

The AMA encourages physicians to assist parents in providing human sexuality education to children and adolescents.

Education on Condom Use

The AMA: (1) Supports joining with appropriate medical and public health organizations and federal agencies in endorsing the use of condoms in reducing the risk of HIV/AIDS and other sexually transmissible diseases among the population; (2) encourages the production of condom education materials that meet standards of accuracy, completeness, social appropriateness, clarity, and simplicity; (3) supports cooperating with other medical societies, the public health community, government agencies, and the media to develop standards for public service announcements regarding condom use in prevention of HIV/AIDS and other sexually transmissible diseases; (4) in cooperation with state, county, and specialty medical societies, encourages physicians to educate their patients about the role of condom use in reducing the risk of sexually transmissible diseases, including HIV disease. While such counseling may not be appropriate for all patients, physicians should be encouraged to provide this information to any patient who may benefit from being more aware of the risks of sexually transmissible diseases; and (5) in collaboration with appropriate specialty medical societies, supports exploring with condom manufacturers the development of a condom-education kit to train physicians to educate patients on condom use.

Disease Prevention and Health Promotion in Correctional Institutions

The AMA urges state and local health departments to develop plans that would foster closer working relations between the criminal justice, medical, and public health systems toward the prevention and control of HIV/AIDS, substance abuse, tuberculosis, and hepatitis. Some of these plans should have as their objectives: (a) an increase in collaborative efforts between parole officers and drug treatment center staff in case management aimed at helping patients to continue in treatment and to remain drug free; (b) an increase in direct referral by correctional systems of parolees with a history of intravenous drug use to drug treatment centers; and (c) consideration by judicial authorities of assigning individuals to drug treatment programs as a sentence or in connection with sentencing.

Prevention and Control of HIV/AIDS and Tuberculosis in Correctional Facilities

Medical Testing and Care of Prisoners: (a) Federal and state correctional systems should provide comprehensive medical management for all entrants, which includes mandatory testing for HIV infection and tuberculosis followed by appropriate treatment for those infected; (b) during incarceration, prisoners should be tested for HIV infection as medically indicated or on their request; (c) all inmates and staff should be screened for tuberculosis infection and retested at least annually. If an increase in cases of tuberculosis or HIV infection is noted, more frequent retesting may be indicated; (d) testing for HIV infection and tuberculosis should be mandatory for all prisoners within 60 days of their release from prison; (e) physicians who practice in correctional institutions should evaluate all tuberculin-positive inmates for HIV infection and all HIV-positive patients for tuberculosis, since HIV status may affect subsequent management of tuberculosis infection or disease and tuberculosis may accompany HIV infection; (f) correctional institutions should assure that informed consent, counseling, and confidentiality procedures are in place to protect the patient, when HIV testing is appropriate; (g) during their post-test counseling procedures, prison medical directors should encourage HIV-infected inmates to confidentially notify their sexual or needle-sharing partners; and (h) correctional medical care must, as a minimum, meet the prevailing standards of care for HIV-infected persons in the outside community at large. Prisoners should have access to all approved therapeutic drugs and generally employed treatment strategies.

HIV/AIDS Education and Prevention: The AMA: (a) Encourages the inclusion of HIV-prevention information as a regular part of correctional staff and inmate education. AIDS education in state and federal prisons should stress abstinence from drug use and high-risk sexual practices, as well as the proper use of condoms as one way of decreasing the spread of HIV; (b) will pursue legislation that encourages state, local, and federal correctional institutions to make condoms available to inmates; and (c) urges medical personnel in correctional institutions to work closely with state and local health department personnel to control the spread of HIV/AIDS, tuberculosis, and other serious infectious diseases within and outside these facilities.

Prison-based HIV Partner Notification Program: The AMA (a) Urges state health departments to take steps to initiate with state departments of correctional services the development of prison-based HIV Partner Notification Programs for inmates convicted of drug-related crimes and their regular sexual partners; and (b) believes that all parties should recognize that maximum effectiveness in an HIV Partner Notification Program will depend on the truly voluntary participation of inmates and the strict observance of confidentiality at all levels.

State Tracking of HIV/AIDS and Other Serious Infectious Diseases

The AMA: (1) Encourages state medical associations to support state legislation to establish requirements for reporting and case follow-up for HIV/AIDS and other serious infectious diseases, nationwide. Specific statutes must be drafted that, while protecting to the greatest extent possible the confidentiality of patient information: (a) provide a method for warning unsuspecting sexual partners, needle-sharing partners, or other close contacts; (b) protect physicians from liability for failure to warn the unsuspecting third party; but (c) establish clear standards for when a physician should inform the public health authorities; and (2) will assist states in their efforts to take whatever actions are necessary to allow blood banks and health departments to share information for the purpose of locating and informing persons who have any transmissible bloodborne disease.

National Health Survey

The AMA supports a national health survey that incorporates a representative sample of the U.S. population of all ages (including adolescents) and includes questions on sexual orientation and sexual behavior.

Also see the AMA's  Infectious diseases  Web site.

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Last updated: Mar 14, 2008
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