The attitudes of British surgical trainees about the treatment of HIV-infected patients
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- Griffin, M.F. & Hindocha, S. Surg Today (2012) 42: 1066. doi:10.1007/s00595-011-0096-2
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As the incidence of HIV increases, the occupational risk of human immuno deficiency virus (HIV) infection also increases, leading to heightened anxiety within surgical practice. This study assessed the attitudes of surgeons treating HIV-infected patients.
Seventy surgical trainees working in two district general hospitals were requested to complete a survey assessing their attitudes regarding the surgical management of HIV-infected patients.
A needle-stick injury was reported by 64% of the trainees. Fifty-four percent of trainees were concerned about acquiring HIV from patients when performing a surgical procedure. There was a significant difference between the number of trainees worried about treating a patient with HIV and the number of trainees wearing eye protection when performing invasive procedures (p < 0.002). Eighty-six percent of trainees were confident they could treat HIV patients safely, but only 63% were aware of the hospital protocol for needle-stick injuries.
There appears to be increasing concern among surgical trainees about carrying out surgical procedures on HIV-infected patients. Despite equipment being fully available, many trainees are not considering the full use of protective theatre garments to minimize the risk of HIV contamination. Further education and training is required to stress the importance of the increasing HIV prevalence and the need for safety during surgical practice.
KeywordsHIVSurgical trainingAIDSBritish trainees
There is a global epidemic in the spread of Human Immunodeficiency Virus (HIV), as each year approximately 2.7 million more people become infected with HIV, and two million people die of acquired immune deficiency syndrome (AIDS) . Consequently, the risk of health care professionals contracting HIV has increased . The risk for surgeons is the greatest due to their daily exposure to patient’s blood through handling of open wounds, needle-stick injuries by glove punctures, as well as facial and body splashes . A surgeon’s cumulative lifetime risk of HIV seroconversion ranges from 1 to 10% . Furthermore, over the next 35 years, it has been estimated that 1 in 1500 surgeons is likely to be infected with HIV .
There have been numerous international studies describing the negative attitudes of health care workers towards people with HIV [5–7]. Fear of contagion, fear of losing patients, unwillingness to care for and inadequate knowledge about treating HIV patients are reported to be the main barriers to HIV care and treatment by physicians . However, there have been few studies describing the attitudes of surgeons toward HIV-infected patients. This study therefore aimed to evaluate the experience and attitudes of British surgical trainees toward HIV-infected patients.
Materials and methods
The questionnaire that was distributed to the surgical trainees, with responses recorded
(1) What is the estimated risk (as a %) of acquiring HIV through a needle-stick injury from a patient who is known to be HIV positive?
16% correct: 1/300 or 0.3%
(2) How many needle-stick injuries have you had in the past 12 months?
36%: 0, 61%: 1, 3%: 2
True n (%)
False n (%)
(3) Is the incidence of HIV in the UK increasing?
(4) I am worried about acquiring HIV infection from patients
(5) I always wear eye protection in the operating theatre
(6) It is my professional duty to provide surgical treatment to any patient, irrespective of their HIV status
(7) There are many (>50%) surgeons who will not treat patients who are HIV positive
(8) Patients with HIV or AIDS should be placed last on the elective list
(9) Patients with HIV or AIDS should be placed last on the emergency list
(10) Performing surgery on HIV positive or AIDS patients is too dangerous
(11) I have performed or assisted with a surgical procedure on a patient who was not known to be HIV positive at the time of surgery
(12) Do you always enquire about a patients HIV status prior to their operation
(13) I feel that I can treat HIV-infected individuals safely
(14) Have you ever performed or assisted in any procedures on a patient who was known to be HIV positive?
(15) I will perform or assist with surgical procedures on HIV-infected individuals
(16) I have reservations about treating HIV-infected patients
(17) I have reservations about treating patients who have AIDS
(18) I am aware of the hospital protocol in case of a needle-stick injury
(19) I find it difficult to ask a patient about HIV when consenting or clerking them for a surgical procedure
(20) I assess the risk of a surgical procedure to the surgeon based upon the patients’ HIV status, rather than the type of procedure being performed
The responses of the 70 surgical trainees were tabulated and analyzed. The risk of acquiring HIV through a needle-stick injury was 0.03% . Only 16% of surgical trainees correctly estimated this statistic, despite the fact that 64% of respondents had experienced a needle-stick injury during the last twelve months. Eighty-seven percent (61/70) of the trainees knew the incidence of HIV in the UK is increasing. Although 54% (38/70) of surgical trainees were concerned about acquiring HIV from patients when performing a surgical procedure, only 26% (17/70) of the trainees were found to be wearing eye protection when performing invasive surgical procedures, which was found to be significantly different (Student’s t test, p < 0.002).
Approximately one quarter of the surgical trainees had reservations about treating people with AIDS (19/70) or HIV (18/70). However, 67% (47/70) of the surgical trainees felt they could safely treat patients with HIV, although only 63% (44/70) could recall the hospital guidelines about treating patients with HIV and post-prophylaxis guidelines after a needle-stick injury.
Encouragingly, three-quarters (51/70) of trainees stated they would perform or assist in a surgical procedure on an HIV-infected patient, with 94% (66/70) agreeing that it is a professional duty to treat patients irrespective of their HIV status. Surgical conduct by the trainees was not highly influenced by the patients’ HIV status, as 90% (63/70) assessed the risk of the surgical procedure according to the type of procedure, and not the patient’s HIV status. Moreover, 93% agreed that HIV patients should not be placed last on the emergency list (65/70), while only 49% (34/70) of trainees felt that HIV or AIDS patients should be placed last on the elective list. Furthermore, only 3% (2/70) of the physicians felt it was too dangerous to perform surgery on HIV positive patients, and only 17% (12/70) felt there are greater than 50% of doctors who will not treat HIV patients).
Only 31% (22/70) of trainees stated that they find it difficult to ask a patient about his/her HIV status before a surgical procedure, although only 7% (5/70) agreed that they always enquire about a patient’s HIV status prior to their operation. Fortunately, only 7% of the trainees had assisted with surgery on a patient who was not known to be HIV positive at the time of surgery, while 31% (22/70) of them had performed or assisted with procedures on patients known to be HIV positive at the time of surgery.
It is clear from this study that there is increasing concern about the risk of contracting HIV from infected patients and treating people with HIV. This surgical attitude was similarly reported by a group of 264 South East Nigerian surgeons, as 83% stated they had reservations about treating patients infected with HIV, and 13.3% viewed them with fear . Duyan et al.  further demonstrated that 82% of 128 Turkish surgeons of various specialties were worried about contracting HIV from patients. Furthermore, one survey established that three-quarters of 504 American orthopedic surgeons were moderately to very concerned about acquiring HIV at work .
Despite their anxiety, the surgical trainees in this study were not utilizing all forms of protective barriers, failing to use eye protection in 64% of cases. Eye protection, surgical clothing and gloves are all apart of the hospital policy for treating HIV/AIDS patients. A recent study confirmed this poor practise in 25 orthopedic surgeons in Scotland, because it was found that eye protection (goggles/visors) was only mandatory in 10 surgical units . Interestingly, studies have shown that the fingers, face, neck and lower limbs of surgeons are more at risk of contamination that other parts of the body [14–16]. Jagger et al.  further demonstrated that the face, specifically the eyes, are more at risk of being contaminated by blood, irrespective of the surgical specialty. Furthermore, the epidermal cell initially infected by HIV is considered to be the Langerhans cells, which are found on the surface of intact mucous membranes, which also highlights the importance of eye protection . For orthopedic surgeons, eye protection is considered to be especially important, as the conjunctiva may become infected from blood-containing aerosols, such as those generated by orthopedic drills .
Universal precautions have been designed by the British Centre for Disease Control (CDC) to prevent the transmission of HIV, hepatitis B virus (HBV), and other blood-borne pathogens to health care professionals from infected patients. These include the utilization of protective barriers such as gloves, gowns, aprons, masks, or protective eyewear to reduce the risk of exposure of the health care worker’s skin or mucous membranes to potentially infective materials.
However, there are still uncertainties about what other precautions surgical trainees should be undertaking during surgery when operating on a HIV-infected patient. For example, double gloving has shown to reduce the number of perforations of the pair next to the skin, which in turn decreases the skin contamination by blood/bodily fluids on the surgeon’s hands. Although this precaution has been found to be highly effective in preventing perforations [14, 19], reports have shown that double gloving is not always utilized [20, 21]. Waterproof synthetic garments have shown to be more effective in preventing liquid strikethrough and bacterial contamination than non-synthetic gowns . Footwear can be a further barrier, as Quebbeman et al. . showed that the high rate of contamination of the legs of orthopedic surgeons could be prevented by wearing Wellington boots. Furthermore, it is important that surgeons keep up to date with their immunization status regarding blood-borne viruses, because there have been reports that not all surgeons are being vaccinated . Two studies have been found that younger surgeons were more likely to be vaccinated, however, training and education is still crucial for surgeons of all ages [20, 23].
Other techniques have been documented to reduce needle-stick injuries. First, needle-stick injuries can occur when a suture is tied with the needle still attached. Therefore, removing the needle before hand tying is a simple precaution . A non-touch technique in which tissues are held with forceps and the needle is held in a holder can also be safer than using hand needles . One study also reported that avoiding placing a suture though tissue directly supported by the opposite hand, by having a protective field over the distal index finger (if the surgeon is right-handed) is useful, as this is the site most often punctured . There have also been successful reports of using other instruments instead of scalpels for dissection to reduce the risk of contamination .
The high occurrence of needle-stick injuries reported in this study is of concern, considering that as a consequence of such injuries there are an estimated 66,000 infections with HBV, 16,000 with HCV, and 1,000 with HIV annually worldwide . Preventing such injuries can be achieved by educating surgical trainees about  using instruments (not fingers) to grasp needles , avoiding hand-to-hand passing of sharp instruments , making sure the needle driver is clamped to the suture rather than the needle when passing to assistants , by ensuring the availability of using blunt-tip suture needles , and by ensuring correct suturing techniques so as few digits are exposed as possible, using instruments as much as possible [20, 27]. Many studies have reported that surgeons never or rarely report needle-stick injuries, largely because surgeons feel the process takes too long, that the risk for transmission is low, and because they do not want to disrupt the surgical list . It is important to emphasize the importance of reporting incidents to the surgical trainees in order to prevent this practise in the future, as the associated risk of infection is significant  and self reporting allows proper post-occupational exposure prophylaxis and accurate documentation of the magnitude of this occupational hazard .
Encouragingly, our surgical trainees felt they had a duty as doctors to treat HIV patients, and this obligation was similarly felt by orthopedic surgeons in Nigeria . However, there have been reports which have shown that surgical trainees will not operate on HIV-infected patients . This discrimination has been accounted for by different factors including the non-availability of equipment to comply with universal precautions, inadequate training and their level of awareness .
Although not thoroughly tested, the knowledge of the surgical trainees was not adequate, as only 16% of participants knew the correct risk of acquiring HIV from a needle-stick injury. This lack of knowledge was also reported in a study of 915 American surgeons, with only 34% correctly stating the seroconversion rate after exposure to a patient with HIV . Knowledge is not only inadequate amongst surgeons, as Faris et al.  reported that among a group of 346 Egyptian heath care workers, 67% had incorrect ideas about the transmission rate of HIV.
In only 7% of cases did our surgical trainees enquire about the patient’s HIV status prior to surgery. Kelen et al.  demonstrated that clinical suspicion is not an adequate method to identify patients who are infected with HIV. This approach relies on all surgeons agreeing on the concept of a ‘high risk group’. However, HIV transmission results from engaging in high-risk behaviors, not from being part of a ‘risk group’ . Therefore, it is important to ensure that surgical trainees have correct knowledge of when it is appropriate to ask about HIV status. Our study is limited due to the small number of surgeons involved in the study, although we do feel that this study showed the concerns of the British surgical trainees when treating HIV-infected patients and the need for further education, which can serve as a basis for further studies. Although the study questionnaire has not been used previously, and no other survey has used such a questionnaire, we believe that the questionnaire used for this study has been shown to be user-friendly and understandable by the target audience, and can be considered for future studies.
Overall, our study shows that British surgical trainees require better education and training regarding preventive methods to reduce the risk of acquiring HIV from patients, and need to be better informed about the risk of HIV transmission. This will decrease the anxiety of the surgical trainees, enabling better surgical care and management of HIV and AIDS patients.
Conflict of interest
M. Griffin and co-authors have no conflicts of interest.