Constitutional values and HIV/AIDS in the workplace: reflections on Hoffman v. South African Airways

South Africa is experiencing an HIV/AIDS epidemic of enormous proportions. The workplace, like all the other sectors, is adversely affected. The tendency of a significant proportion of employers has been to discriminate against employees and job applicants living with HIV/AIDS through the use of HIV testing to exclude those that are HIV-positive. In the case of Hoffman v South African Airways, the Constitutional Court was asked to determine the constitutionality of excluding a job applicant on account of an HIV-positive status. The Court ruled in favour of the applicant and ordered instatement. Through an analysis of Hoffman v South African Airways, the article examines how constitutional values are impacting on HIV/AIDS-related ethics in the workplace.

Ethical issues in early detection of HIV infection to reduce vertical transmission

Proposals to make prenatal HIV testing routine and universal dramatize ethical issues regarding early detection of HIV. These proposals would abolish pretest counseling and written informed consent for prenatal HIV testing. Ethical concerns include whether pregnant women are adequately informed that they may refuse such testing and whether patients have an opportunity to obtain more detailed information about the benefits and risks of HIV testing in this context. Several pertinent research questions need to be studied, including whether pregnant women find routine universal HIV testing acceptable and whether safeguards adequately protect women who receive testing. If analogous policies to enhance early detection of HIV are considered in other clinical contexts, the important clinical and ethical differences between vertical transmission and other situations of HIV transmission must be kept clearly in mind.

Exposure to HIV: medical management and legal implications

The management of exposures to HIV, whether occurring in the occupational or non-occupational setting, involves balancing the risk and inconvenience of antiviral therapy that lacks strong evidence of efficacy against the benefit of it possibly preventing a potentially fatal disease. Clinicians increasingly will be responsible for managing Health Care Workers (HCWs) and other persons exposed to HIV. This will require making a clinical assessment of the risk of HIV transmission and making recommendations for postexposure prophylaxis (PEP) according to the CDC, and other guidelines. Management also requires applying the elements of the doctrine of informed consent, considering involuntary testing of source patients, and reporting of exposure incidents. Proper management will protect all those involved: the exposed person will be protected from unacceptable risks either of contracting HIV, should PEP be indicated, or harm caused by PEP when it is not; the source patient will be protected from unconstitutional invasions of privacy. Finally, the clinician will be protected from claims of malpractice as a result of management of an HIV exposure.

Compared interest between hair analysis and urinalysis in doping controls. Results for amphetamines, corticosteroids and anabolic steroids in racing cyclists

In France during a famous bicycle race, the newspapers documented the degree in which doping seemed to be supervised in some teams by managers and doctors. Use of anabolic steroids and other substances was officially banned in the mid-seventies by sports authorities. This policy has been enforced through urine testing before competition. It is well known, however, that a latency period is all that is necessary to defeat these tests. Nevertheless, hair analysis could be a promising tool when testing for periods that are not accessible to urinalysis any more. We have developed different sensitive methods for testing hair for amphetamines, anabolic steroids and their esters and corticosteroids. For amphetamines, 50 mg of hair were digested with 1 M NaOH, extracted with ethyl acetate, derivatized with TFA and analyzed by gas chromatography positive chemical-ionization mass spectrometry. For corticosteroids, 50 mg of powdered hair were treated with methanol in an ultrasonic bath and subsequently purified using a C18 solid phase extraction column. Analysis was realized by high performance liquid chromatography coupled to electrospray-ionization tandem mass spectrometry. For anabolic steroids and their esters, 100 mg of powdered hair were treated with methanol in an ultrasonic bath for extraction of esters, then alkaline digested with 1 M NaOH for an optimum recovery of other drugs. The two liquid preparations were subsequently extracted with ethyl acetate, pooled, then finally highly purified using a twin solid phase extraction on aminopropyl and silica cartridges. Residue was derivatized with MSTFA prior to injection. Analysis was conducted by gas chromatography coupled to a triple quadrupole mass spectrometer. Thirty cyclists were sampled and tested both in hair and in urine. Amphetamine was detected 10 times in hair (out of 19 analyses) compared to 6 times in urine (out of 30 analyses). Corticosteroids were detected 5 times in hair (methylprednisolone 1 case, triamcinolone acetonide 3 cases and hydrocortisone acetate 1 case) in hair (out of 12 analyses) compared to 12 times (triamcinolone acetonide 10 cases and betamethasone 2 cases) in urine (out of 30 analyses). Anabolic steroids were detected twice (nandrolone 1 case, and testosterone undecanoate 1 case) in hair (out of 25 analyses) compared to none in urine (out of 30 analyses).

Random mandatory drugs testing of prisoners: a biassed means of gathering information

BACKGROUND

Our objective was to develop and test a methodology for inferring the percentage of prisoners currently using opiates from the percentage of prisoners testing positive for opiates in random mandatory drugs testing (rMDT).

METHODS

The study used results from Willing Anonymous Salivary HIV (WASH) studies (1994-6) in six adult Scottish prisons, and surveys (1994-5 and 1997) in 14 prisons in England and Wales. For Scottish prisons, the percentage of prisoners currently using opiates was determined by assuming, with varying empirical support, that: current users of opiates in prison were 1.5 times as many as current inside-injectors; and current inside-injectors were 0.75 times as many as ever injectors in prison. We also assumed that current inside-users' frequency of use of opiates (by any route) was equal to the frequency of inside-injecting by current inside-injectors in Aberdeen and Lowmoss Prisons in 1996, namely six times in 4 weeks. We assumed that some scheduling of heroin-use prior to weekends takes place, so that only 50% of current inside-users of opiates would test positive for opiates in rMDT: these assumptions allow us to arrive at WASH-based expectations for the total percentage of prisoners testing positive for opiates in rMDT. For England and Wales, a multiplier of 118/68 was applied which was derived from prisoners' interviews, to convert the results from ever inside-injectors, as determined by WASH studies, to the percentage of current inside users of opiates. We made the same assumptions on frequency of inside-use of opiates as in dealing with the Scottish results.

RESULTS

We expected 202.7 opiate positive results in April to September 1997 in rMDTs at six adult prisons in Scotland, 226 were observed. We expected 227.0 at a set of 13 adult prisons and one other in England and Wales; 211 were observed.

CONCLUSIONS

Further testing of the methodology for prisons in England and Wales will be possible when 1997 WASH data are released. So far, the methodology has performed well. From it, we infer that 24% of inmates at the six adult prisons in Scotland were current inside-users of opiates, compared to 11% at the 14 adult prisons where survey data were available in England and Wales. The corresponding April to September 1997 percentage of opiate positives in rMDT were: 13% (results from the six Scottish prisons) and 5.4% (results from 14 prisons in England and Wales), a two-fold under-estimate of % current users of opiates in prison (24% and 11%). Planning of drug rehabilitation places for prisoners should thus be based on twice the percentage of prisoners testing opiate positive in rMDT. This correction factor of two should be kept under review.

Substance abuse and dependence in physicians: detection and treatment

Substance abuse continues to increase and permeate all sectors of US society including the medical profession. This article details the importance of testing everyone associated with health care organizations, including physicians, as a means of protecting patient welfare, increasing quality of care, and reducing negligence lawsuits, as well as providing treatment and recovery opportunities for those with addictions.