Commentaries

lessons from Controversy in Applying Universal Precautions for HIV/AIDS Jeffrey K. Clark, Collin C. Schwoyer

he human immunodeficiency virus (HIV) epidemic T poses numerous challenges for schools such as de- ciding what educational curricula are appropriate, devel- oping guidelines for presence of and administering to the needs of staff and students with HIV, and implementing universal precautions for various educational settings. Reasonable methods to address these challenges must be presented in a manner acceptable to staff, persons infec- ted wit HIV, students, parents, and the public. This paper identifies potential problems with implementing universal precautions and suggest guidelines to minimize controversy.

Cases of HIV among school-age children represent only a fraction of the total population infected with HIV. The increasing proportion of women infected with HIV is re- flected in the increased birth rate of HIV-infected infants.’ Because HIV mortality decreased as HIV morbidity in- creased, quality of life for HIV-infected children con- tinues to improve.2 More than 50% of children with HIV infection live to age of school attendance.’” This popula- tion is estimated to be as large as 20,000.6 These trends indicate the number of HIV-infected students attending school will continue to increase. Hochhauser and Rothenberger contend “The schools will face an increased number of HIV-infected students from the top down (high school and below) and from the bottom up (kindergarten and above).’”

School attendance of students infected with HIV has generated complicated social, ethical, and legal questions that often center on parents’ concern for their child’s health. The right of students with HIV to attend school continues to be supported by medical, legal, and school authorities.n” Most schools have an attendance policy re- lated to HIV-infected students. One survey found 89% of states had developed such policies.’’ Medical evidence supports the assumption that HIV is not transmitted by casual contact. National Association of State Boards of Education guidelines recommend students with HIV be allowed to attend school.” As the number of students with the HIV infection increases, the need to train school per- sonnel on universal precautions is evident.

Jefiey K . Clurk. HSD, Assistant Professor, Dept. of Physiology and Health Science. Bull Stute University, Muncie. IN 47306: and Collin C. Sch woyet: EdD, CHES, Munager, Community Health Services, Jeferson County Health Dept.. Louisville, KY 40201. This article was submitted November 16. 1993, and revised and accepted.for publication May 20, 1994.

In December 199 1, the Occupational Safety and Health Administration [OSHA] announced the Occupational Exposure to Bloodborne Pathogens Standard, designed to protect workers from exposure to bloodbome patho- gens. In response to these standards school districts must implement training in universal precautions for their per- sonnel. Does the training meet all the needs of the school and the community?

THE INCIDENT Louisville is the largest population center in Kentucky.

The incidence ofAIDS in the metropolitan area increased 41% from 1991 to 1992. Persons younger than age 19 account for 2.5% ofAIDS cases in the metropolitan area.’? The countywide school district is the 19th largest in the nation, with nearly 100,000 students.

The school district has guidelines for personnel to fol- low if a student health problem cannot immediately be controlled in the classroom. The guidelines recognized stages in health problems. The school district initiated training in universal precautions during the 1988- 1989 school year and updates have been offered. While mate- rials for universal precautions were located in the school’s main office, many teachers provided their own supplies.

A controversy began when a group of parents, accom- panying a teacher on a field trip, observed the teacher using universal precautions on a particular student. This action as well as other factors, alerted parents that a stu- dent with HIV infection could possibly be attending their school. After the field trip, the parents confronted the prin- cipal about the student’s condition and attendance. Due to confidentiality, the principal was unable to satisfacto- rily answer concerns of the parents.

Numerous factors supported the parent’s concern. The student had performed below grade level and had shown signs of failure to thrive. The student had numerous bleed- ing incidents during which universal precautions were implemented without controversy by classroom teachers. The student’s guardian expressed frustration at the child’s health status and indicated to the teacher that physicians were unable to determine the cause of the child’s condi- tion. Adding to the controversy, the student’s mother re- cently died from undisclosed reasons. Some parents and faculty believed the mother died of AIDS.

In the days following the field trip, a group of parents continued to voice their concerns. Parents expressed frus-

266 Journal of School Health August 1994, Vol. 64, No. 6

tration that the school was not responding to their per- ceived concerns. One demand asked that the student not be allowed to attend school with the other children. Ac- companying this demand was the implied threat that if the student was not removed, the media would be in- formed. In any event, media coverage became daily and widespread.

School personnel attempted to maintain a normal school atmosphere using school district crisis teams that respond to emergencies, open meetings for parents and concerned public, and informational meetings for faculty and staff. Jefferson County Health Dept. officials provided needed technical assistance to the school and community. School personnel indicated these efforts maintained normal school days for students. Parents, how- ever, were anything but calm, with some continuing to be extremely irrational and emotional, venting their feelings, frustrations, and accusations: Closure to the incident was unsatisfactory to almost all involved. As the student did not return to school, because of undisclosed reasons, me- dia attention simply ceased. Nevertheless, parents as well as teachers and staff continued to hold unresolved con- cerns. To the authors’ knowledge, no changes occurred in school districts’ guidelines, training, or procedures as a result of this incident.

THE IMPLICATIONS Although school personnel acted within policies, with

the teacher appropriately using universal precautions, the presence of uninformed parents triggered this controversy. Parents’ fears and lack of accurate information were the catalyst for the controversy arising from use of universal precautions. Although a school district’s policies are fol- lowed, emotional responses to universal precautions can still erupt. At this point in the HIV epidemic, studies show that most people are aware of how HIV is tran~mitted.’~-’’ This controversy occurred not because of parent’s lack of knowledge. I t occurred because of parent’s emotional re- sponse to a perceived in-school threat to the well-being of their children.

This type of controversy often results from a predict- able fear reaction, even when parents know better.” A good analogy might be seen in the reaction a person has when placing a hand on a glass jar containing a rattle- snake! Although the person knows the snake cannot bite through the glass, one still flinches when the snake coils and strikes.

All school teachers, staff, and students had prior expe- rience with universal precautions. As long as universal precautions were practiced only with school groups, no controversy developed. Once precautions were practiced in the presence of individuals unfamiliar with the need for routine precautions, unwarranted assumptions were made and the controversy began. To prevent similar inci- dents in the future, schools are advised to:

1 . Develop proactive universal precaution policies and guidelines.

2. Develop attendance policies for HIV-infected indi- viduals based on National Association of State Boards of Education recommendations. lo

3 . Implement universal precautions, with thought given to constituent as well as service populations involved.

4. Provide to all teachers, staff, and volunteers univer- sal precautions training, annually or biannually. Ensure all universal precaution supplies are accessible.

5 . Provide administrative support to teachers, staff, and volunteers who practice universal precautions.

6. Distribute a description of universal precautions to parents at the start of the school year.

7. Demonstrate universal precautions at open houses and parent-teacher organization meetings.

8. Place illustrations in student handbooks to help keep students and others aware of the importance of following universal precautions.

9. When appropriate, use community organizations to keep the public informed of universal precautions.

10. Encourage media coverage to keep thc public in- formed on school attendance and universal precaution policies.

11. Encourage school media and constituent spokes- persons to address only those questions concerning school policy and guidelines, referring to the public health de- partment questions and inquiries concerning communi- cable diseases, universal precautions, and public health recommendations.

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Surgeon General ‘s Workshop on Children with HIVInfectioii unil Tlit*rr Families. Washington, DC: US Dept of Health and Human Services: 1987, publication no HRS-D.MC 87-1.

3. Santelli JS, Bim AE, Linde J. School placement for human immunodeficiency virus-infected children: The Baltimore city experi- ence. Pediatrics. 1992;89:843-848.

4. Navarro M. Growing up condemned with the AIDS virus. , ‘ V O ~ ~ York Times. March 21, 1993;33,36.

5. Armstrong FD, Seidel JF, Swales TP. Pediatric HIV infection: A neuropsychological and educational challenge. J Leurnrng Disahilitir,.

6. Annunziato PW, Frenkel LM. The epidemiology of pediatric

7. Hochhauser M, Rothenberger JH. AIDS Erhrcu/iort Dubuque,

8. Board ofEducation of‘the Ciry ofPlainfirld v Cooper.niirii. I Y8S 9. White v Western School Corporation, 1985.

10. Katsiyannis A. Policy issues in school attendance ofchildren with AIDS: A national survey. JSpec Educ. 1992;26(2):219-226.

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12. AIDS/HIV Surveillance Program. AIDS Survtilltrncc Hepor.~. Louisville, Ky: Jefferson County Health Department; February 23. 1994.

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14. Hardy AM. AIDS knowledge and attitudes for October-Deccm- ber 1990: Provisional data from the National Health Inrewtcw Survcy Advance Data From Vitaland Health Statistics. no 204. Hyattsv i l le. Md: National Center for Health Statistics; October-December. I YYO.

15. McGill L, Smith PB, Johnson TC. AIDS: Knowledge. attitudes. and risk characteristics of teens. J Ser Educ Therap*. 1989; 15:30-35.

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