On Valentine's Day, our dear friend, midwife Robin Lim, founder of the Bumi Sehat Birth Center in Indonesia performed mouth-to-mouth resuscitation on a newborn. He was premature and the oxygen masks she tried to use didn't fit properly and wouldn't deliver the air he desperately needed to his brand new lungs. With only moments to spare before lack of oxygen damaged his brain and stopped his heart, Robin did what any midwife would do. She breathed life into the boy over and over again, until he was able to do the job himself.
The baby had open lesions on his fragile, wet skin and Robin tasted blood as she worked. She knew she was risking exposure to who-knows-what diseases, but a baby needed her and Robin would do whatever it took to let this baby live.
The mother was sick too and later diagnosed with HIV. No one knew before she went into labor that she was infected. She didn't have prenatal care or HIV testing and therefore didn't receive antiretroviral medications, which would have prevented transmission of the disease to her newborn. It wasn't until after her baby's birth and just hours later, his death, that she found out. That was also when Robin learned she too had been exposed to HIV.
Risk of exposure to HIV and other diseases is part of the job for virtually every healthcare worker. Even here in the U.S., where gloves, masks, gowns and equipment help healthcare workers avoid being exposed, accidents happen -- patients "splash" their nurses; needles bounce back and prick the skin after a syringe is removed from a vein. It's scary, but I suspect most healthcare workers in a situation like Robin's would do the same thing she did. We'd breathe for that baby, even knowing he wouldn't live a full day. Here in the developed world where testing is easy, treatment is accessible and precautions are available to prevent exposure, the decision to "breathe" is easier to make because HIV is no longer a death sentence.
Back in 1990, HIV/AIDS had been with us for less than a decade. A patient arrived through the emergency room with the rough, unhealthy look many homeless people have, a history of drug abuse, prostitution and no prenatal care. She was asked to agree to HIV testing, but had the right to say, "no," and we weren't surprised when she refused. Back then, medications could slow disease progression down, but everyone knew if you were positive, it was only a matter of time. Many people simply didn't want to know, especially if they couldn't access healthcare. In some parts of the world even today, that part of the HIV story hasn't really changed.
When her labor developed complications, her doctor and I put on our gloves, gowns, masks and drapes and prepared our patient for a C-section. Worried about her baby we worked quickly. I passed the doctor a scalpel, he made an incision and reached out to hand it back and accidently brought the blade down on my hand. Though it rested on my glove for only a second, it cut through the latex and I started to bleed. My patient's blood on the outside of my glove seeped through to meet my own blood on the inside. I changed my gloves and we finished the surgery.
Later, when mother and baby were tucked into bed we told her what had happened. I told her I was getting tested for HIV to reassure her that she had not been exposed. I asked, mother-to-mother, if she would agree to be tested too. She agreed. For the next year, I had blood drawn every few months and breathed a sigh of relief each time they confirmed I did not have HIV.
What are the odds a healthcare worker will get HIV from a stick, poke, splash or slice? "Back then," we didn't know, which made every exposure terrifying. Now we know the risk of acquiring HIV from a needle-stick is less than one percent, and from exposure (such as a splash) not involving a puncture or cut is less than 0.1 percent.
A lot has changed in 20 years. Robin is making plans to add a lab to the birth center so more patients have access to prenatal HIV testing and counseling. She's also undergoing treatment called Post-Exposure Prophylaxis (PEP). It's available to anyone with access to HIV/AIDS healthcare services and can reduce the risk of HIV infection tenfold. PEP has to begin within 72 hours of exposure, before the virus has time to rapidly replicate in the body. It consists of two-three antiretroviral medications, taken for 28 days. These drugs can cause such serious side effects; it's hard for some patients to finish the program. PEP isn't 100 percent effective and doesn't guarantee the person won't become infected. But even if infection occurs despite prophylaxis, early suppression of the virus can lower the "set point" for viral load and slow the course of HIV disease substantially.
Will we ever reach the point where HIV is just a bad history lesson? That's the goal and if we all keep working together, we believe someday soon, mothers, babies and healthcare workers will no longer worry about exposure because we will have achieved an AIDS-free generation.
Resources:
American Academy of Family Physicians Family Doctor.org
Occupational Exposure to HIV: Advice for Health Care Workers
US Department of Health and Human Services AIDS.gov
Post Exposure Prophylaxis