OpiniãoAs discussed above, it is now well established that the health workforce is at higher risk than the general population of exposure to infectious diseases generally. While there is no dispute as to the importance of occupational transmission of TB, as discussed as well by Wheeler (2009), there is less consensus regarding the importance of occupational HIV, albeit at least 4-5% of HIV is thought to have been acquired at work. Nonetheless there are few studies that explore the allocation of resources and programmes in this regard. A relevant study by Kiragu and colleagues conducted in Zambia in 2008, (also included in the Systematic Review), focused on the development and testing of an HIV risk reduction workplace programme for hospital staff. This intervention included a peer education programme. Two hospitals were selected where the intervention would be implemented, and three other hospitals served as comparison sites. The intervention was implemented by 79 local staff. This study found that financial challenges limited the intensity with which the project could be implemented and that more concerted efforts could yield higher results. For example, the authors found that participation in the intervention was associated with a nearly six-fold increase in PEP awareness and nearly triple the proportion of respondents reporting high HIV knowledge. Sustained and supportive supervision of programme staff was deemed essential to success.
Similarly, the realist review of the other articles in Tables 2 (PICO 1 results) and 10 (PICO 3 results), also noted that it essential that programmes are provided with adequate financial resources. The study by Kiragu and colleagues (2008) revealed that a major issue of concern in many hospitals is a lack of discrete access to condoms. In many facilities in this region, condoms are stored in designated locations with restricted access. As a result, many nonclinical personnel cannot access condoms at their workplace, and are forced to buy them, seek free ones elsewhere or do without. The programme described by Kiragu made condoms easily available to employees. This strategy was highly successful and removed the social and cost barriers associated with condom access at work.
The evidence, as noted above, suggests that provision of resources specifically for sexual and reproductive health initiatives for health workers is essential to prevent the spread of infection. The importance of linking sexual and reproductive health and HIV is widely recognized (IPPF, UCSF, UNAIDS, UNFPA, WHO 2008). A comprehensive review produced by International Planned Parenthood Federation (IPPF), University of California San Francisco Global Health Sciences (UCSF), UNAIDS, United Nations Population Fund (UNFPA), and the WHO suggest that linking occupational health services with sexual and reproductive health programmes will result in a decreased duplication of efforts and competition for resources, and therefore should be included in the programmes developed in applying these guidelines.
WHO Guidelines indicate that every healthcare setting should have a TB infection control plan as part of an overall infection control programme. As noted by many experts, including, for example, Jensen et al. (2005) in discussion of the US CDC guidelines in this area, the specific details of the TB infection control programme will differ, depending on whether patients with suspected or confirmed TB disease might be encountered in the setting or whether patients with suspected or confirmed TB disease will be transferred to another health-care setting. US guidelines, as consistent with WHO guidelines, also recommends that all healthcare workers should receive baseline TB screening, even in settings considered to be low risk, and the new TB Guidelines confirm this recommendation. Infection control plans might need to be customized to balance the assessed risks and the efficacy of the plan based on consideration of various logistical factors. Although these are all high quality recommendations, the document does not adequately address issues of HOW to implement such initiatives and what types of resources are required to do so.
As mentioned above, there are few well-established HIV and/or TB treatment programmes geared toward health workers, making the estimated costs and financial structures of such initiatives uncertain. One study by Deghaye et al. (2006) published the financial cost of establishing a comprehensive treatment programme for healthcare workers in South Africa. The authors found that the estimated cost would be between R6000 (US $838) and R9000 (US $1256) per person per year. Another South African study, by Badri et al. (2006), converting costs in South African Rand into US dollars, estimated cost per patient year for those on Highly Active ART (HAART) at USD $1342 using South African public sector prices for WHO first line regimens and USD $793 if anticipated local drug prices were assumed.
More importantly, not only is the cost of the medication itself somewhat independent of the mode of service provision, and is generally provided free of charge anyhow, it is more relevant to focus on adequate financing of service delivery. As noted in the discussion of Statement 3, in an attempt to delineate the most cost-effective manner of service provision for this target population Moodley and Bachmann (2002) found that the hospitals surveyed in South Africa that did in fact provide primary health care and the management of chronic illness as part of their occupational health services none experienced logistical or financial problems as a result. As noted, given the array of services that should be provided as part of an occupational health service (based on other WHO and ILO guidelines, and world consensus), including primary, secondary and tertiary prevention of bloodborne and airborne diseases generally (hepatitis, influenza, etc.), the inclusion of HIV and TB prevention, treatment, care and support, should not provide a particular financial burden. As such the issue is the need for proper financing of occupational health services and health and safety committee functioning, including training.
There are numerous studies addressing various aspects of the cost-benefit of specific workplace primary and secondary prevention measures, including studies by Yassi and colleagues, with respect to primary prevention, for example with respect to preventing needlestick injuries (e.g. (Yassi et al.1995a) and back injuries (e.g. Spiegel et al., 2002) as well as secondary prevention of musculoskeletal injuries (e.g. Yassi et al. 1995b). The cost-benefit of providing a comprehensive occupational health services compared to no service, or compared to a partial service, has never been explicitly evaluated .
The bigger question here is the issue of inclusion of families. As noted for recommendation #1, this area has not been the subject of previous guidelines, albeit there is a good argument to be made, supported by evidence (see Table 11). For example, well-resources staff clinics in large multinational companies, found that if families are not included, the success of the programme can be seriously undermined. Although the vast majority of employers do not provide such comprehensive services to families of employees, some do, as discussed above. The findings from the realist review of the articles identified through the Cochrane-style Systematic Review as shown in Table 11, plus the Swaziland programme's reported experience, indicate that inclusion of families is important.
The other noteworthy finding in the realist review is the importance placed on adequate resources as a determinant of success. The programme described in Table 11 in three hospitals in Zambia noted that the financial challenges experienced hampered crucial activities such as retraining of peer educators, and the ability to provide them with sustained and supportive supervision. It also limited available educational materials, making it difficult to respond adequately to emerging issues and topics. Although hospitals offered some support, the financial challenges limited the intensity with which the project could be implemented. These authors stress the importance of providing adequate funding to achieve success.
Thus, while there is ample evidence that programmes to prevent occupational and non-occupational transmission of HIV and TB among health workers are needed, and that the exact details of the costs remain vague and context-specific, adequate financial resources are certainly needed for such programmes. Financial resource cost estimations must also consider human resources implications and programme specific materials, not just the cost of medications and related costs
- The GG concludes that it is well established that the healthcare workforce is at higher risk than the general population of exposure to infectious diseases generally. The GG also concludes that there is good rationale to include sexual and reproductive health issues in comprehensive occupational health programmes to prevent, diagnosis, treat, care and support health workers with respect to HIV and TB. Thus the GG stresses the following:
- Resources to enhance the adoption of prevention, treatment, care and support services should be identified and developed when the programme is introduced;
- Services should be costed to guide resource allocation;
- Allocation of resources for items such as safety engineered syringes and respirators should be strongly considered to protect health workers in higher risk settings; and
- Resources should also be allocated for sexual and reproductive health components of programmes for health workers.