Keeping a positive outlook

19 October, 2011 / Infocus
 

All it took in the end was a brief phone call one afternoon in April 2008 and Allan Reid’s career, as he knew it, was over.

A matter of weeks after leaving the surgery for the last time he was also homeless and facing a GDC professional conduct charge.

If you are unfamiliar with his story you could be forgiven for thinking the Glasgow Dental School graduate had severely injured a patient or been arrested for some serious crime. But no, all Allan Reid had ‘done’ was to contract a virus. However, the stigma surrounding this particular virus meant he was banned from working in his chosen profession of 17 years and left a legacy that he is still dealing with to this day.

Allan was diagnosed HIV positive at the end of 2007 after he had been advised to get tested by his former long-term partner, who had recently been in touch to tell him that he himself had received a positive diagnosis.

But, thanks in part to his work as a HIV-friendly dentist in the Lewisham area of South London – which has some of the highest levels of HIV in the country – Allan was relatively unconcerned about his own health. He knew that the advances in antiviral medicine meant HIV was no longer the death sentence it had been in the late 1980s and that he could live a long and healthy life, albeit on once-daily antiviral medication for the foreseeable future.

He explained: “It wasn’t all doom and gloom for me as it might be for someone who didn’t understand much about the condition. I knew that it was manageable and that I could deal with it. I knew if I was diagnosed early it can be treated effectively and I could be expected to live a normal, healthy life. So, in the grand scale of things it wasn’t too big a deal, health-wise for me… The biggest impact for me was what an HIV diagnosis meant for my job.”

What Allan was referring to is the Department of Health (DoH) guidance that prohibits HIV positive healthcare workers from carrying out exposure-prone procedures. And, as pretty much every procedure in dentistry is considered exposure-prone, a positive diagnosis meant that his career treating patients was over.

However, as Allan was up-to-date on the latest evidence surrounding the risk of HIV transmission between dentists and patients, his initial despair turned to frustration and then anger as he fully came to terms with what he describes as the discrimination he was faced with. He said: “Antiviral medication that can allow people to achieve an undetectable blood viral load has been around in the UK since 1997, and advances in treatment mean that 95-99 per cent of people taking these antivirals are undetectable.

“The evidence has been known anecdotally for many years and then shown over time in research studies that undetectable effectively means non-infectious.”

This meant that even if there was blood-to-blood contact between dentist and patient, which in itself is a rare occurrence, the chances of the HIV virus being passed on is negligible. With this in mind, and with the advice of a professional friend, he fatefully decided to keep his diagnosis secret and continue to work.

“By the time I had confirmation of my diagnosis I had a plan in place,” he explained. “I had made the decision that I wasn’t going to disclose. I had a friend who was a HIV consultant and he said that, in London especially, there were many healthcare workers – nurses, dentists, doctors – that do the same.

“They either don’t go for testing and put their own health at risk because of what the implications will be for their job, or they test secretly and just carry on under the radar. He said to me: ‘You are not alone in this, my advice is just to keep your head down. It’s going to change fairly soon (the regulations), so just keep your head down and carry on.'”

However, his intention to stay under the radar was blown out of the water after only a few months when someone who he had confided his diagnosis with sold his story to the national press. Allan had told none of his colleagues in the dental world as he didn’t want to put any of them in the position where they were withholding information, but he had told a handful of close friends.

When the story broke, on 16 April 2008, the decisive phone call just topped off what had been a bad day anyway. Allan explained: “It was just the worst possible day for it to happen – I was running so late with patients waiting and a bridge that I was meant to fit that hadn’t come back from the lab – you know, your typical day from hell and then…

“The receptionist phoned through to the surgery at about 4.30pm and told me she had just had a strange phone call from the Health Protection Agency, saying they needed to speak to me urgently. I knew immediately what it was. I just knew.”

The HPA told him that Lewisham PCT had received a phone call from a journalist with the Sun claiming that he was HIV positive and was continuing to work. Allan decided to come clean, he said: “I had always said that if I was found out and confronted I would say that it was true, so I said yes it was actually true.

“So that was it, the ball was set in motion and I left the surgery for the last time that day.

“The PCT were just completely dispassionate, as they would be. There were no niceties, it was simple: my contract was gone and I was reported to the GDC.”

Allan revealed that the level of support he received was practically useless. He was sent for an occupational health assessment but the person he saw had no notes on him from the PCT so he was unable to provide any help at all. He continued: “It was very badly handled, but by that time I knew that was the standard because I had heard stories of other dentists who had been through the same and their dealings with the PCTs.

“I think when they get that information, allied to the Sun story, they are running around like headless chickens, worried about mass panic. The perceived risks get blown out of all proportion and you are just in the middle of this terrible situation.”

With no income and a hefty London mortgage to pay, Allan soon found himself struggling to make ends meet. He contacted his mortgage company and they suggested, as he had no way to continue making payments, a voluntary repossession. So, only two years after buying the house and spending countless hours renovating and redecorating, he was forced to hand back the keys and walk away. “This was the house for my retirement,” he said.

“I wasn’t planning on living anywhere else. This was my project to do up a house and stay there for the rest of my days.”

With nothing tying him to the UK and a GDC case still hanging over him, Allan decided to stay with some friends in Italy for a while, to come to terms with things and try to figure out a plan for the future. He ended up staying for a year as his friends closed ranks around him. He said: “I had a really great support network of friends who were just completely outraged at my treatment.

“My Italian friends were especially outspoken and they often raged at the injustice whenever I was feeling down. So you really do draw strength from that.

“I was very lucky that my friends were there to rally round me when I needed them.” Ironically HIV positive dentists in Italy are permitted to practice.

However, despite learning Italian and taking cookery lessons in the picturesque surroundings of rural Sardinia, where he worked in a friend’s restaurant, Allan knew he would have to come back to the UK at some point and face the GDC hearing.

He had spent a great deal of time in that last year compiling evidence and making short trips back to the UK to meet his legal team.

So, aided by Professor Margaret Johnson of the Royal Free Hospital in London and former chair of the British HIV Association who agreed to act
as an expert witness in his case, Allan took on the GDC panel and was shocked by their lack of knowledge about HIV.

He said: “There were two dentists on the GDC panel and one of them had to be twice corrected for referring to HIV as an airborne virus…”

The outcome of the hearing saw him given a rap on the knuckles for not following the guidance and given a suspension.

“But the important thing is what came out in the determination,” Allan explained. “They acknowledged the risk of HIV dentists passing on the virus to patients is negligible. It was a landmark statement for them to make and a really good result.”

After his suspension was lifted, as far as the GDC was concerned, he was fit to practise – except that the DoH guidance still precluded him from working.

And Allan’s frustration just kept building, he said: “Every time I put forward another piece of evidence, and another, and another, not one time did anybody face me and place a counter argument. Not once.

“So you start to see that it isn’t about risk, it’s about public perception and keeping people happy. When you boil it down it isn’t risk, it’s discrimination.”

But, despite his growing frustration, Allan decided to put his energies into doing something positive – going back to university to enrol on a Masters in Public Health at Imperial College London.

While there, he wrote his dissertation on HIV positive dentists in the UK and his dissertation supervisor was coincidentally one of the academics involved with drawing up the DoH guidance itself.

So, with the governments in Westminster and Holyrood currently reviewing the recent tripartite working group’s report on the management of HIV-infected healthcare workers, it would appear that it is only a matter of time before the guidance is relaxed and dentists like Allan are allowed to work with patients once again.

Biography

Allan graduated from Glasgow Dental School in 1991 and worked in practices in Paisley and Glasgow before moving down to London in 2003.

He was diagnosed HIV positive in 2007 and hasn’t worked in practice since April 2008.

He has continued to pay his Annual Retention Fee every year and was fully restored to the GDC’s register in July 2009.

Since his diagnosis he has continued to accrue CPD points at his own expense, averaging up to 100 hours each year, despite not being able to work.

In January this year, he won a decision through the Press Complaints Commission to have the Sun story removed from the archives and from all online searches on the grounds it was out of line with the recommended guidance for reporting on HIV and AIDS in the media. The Sun’s managing editor Graham Dudman conceded the reporting was scaremongering and even assisted in the further removal of stories in the Evening Standard and other local newspapers’ online archives.


HIV: The story so far

The retrovirus associated with HIV and AIDS was first identified in 1986. Ten years later a number of drugs had been developed which in combination could control the disease Ð a treatment known as highly active antiretroviral therapy or HAART. However, this was too late to alter the fate of an American dental patient named Kimberly Bergalis who died of AIDS in 1990. She was one of six dental patients who were believed to have been infected with HIV by Dr David Acer, a dentist in Florida who was known to have AIDS.

The facts surrounding this one and only presumptive transmission of HIV from a dentist to a patient have been the subject of an extended debate that has failed to establish the route of transmission in the six patients. Nor could any criminal intent be excluded on the part of the dentist.

Kimberly’s slow demise was frequently documented in the press and on television. A play called Patient A (Lee Blessing) was written about the episode. Regulatory bodies in most countries responded to the extensive emotional coverage in different ways Ð some banned HIV-infected oral healthcare professionals from working outright, others promulgated updated infection control guidelines. In the UK the government and its advisors opted for the ultimate precaution. They decided to prohibit healthcare workers with HIV from undertaking procedures which were exposure-prone. The definition of ‘exposure prone’ categorised dentistry with orthopaedic surgery.

Apart from the case of Dr Acer, no other transmissions of HIV in the dental setting have been demonstrated. The data available from patient notification (look back) exercises support the conclusion that the overall risk of transmission of HIV from infected health care workers to patients is extremely low. Between 1988 and 2008 in the UK, there were 34 patient notification exercises. However, there was no detectable transmission of HIV from an infected health care worker to a patient despite 9,849 having been tested.

Since the Acer case over 20 years ago there have been two developments that have lead to a review of the precautionary response adopted in the UK:

  • Advances in the medical management of HIV disease

 

  • Significant improvements in infection control standards.

 

HAART, introduced in 1997, successfully diminishes viral replication and can lead to undetectable levels of HIV in plasma. Indeed studies have shown that HAART is sufficiently effective to protect (at least 96 per cent of the time) an uninfected partner when having unprotected sex with a person who has been taking anti-retroviral medication to treat their underlying HIV status.

Infection control standards in UK dental surgeries have been upgraded again with the universal adoption of HTM 01-05. In addition, the introduction of bodies like CQC and its equivalent in Wales, Scotland and Northern Ireland will provide a regular audit of those newly elevated infection control standards, thereby assuring the track record that has already be proven to successfully prevent transmission of blood-borne pathogens (in both directions).

The way is now open for the Department of Health to remove the punitive restrictions depriving dentists living with HIV from practising. The Government’s Chief Medical Officer received the Tripartite Working Group’s report on the management of HIV-infected healthcare workers on 20 April 2011 and it is likely we will see an announcement from the Department of Health on this subject in the near future, prior to a public consultation on the proposed changes.

About the author

David Croser was the clinical lead for the dental service dedicated to HIV patients in Kensington, Chelsea and Westminster. The service ran for 20 years under the auspices for the Community Dental Service.

David is now the communications manager at Dental Protection.

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