Infections transmitted in body fluids: HIV (ILO/IMO Guidelines Appendix E B 20-24)

Impairment and risks

The risks of transmission of infection through body fluids while at sea because of living and working conditions are remote. Aspects of lifestyle: sexual relations and practices, the use of injected illicit drugs and the adequacy of infection control practices in clinical care determine transmission risks. Because of the form of transmission and consequent stigmatisation of those with such conditions the process of assessment and decision taking on fitness has to take account of legal and ethical as well as scientific information.
The scope for exposure while undertaking normal maritime duties is limited to the treatment of accidents where blood has been spilt. Normal precautions designed to prevent wound infection also ensure that those providing emergency treatment are at very low risk of becoming infected, should the casualty have an infection that is transmissible in body fluids.
Risks of sudden incapacitation and of acute illness while at sea are very low in the early stages of HIV infection. However some of the treatments used may cause problems in some individuals that can reduce performance, while all treatment require regular monitoring to check that the infection remains under control and is not becoming resistant to the medications used. Provided that the progress of the infection is being monitored this will provide an indication of the need to restrict employment.

HIV and AIDS

Rationale and justification

• The HIV virus is transmitted in blood and body fluids and so infection arises from sexual contact, needle sharing in drug misusers and from contamination during medical procedures. It is also transmitted from mother to baby. The HIV virus is less infective by these routes than hepatitis B.
• The infection, apart sometimes from mild symptoms soon after the initial infection, remains latent for a long period. Progress from initial infection to disease that is relevant to work at sea is usually over many years and may be virtually halted by effective treatment. During this time the HIV virus can be detected in the blood as can its effects in terms of damage to CD4 lymphocytes. The infected person can transmit infection to others if there is contact with their blood or other body fluids.
• Untreated infection slowly progresses until the body's immune mechanisms are damaged enough to allow serious or fatal infection by other micro organisms or the development of certain malignancies
• A wide range of complications are associated with the later stages of HIV infection including:
  • Severe weight loss >10% of weight
  • Unexplained chronic diarrhoea for > 1 month
  • Unexplained or persistent fever for > 1month. This may be either intermittent or continuous
  • Infections: oral candidiasis, oral hairy leucoplakia, pulmonary tuberculosis, severe bacterial infections, acute necrotising ulcerative stomatitis or gingivitis, cytomegalovirus
  • Malignancies: non-Hodgkins lymphoma, cervical cancer, Kaposi sarcoma.
• Treatment will greatly delay damage to the immune system and thus prevent secondary infection and AIDS related malignancies. The effectiveness of treatment regimes is increasing, but the HIV virus can develop resistance to anti viral agents and for this reason combination therapy (HAART – highly active antiretroviral therapy) is often used. This can increase the likelihood of side effects and careful long term monitoring is essential
• Dementia occurs in some of those with prolonged HIV infections. It does not appear to be related to secondary infection. Its presence can be identified using psychometric tests.
• The incidence of HIV+ status varies markedly between countries and between groups of people depending on their exposure to the risks of sexual, blood borne or mother to child infection.
• The progression from asymptomatic infection to AIDS, where serious complications arise, is relatively slow and is unlikely to occur between one medical assessment and the next.
• CD 4 lymphocyte counts are important predictors of risk:

A recent CD4 count above 350 cells/mm3 indicates a low risk of complications

Assessment and decision taking

Background

Unless the diagnosis is disclosed to the examiner, it is usually impossible to detect a HIV positive asymptomatic seafarer. Seroconversion may be associated with a brief influenza-like illness. The presence of generalised lymphadenopathy or oral hairy leukoplakia may also be indications of HIV infection.

Signs and symptoms of advanced HIV disease such as persistent infections or significant weight loss will normally mean that the seafarer's immune system is weakened and they will need frequent and close specialist supervision. If HIV status has not been recognised early this may be the presenting stage of the disease. Fitness for work at this stage will depend on the scope for treatment of the HIV infection and any complications of it.

HIV positive seafarers, who are aware of their status and have declared it need to be given a fair examination based on rational and fair criteria to determine whether a seafarer is Fit, Unfit or Temporarily Unfit (and the appropriate time to be allowed for return to work).

Specialist advice is needed to assist in the determination of the possible consequences of the disease and its treatment for the time period prior to their next reassessment.

Much work has been done on the employment of people who are HIV+ but none specific to the Maritime industry. These criteria are based on the available studies.

There is extensive guidance on post-exposure prophylaxis available in the health care sector.

Clinical assessment and proposed criteria

In all cases of confirmed HIV positive status the assessment and decision taking process should be informed by advice from the clinician responsible for the care of the individual. It is the clinician and not the Approved Doctor who is responsible for the determining the frequency of surveillance needed to guide clinical care, where it needs to take place and for provision of medications needed while the seafarer is at sea. However it is for the Approved Doctor to take the final decision and issue a fitness certificate in line with the guidance below. Wherever possible there should be continuing close liaison between the treating doctor and a single Approved Doctor who determines fitness to work at sea.

a) Undeclared HIV status

Pre employment HIV testing is not recommended. It is illegal in many jurisdictions. It can only be justified if it can be shown to predict likely risks while working at sea prior to the next medical assessment. However if physical signs that raise suspicions of HIV disease are found during a pre-employment examination the clinician to whom the seafarer is referred for investigation would be expected to have performed tests for HIV and advised the seafarer of the results.
HIV testing should be a matter for the individual and their clinical advisers and not a condition for obtaining employment. The finding of HIV+ status has major implications for an individual. Detection and rejection for employment together are likely to have a very severe effect. Those who carry out HIV testing need to recognize their obligation to counsel the person tested and arrange referral, investigation and treatment if a positive result is found.
It may be appropriate, depending on incidence of HIV and individual risk factors, to advise seafarers of the benefits of voluntary testing so that any required treatment can be initiated early and they can take informed decisions about their career and lifestyle.

b) Declared HIV + status, asymptomatic.

An individual who is HIV positive, but without other signs or symptoms, can be so either because they are at an early stage of the infection and their immune system is still functioning well or because they are on antiretroviral therapy and have a well restored immune system.

A seafarer who is receiving medication for HIV is obligated to give details to the assessor so that any side effects can be considered. 

For those who have declared that they are HIV positive the widely used WHO staging categories provide a valid basis for fitness determination.

• Clinical Stage 1
  Acute retroviral infection
  Asymptomatic
  Persistent generalized lymphadenopathy
  Performance scale 1: asymptomatic, normal activity

c) HIV + status, symptomatic

• Clinical Stage 2
  Weight loss, < 10% of body mass
  Minor mucocutaneous manifestations
  Herpes Zoster in the last 5 years
  Recurrent upper respiratory tract infection
  Performance scale 2: Symptomatic, normal activity

• Clinical Stage 3
  Weight loss, >10% of body mass
  Unexplained chronic diarrhoea>1 month
  Unexplained prolonged fever> 1 month
  Oral candidiasis
  Oral hairy leukoplakia
  Pulmonary tuberculosis
  Severe Bacterial infections
  Performance scale 3: bed ridden < 50% of the day during the last month.

d) AIDS complex

• Clinical Stage 4
  HIV wasting syndrome: weight loss >10% body mass, plus unexplained chronic diarrhoea (>1 month) or chronic weakness and unexplained fever(>1 month)
  Pneumocystis carinii pneumonia
  Toxoplasmosis of the brain
  Cryptosporidiosis with diarrhea greater than a month.
  Cytomegalovirus
  Cryptococcus (extrapulmonary)
  HSV infection
  Progressive multifocal leuko-encephalopathy Any disseminated mycosis
  Candidiasis of the mouth, trachea, oesophagus, bronchi or lungs
  Atypical mycosis
  Non-typhoid salmonella septicaemia
  Extrapulmonary tuberculosis
  Lymphoma
  Kaposi sarcoma
  HIV encephalopathy
  Performance Scale 4: bedridden for>50% day during the last month.

1. Determine staging and any complicating factors

• Are there detectable signs of HIV dementia? (Presence indicates high probability of progressive cognitive impairment)
• Is the CD4 lymphocyte count above 350 (Below 350 there is a well established excess risk of infection)? This justifies a period of temporary unfitness until treatment has been given, the count has risen and the absence of secondary infection is confirmed.
• Are there any side effects from treatment or drug interactions that can be disabling in the short term or lead to longer term damage? (The effects of medication use on fitness are complex. Compliance with therapy slows progression.) Side effects are commonest in the first few weeks after a change of medication. Common side effects include nausea, diarrhoea, headaches and blood abnormalities.
• Is there good liaison between the treating doctor and the Approved Doctor? If not is the individual's compliance with medication or with regular clinical surveillance to identify complications from the infection or from medication in doubt? If there is doubt on the part of the Approved Doctor then the duration of any certification will need to be very limited, and the Approved Doctor should aim to ensure that the seafarer will comply with recommendations on treatment, surveillance and side effect reporting and that information on their status is regularly provided by the doctor with clinical responsibility for treatment.

Stage 1 AND no complications AND CD4 count above 350 AND never been on treatment OR has been on stable treatment free from side effects AND requiring surveillance less that every six months. Fit. Limit duration to time of next specialist appointment if surveillance leading to change in treatment is anticipated. CD4 counts are normally checked at least once every six months.

Stage 2 with no impairing complications AND CD4 count more than 350 AND/OR on antiretroviral medication requiring surveillance more than every six months. Restricted, near coastal

Stage 2 with impairing complications OR Stage 3 or 4, AND treatment being changed or adjusted with scope for cure of HIV associated conditions and improvement in symptoms AND rise in CD4 count to level above 350 OR reduction in side effects from medication. Temporarily unfit

Stage 3 or 4 without scope for improvement. Permanently unfit

Investigation and treatment in a seafarer who is classified as temporarily unfit will be a matter for a clinician with relevant skills. An effective dialogue is needed to ensure that a realistic assessment of current clinical state and the risks of progression are known. The seafarer should always see the same Approved Doctor (AD) who should be in contact with the specialist responsible for surveillance and treatment. The needs up to date information on CD4 counts, medication changes, complications and time to next specialist appointment to decide on fitness.

Advice to seafarers

The likelihood of eventual unfitness needs to be considered within a clinical setting so that advice can be given on when a career at sea may need to be abandoned and an onshore alternative sought.
Seafarers who have not had an HIV test should be advised, when appropriate, on the advantages and consequences of voluntary confidential testing and where this can be obtained.