Background and Objective:
The health sector has a vital role to play in delivering prevention, diagnosis, treatment as well as care to the population it serves, and in combating stigma and discrimination. To do so, health workers' own health, rights and working conditions must be protected. The World Health Organization, International Labour Office and the International Organization for Migration note that "although health workers are at the frontline of national HIV programmes, they often do not have adequate access to HIV services themselves". The increased risk to health workers of developing tuberculosis (TB) has also been well-established and is a growing concern. These guidelines were designed to focus on reinforcing and accelerating the implementation of best health practices for health workers who are living with, or have been affected by HIV or TB, or with risk to be exposed to HIV and TB in the workplace. The ultimate goal is to contribute to the improved health of health workers and to retain them in the workforce.
This document presents an evidence-informed policy for the provision of improved access to HIV and TB prevention, treatment, care and support for health workers. This policy guideline complements and synthesizes other WHO guidelines, especially related to TB infection control, HIV control in the workplace, health-systems strengthening, clinical diagnoses and treatment for HIV and TB, as well as reproductive health and occupational health. Indeed the primary purpose of these guidelines is to draw together previously developed clinical and policy guidelines, along with recent evidence, into a coherent set of recommendations that aim to provide improved access of health workers to HIV and TB services.
Target Audience and Scope:
The main target audience for these policy guidelines consists of policy makers in member states as well as all employers of health workers. The recommended policy guidelines are expected to be useful for health and labour departments, regional policy-makers, health facility managers, and all front-line health workers - including informal health givers of which the large majority are women. It is expected that these guidelines will also be useful to representatives of health workers, including unions and health professional associations, as well as occupational health and infection control practitioners.
The guidelines were scoped to provide guidance for the target audience on how to implement interventions to promote policies and programmes where change is desired in order to address the identified need to integrate existing guidelines relevant to HIV and/or TB in health workers into one comprehensive source that taken together will improve access of health workers to needed evidence-based services.
Protocol for Guideline Formulation:
The evidence base for this policy guideline was established through a systematic evidence review that contained several components. An in-depth study of five African countries was commissioned to help with guideline development; a review of existing guidelines was conducted complemented by a preliminary literature review of the evidence; a 17-country survey from across all WHO regions was conducted to provide input to these guidelines; a Cochrane-style systematic evidence review focusing on questions not previously reviewed in depth for other recent guidelines was also conducted, supplemented by a systematic realist-style narrative review to ascertain determinants of success. This multi-component systematic evidence review is consistent with the growing trend, supported by the WHO, to supplement the traditional Cochrane-style approach with other methods.
The evidence review highlighted some areas where evidence supports interventions, and highlights important determinants of successful outcome, as well as areas in need of more research. The recommendations that were developed were informed by the evidence from the systematic evidence review, but were also explicitly based on additional factors, notably potential benefits versus potential harms; principles and value preferences; feasibility; and anticipated cost.
Following the initial work in preparing draft recommendations, with assistance and preliminary approval from the Guideline Review Committee, two large consultation meetings were held -in July and September 2009 - supplemented by telephone and email interactions with multiple stakeholders and experts.
Working groups were formed during the consultations, focusing on the wording and evidence related to specific recommendations. The final grading of the evidence and decisions regarding the recommendations were conducted with extensive input of the entire multi-stakeholder, multi-disciplinary expert group assembled as the Guideline Group (GG) and partners (listed above).
Values and Principles:
The values and principles underlying the recommendations are explicitly set out in this document. These values include respect for human rights; gender equity and adopting gender-sensitive policies and programmes; involvement of people living with HIV and TB; involvement of front-line health workers and their representatives, employers; worker rights; hierarchy of controls and the primacy of prevention; and the valuing of promoting effectiveness and efficiency through transcending traditional boundaries.
Quality of Evidence:
This document presents each recommendation, along with a brief review of the evidence and discussion of key points, followed by important references and existing WHO guidelines that support the recommendation. A table is presented for each recommendation outlining the rating of the quality of the evidence, advantages and disadvantages, principles and values, cost and feasibility considerations, and the overall conclusion regarding the strength of the recommendation. Details of the Cochrane-style systematic evidence review process are described in Yassi A, O'Hara LM. LoChang J, Lockhart K, Spiegel JM (2009).
While the quality of evidence was generally only moderate at best, often due to poor reporting on the part of the investigators as is often the case with respect to policy interventions, especially in workplace settings, the evidence was generally highly consistent, and, in taking into account the other factors influencing decisions on recommendations, all recommendations advanced in these guidelines are either strongly supported or very strongly supported.
The area where the evidence and arguments were least clear related to the inclusion of families (other than for TB case finding, where the evidence was clearly supportive). This is largely because the only programme published that provides comprehensive access of a workforce including families is the one in Swaziland that , while widely heralded as a success, has never been the subject of rigorous evaluation. In a qualitative study of the Swaziland HIV centers for health workers, about half the respondents supported including family members for priority access to ART, while half felt that including family members would anger patients on waiting lists. However, as noted, both by these authors and those studying programmes in other sectors as well as in the health sector itself, there is a strong need for guidelines in this area as evidence strongly indicates that informal mechanisms are currently problematic and hinder the goal of improved access for health workers to HIV and TB prevention, treatment, care and support.
The main arguments in favour of providing priority access can be summarized as follows: First, the global deficit of health workers means that health workers are a particularly valuable resource. This deficit is a critical bottleneck in the provision of care for the still enormous numbers who need HIV/TB services. (WHO World Health Report, 2006) Therefore, the wider population will suffer if the lives and working capacity of health workers are not protected. This argument has stronger application to professionally trained health workers than to general service workers in labour surplus economies. Secondly, health workers are exposed to occupational risk, particularly for TB, in addition to the risks incurred by the general population. Health workers who are HIV positive are at particularly increased risk of opportunistic infections through work-related exposure. It is the duty of employers to minimize the risks of occupational exposure, and to provide appropriate remedies (including facilitated access to treatment and care) in the event of an occupationally acquired illness or where there is a reasonable presumption that the illness may have been occupationally acquired. Even in the case of non-occupational exposure it is good employment practice to provide facilitated access to treatment and care in the interests of preserving workforce productivity and good workforce morale. Thirdly, health workers have access to diagnostic kits, drugs and the professional opinion of colleagues and there is evidence that health workers self diagnose and treat (or diagnose and treat in collusion with colleagues) through informal channels anyway. Giving health worker formal preferential access legitimizes what is largely happening anyway and gives some protection from undesirable practices, for example self-prescribing dangerous drug combinations.
With respect to family members the following is noted: First, the illness or premature death of persons who are not themselves health workers can have a profound impact on the size and productivity of health human resources, if the related health worker withdraws in whole or part from employment to care for family members, or if family illness affect the motivation or concentration of health workers at work. Secondly, the practice of health workers' sharing medications with infected family members is widely known, although the exact prevalence of this practice is undefined. However, by definition, while family members may be exposed to elevated risk by association with related infected health workers, most obviously for TB but also for HIV, non-health workers are not exposed to occupational risk. Additionally, while the duty of employers to provide services for families of employees, although applied in practice in some sectors and supported by ILO conventions, is less well defined and adds considerable cost.
In view of the evidence as well as principles and values underlying this policy, the GG has chosen to recommend that household immediate family members of health workers should be included for priority access to diagnosis, counseling and support (e.g. Voluntary Counseling and Testing [VCT]) and case finding for TB; and that all household immediate family members of HIV-infected health workers should be offered priority access to ART, as clinically appropriate. ( Note that priority access to HIV and TB services for immediate family members living in the same household as the infected health worker is recommended, but not priority access to all services to all family member of a health worker in all circumstances)
The other area where considerable discussion occurred related to the site for providing priority access for health workers. The general consensus in the literature is that staff clinics in the workplace are the preferred site (provided that confidentiality can be maintained, and a holistic programme offered) particularly due to the logistical simplicity, and the potential to improve the normalization of services for these diseases in conjunction with staff health concerns generally. There is also general consensus that providing access through a comprehensive occupational health programme is desirable from a cost and integration perspective. Offering annual testing (including VCT and TB screening) in staff clinics as part of existing annual check-up of general health is recommended by international organizations as good practice, and supported by evidence as a preferred approach. For example, a cluster randomized trial of on-site versus off-site VCT services provided by employer-funded HIV programmes found that there was a significantly greater uptake of services when provided on-site. Nonetheless, other models, most notably the Swaziland model, provides advantages as well. While the staff clinic model of service delivery for health workers provides a host of advantages, the option for health workers to be tested and treated if preferred at another facility could also be offered.
Recommendations
After careful consideration, 14 recommendations were developed:
- Introduce new, or refine existing, national policies that ensure priority access for health workers and their families to services for the prevention, treatment and care for HIV and TB. (STRONG RECOMMENDATION for Health Workers for priority access to full services; STRONG RECOMMENDATION for TB case finding in families; MODERATE for families with respect to ART based on moderate quality of evidence, moderate benefits of desired effects, very strong values and preferences, moderate costs and strong feasibility.)
- Introduce new, or reinforce existing, policies that prevent discrimination against health workers with HIV or TB, and adopt interventions aimed at stigma reduction among colleagues and supervisors. (STRONG RECOMMENDATION based on moderate quality of evidence, very strong benefits of desired effects, very strong values and preferences, strong costs and strong feasibility.)
- Develop or strengthen existing occupational health services for the entire health workforce so that access to HIV and TB prevention, treatment and care can be realized. (STRONG RECOMMENDATION based on moderate quality of evidence, very strong benefits of desired effects, very strong values and preferences, strong costs and moderate-strong feasibility.)
- Develop or strengthen existing infection control programmes, especially with respect to TB infection control, and ensure integration with other workplace health and safety programmes. (STRONG RECOMMENDATION based on moderate quality of evidence, very strong benefits of desired effects, very strong values and preferences, very strong costs and very strong feasibility.)
- In conjunction with health workers' representatives, develop and implement programmes for regular, free, voluntary, and confidential counselling and testing for HIV and TB, including addressing sexual and reproductive health issues, as well as intensified case finding in the families of health workers with TB. (STRONG RECOMMENDATION based on moderate quality of evidence, strong benefits of desired effects, moderate values and preferences, moderate-high costs and strong feasibility.)
- Develop and implement training programmes for pre-service, in-service and continuing education on TB and HIV prevention, treatment and care services, integrating with existing programmes and including managers and worker representatives as well as health workers. (STRONG RECOMMENDATION based on weak quality of evidence, very strong benefits of desired effects, very strong values and preferences, conditional to country setting costs and conditional to country setting feasibility.)
- Disseminate policies in the form of guidelines and codes of practices for application at the level of health facilities, and ensure provision of budgets for the training and material inputs to make them operational. (STRONG RECOMMENDATION based on moderate quality of evidence, strong benefits of desired effects, strong values and preferences, conditional to country setting costs and conditional to country setting feasibility.)
- Adapt and implement good practices in occupational health and the management of HIV and TB in the workplace from all sectors. (STRONG RECOMMENDATION based on weak quality of evidence, strong benefits of desired effects, very strong values and preferences, weak costs and moderate feasibility.)
- Establish and provide adequate financial resources for prevention, treatment, care and support programmes to prevent the occupational or non- occupational transmission of HIV and TB among health workers. (STRONG RECOMMENDATION based on very weak evidence, strong benefits of desired effects, very strong values and preferences, low costs and conditional to country setting feasibility.)
- Provide universal availability of free and timely PEP to all health care providers, for both occupational and non-occupational exposures, with appropriate training of counsellors and information on the benefits and risks provided to all staff. (STRONG RECOMMENDATION based on moderate evidence, strong benefits of desired effects, very strong values and preferences, strong costs and moderate feasibility.)
- Provide free HIV and TB treatment for health workers in need facilitating the delivery of these services in a non-stigmatizing, gender-sensitive, confidential, and convenient setting when there is no staff clinic and/or their own facility does not offer ART, or where health workers prefer services off-site. (STRONG RECOMMENDATION based on weak evidence, strong benefits of desired effects, very strong values and preferences, strong costs and moderate feasibility.)
- In the context of preventing co-morbidity, provide universal availability of a comprehensive package of prevention and care for all HIV positive health workers, including IPT and CTX prophylaxis, with appropriate information on the benefits and risks. (STRONG RECOMMENDATION based on moderate quality of evidence, strong benefits of desired effects, moderate values and preferences, strong costs and conditional to country setting feasibility.)
- Establish schemes for reasonable accommodation and compensation, including, as appropriate, paid leave, early retirement benefits and death benefits in the event of occupationally-acquired disease. (STRONG RECOMMENDATION based on weak quality of evidence, strong benefits of desired effects, very strong values and preferences, conditional to country settings costs and conditional to country setting feasibility.)
- Develop and implement mechanisms for monitoring the availability of these TREAT policy guidelines at the national level, as well as the dissemination of these policies and their application in the healthcare setting. (STRONG RECOMMENDATION based on moderate quality of evidence, very strong benefits of desired effects, very strong values and preferences, moderate costs and moderate feasibility.)
Integrating Framework:
These 14 statements are grouped into 6 categories as shown below, that together provide guidance to member countries. While the framework itself is not the focus of the policy, it is presented to assist member countries and the various target audiences within the countries, to appreciate the synergistic nature of the multiple components.
The recommendations are grouped into one over-arching policy recommendation to implement national policies to provide priority access to HIV and TB services for health workers (statement 1); supporting policies and needed infrastructure (statements 2-5); training and codes of practice to guide policy implementation (statements 6-8); recommendations related to funding of programme elements and medications (statements 9-12); compensation (statement 13); and finally monitoring (statement 14).
Implementation Plan
A monitoring and evaluation group should be established within ILO/WHO, which would oversee the development of a detailed implementation plan, followed by a series of dissemination meetings at the country level. The implementation details should be developed at the regional level. Virtual meetings and other innovative suggestions must be employed with the aim of prioritizing funds for implementation and adaptation at country level.
Existing technical working groups should be utilized as a first point for implementation of guidelines and roles and responsibilities must be adopted by country officers to initiate stakeholder discussion and empower key players to adapt and translate guidelines. Implementation of the recommendations into national programmes should be considered in conjunction with an action plan for implementation at the facility level. Successes and challenges of this complex package of recommendations must be measured. A work plan linked to targets with measurable results and the coordination of distribution policies is essential.
Implementation must use an adaptation approach to promote the formulation and implementation of the new guidelines. Shared ownership by partners, civil society, unions and health professional associations is essential. Relationship building and shared principles are required to ensure success and to ensure that cultural and economic differences of individual countries are considered.
Bearing in mind the crucial importance of these policy guidelines, simplified advocacy materials will be developed to assist the users . This is in line with the proposal on implementation strategy as put forward by the partners and stakeholders during international consultations in September 2009 (refer Annex 2 pp 121-123).
Following its publication and launching by WHO and ILO, the guideline will be reviewed after 2-5 years to ensure consistency with possible new developments related to the subjects covered.