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Handbook of Operating Procedures
  • Policy Process

    • Handbook of Operating Procedures
    Chapter 9 - General Provisions
    Previous Publication Date: September 1, 1997
    Publication Date: May 12, 2023
    Policy Reviewed Date: May 12, 2023
    Policy Owner: VP for Academic Affairs


    9.22 Acquired Immune Deficiency Syndrome, Human Immunodeficiency Virus Infection and Hepatitis B Virus

    I. POLICY STATEMENT

    The University of Texas at San Antonio (UTSA) recognizes Human Immunodeficiency Virus (HIV) and Hepatitis B Virus (HBV) as serious public health threats and is committed to encouraging an informed and educated response to issues and questions concerning these infections. 

    II. RATIONALE

    The purpose of this policy is to provide guidance to ensure compliance with University of Texas System policy and state guidelines, which cover areas of administrative policy, residence life, health education, testing, confidentiality, and patient care.

    III. SCOPE

    This policy is applicable to all UTSA faculty, staff, students and visitors (including the general public, volunteers, contractors, sub-contractors and their employees) while they are on UTSA premises or engaged in University work or study at other premises.

    IV. WEBSITE ADDRESS FOR THIS POLICY

    http://www.utsa.edu/hop/chapter9/9.22.html

    V. RELATED STATUTES, POLICIES, REQUIREMENTS OR STANDARDS

    1. Federal Statute
      1. Occupational Safety and Health Administration Standards, CFR 1910.1030 - Bloodborne Pathogens - OSHA does not apply to the Texas state government or any of its agencies, or a political subdivision of Texas, such as a city or county government (see 29 U.S.C. § 652(5)). UTSA uses this standard as guidance for the UTSA Bloodborne Pathogen Exposure Control Plan. The standard may be applicable to contractors of UTSA.
    2. State Statutes
      1. Texas Health and Safety Code, Title 2 Health, Subtitle D, Chapter 81, Section 81.001, Communicable Disease Prevention and Control Act
      2. Texas Health and Safety Code, Title 2 Health, Subtitle D, Chapter 85, Acquired Immune Deficiency Syndrome and Human Immunodeficiency Virus Infection
      3. Texas Health & Safety Code Ann., Subtitle F, Chapter 121, Local Public Health Reorganization Act
      4. Texas Administrative Code, Title 25, Chapter 96, Bloodborne Pathogen Control
      5. Texas Education Code, Section 51.919 - HIV and AIDS Policy; Information Dissemination
    3. Other Policies and Standards
      1. UTSA Bloodborne Pathogen Exposure Control Plan

    VI. CONTACTS

    If you have any questions about HOP policy 9.22 Acquired Immune Deficiency Syndrome, Human Immunodeficiency Virus Infection and Hepatitis B Virus contact the following office:

    1. Academic Affairs
      210-458-4110

    VII. DEFINITIONS

    1. Acquired Immunodeficiency Syndrome (AIDS): A chronic, potentially life-threatening condition caused by the HIV infection. By damaging the immune system, HIV interferes with the body’s ability to fight off infections and disease.
    2. Bloodborne Pathogens Exposure Control Plan: A written control plan providing direction on the elimination or minimization of exposure to bloodborne pathogens in occupational and educational settings in accordance with the Texas Health and Safety Code, Sec. 81.304, and with guidance from the Occupational Safety and Health Administration Standards, CFR 1910.1030 - Bloodborne Pathogens.
    3. Hepatitis B (HBV) – viral liver infection spread through bodily fluids. 
    4. Hepatitis B e antigen (HBeAg): A Hepatitis B viral protein. The presence of this antigen may serve as an indicator of the hepatitis B virus. Its presence in the blood of a person correlates with higher levels of circulating virus and therefore with greater infectivity of that person's blood; the presence of HBeAg in blood can be detected by appropriate testing.
    5. Human Immunodeficiency Virus (HIV): The virus that can lead to AIDS, a sexually transmitted infection that occurs by contact with or transfer of blood, pre-ejaculate, semen, and vaginal fluids. Non-sexual transmission can occur by contact with infected blood, or from mother to child during pregnancy, childbirth, or breast-feeding. Within this policy, “HIV infection” denotes the total spectrum of the disease, from HIV seropositive but asymptomatic infection to fully developed AIDS.
    6. Invasive Procedure: An invasive procedure is one where purposeful/deliberate access to the body is gained via an incision, percutaneous puncture, where instrumentation is used in addition to the puncture needle, or instrumentation via a natural orifice. It begins when entry to the body is gained and ends when the instrument is removed, and/or the skin is closed. Invasive procedures are performed by trained healthcare professionals using instruments, which include, but are not limited to, endoscopes, catheters, scalpels, scissors, devices and tubes.
      1. Where invasive procedures also involve the administration of a medicinal product, these could be categorized as being part of an ‘invasive procedure’ when operator skill is required for its administration within the body, that is, when an internal action is performed to administer the product or the product is administered to a targeted anatomical area, for example, Zhu et al. 15 There are also procedures which involve operator skill to target something inside the body (e.g., electromagnetic radiation in the eye) without an incision, percutaneous puncture or instrumentation via a natural orifice. These types of procedures do not fall within the definition of aninvasive procedure.
    7. Health Care Worker: A person who provides direct patient health care services pursuant to authorization of a license, certificate or registration or in the course of a training or education program.

    VIII. RESPONSIBILITIES

    1. Employees and Students
      1. Comply with university policies and procedures.
    2. Director for UT Health, Wellness 360            
      1. Provide students with access to quality physical and mental health care.
      2. Promote student success and wellbeing. 
    3. Director for Athletic Health Services
      1. Provide student athletes with access to physical and mental health care.
      2. Enhance the health, wellness and performance of each student athlete.
    4. People Excellence
      1. Provide faculty and staff learning opportunities, activities, programs, and other resources to make choices and changes that lead to a balanced and healthy lifestyle through the UTSA Wellness program.

    IX. PROCEDURES

    1. UTSA departments are charged with the responsibility to implement the programs and procedures unique to their area as outlined by Texas law, UT System policies, UTSA policies and department policies and procedures. General procedures for UTSA departments are provided below.
    2. General Procedures
      1. Admissions to Schools--The existence of HIV or HBV infection should not be considered in admissions decisions unless current scientific information indicates required academic activities will likely expose others to risk of transmission.
      2. Residential Housing--Residential housing staff will not exclude HIV-infected or HBV-infected students from University housing and will not inform other students that a person with HIV or HBV infection lives in University housing.
      3. Employment--The existence of HIV or HBV infection will not be used to determine suitability for employment by the University. An employee infected with HIV or HBV may remain employed as long as they are able to perform the essential functions of the job, is able to meet job performance standards, and does not engage in job-related activities which currentscientific information indicates may expose others to risk of transmission.
      4. Class Attendance--A student with HIV or HBV infection should be allowed to attend all classes without restrictions as long as the student is physically and mentally able to participate and perform assigned work and poses no health risk to others.
      5. Health Care Workers and Students Assigned to Work Within Clinical Settings –Currently available data provide no basis for recommendations to restrict the practice of  Health Care Workers infected with HIV or HBV provided the infected Health Care Workers practice recommended clinical safety techniques, and comply with universal infection control precautions and current recommendations for sterilization/disinfection
        1. Health Care Workers should know their HIV and HBV status. Those infected with HBV should know their HBeAG status.
        2. All Health Care Workers providing direct patient care should have a complete series of Hepatitis B vaccine prior to the start of direct patient care or complete the series as rapidly as is medically feasible, or should be able to show serologic confirmation of immunity to Hepatitis B virus. Programs offered in conjunction with UT Health San Antonio may also require the Hepatitis B vaccine. Student educational materials and questions regarding HIV and Hepatitis B virus can be addressed at Wellness 260. Contact Wellness at 210-458-4142 or by visiting their office at RWC 1.500 (UTSA Main Campus).
      6. Access to Facilities--A person with HIV or HBV infection should not be denied access to any University facility because of HIV or HBV infection.
      7. Testing for HIV and HBV Infection
        1. Mandatory Testing--No programs for mandatory HIV or HBV testing of employees, students, or patients will be undertaken without their consent unless authorized or required by law, court order, or as specified in this section or section 7.8 below.
        2. Voluntary Testing for HIV and Counseling--Wellness 360 at UTSA offers or refers students for confidential or anonymous HIV counseling and testing services. Contracted services from UT Health and outsourced occupational services may refer out for these services as well. All testing conducted by a component institution will include counseling before and after the test. Unless required by law, test results should be revealed to the person tested only when the opportunity is provided for immediate, individual, face-to-face counseling about the meaning of the test; the possible need for additional testing; measures to prevent the transmission of HIV; the availability of appropriate health care service, including mental health care, and appropriate social and support services in the geographic area of the person’s residence; the benefits of partner notifications; and the availability of partner notification programs.
        3. Partner Notification--A health care professional who knows a patient is HIV positive and who has actual knowledge of possible transmission of the virus to a third party will notify a partner notification program established by Texas Department of State Health Services (DSHS).
        4. Informed Consent for HIV Testing - Unless otherwise authorized or required by law, no HIV test should be performed without informed consent of the person to be tested. Consent will be written on a separate form, or the medical record will document that the test has been explained and consent has been obtained. The consent form will state that post-test counseling will be offered or the medical record will note that the patient has been informed that post-test counseling will be offered.
        5. Reporting of Test Results--HIV and HBV test results will be reported in compliance with all applicable statutory requirements, including the Communicable Disease Prevention and Control Act, Texas Health and Safety Code, § 81.001.
        6. Conditions of HIV Testing of Employees at Institution's Expense--Employees will be informed that they may request HIV testing and counseling at the institution's expense if the employee documents possible exposure to HIV while performing duties of employment; and the employee was exposed to HIV in a manner that is capable of transmitting the infection as determined by guidelines developed in accordance with statements of the DSHS and the Centers for Disease Control and Prevention (CDC).
        7. Qualifying for Workers' Compensation Benefits--State law requires that an employee who bases a workers' compensation claim on a work related exposure to HIV must provide a written statement of the date and circumstances of the exposure and document that within ten (10) days after the exposure the employee had a test result that indicated absence of HIV infection. An employee who may have been exposed to HIV while performing duties of employment may not be required to be tested, but refusal to be tested may jeopardize Workers' Compensation benefits.
        8. Testing Following Potential Exposure to HIV or HBV-- Testing of employees or students exposed to material that has a potential for transmitting HIV or HBV as a result of employment or educational assignments should be done within ten (10) days after exposure and should be repeated after one (1) month. Testing for HIV also should be done after three (3) and six (6) months. UTSA vendors and contractors should follow their employer’s established guidelines and protocols as well as the DSHS, U.S. Public Health Service, and CDC guidelines.
          1. In cases of exposure of an employee or student to another individual's ("Individual" in this paragraph) blood or body fluid, a component institution, at the institution's expense, may test that Individual for HIV and HBV infection with or without the Individual's consent, provided that the test is performed under approved institutional guidelines and procedures included in the institutional Handbook of Operating Procedures that provide criteria for testing and that respect the rights of the person being tested. This includes post-test counseling If an HIV test is done without the Individual's consent, the guidelines must ensure that any identifying information concerning the Individual's test will be destroyed as soon as the testing is complete and the person who may have been exposed is notified of the result. Test results will be reported in compliance with all applicable statutory requirements.
          2. A UTSA law enforcement officer may request DSHS or a health authority duly authorized pursuant to the Local Public Health Reorganization Act, Texas Health & Safety Code Ann., Subtitle F, Chapter 121, to order testing of another person who may have exposed the law enforcement officer to a reportable disease, including HIV infection. The request for such testing may be made only if the law enforcement officer experienced the exposure in the course of employment, if the law enforcement officer believes the exposure places the law enforcement officer at risk of the reportable disease, and the law enforcement officer presents to DSHS or the health authority a sworn affidavit that delineates the reasons for the request.
      8. Confidentiality of Records--Except where release is required or authorized by law, information concerning the HIV status of students, employees or patients and any portion of a medical record will be kept confidential and will not be released without written consent. HIV status in personnel files and Workers' Compensation files is to remain confidential and have the confidentiality status of medical records.
      9. Education and Safety Precautions for Health Care Workers-- All Health Care Workers shall be provided instruction on universal infection control precautions. Each health care worker who is involved in direct patient care should complete an educational course about HIV and HBV infection based on the model education program and workplace guidelines developed by the TDH and the guidelines of this policy.
      10. General Employee Educational Pamphlet--Component institutions should provide each employee an educational pamphlet about methods of transmission and prevention of HIV infection. The pamphlet will be What You Should Know About HIV (texas.gov), a pamphlet based on the model developed by the DSHS. The pamphlet should be provided to new employees on the first day of employment and to all employees annually. Programs should routinely be offered to students based on the model HIV education and prevention program developed by the DSHS and tailored to the student’s cultural, educational, language and developmental needs. 
      11. Student Health Centers – Each student health center should provide information on prevention of HIV infection, including the value of abstinence and long-term mutual monogamy, information on the efficacy and use of condoms, and state laws related to the transmission of HIV and to conduct that may result in such transmission.
        1. The following pamphlet, What You Should Know About HIV (texas.gov) will be available to students on request.
      12. Guidelines for Laboratory Courses--Component institutions that offer laboratory courses requiring exposure to material that has potential for transmitting HIV or HBV should adopt safety guidelines for handling such material and distribute these guidelines to students and staff prior to their coming in contact with such material.
      13. Education of Students Entering Health Professions--UTSA collaborates with UT Health and dual degree programs, specifically the Department of Social Work, and should include within the program curricula information about methods of transmission and methods of prevention of HIV and HBV infection, including universal infection control precautions; federal and state laws, rules and regulations concerning HIV infection and AIDS; and the physical, emotional and psychological stress associated with HIV and HBV infection
      14. Unemployment Compensation Benefits--Each component institution will inform employees that state law provides that an individual will be disqualified for unemployment compensation benefits under certain conditions. UTSA provides this information and forms on the Administration and Operations webpage.
      15. Health Benefits--No student or employee will be denied benefits or provided reduced benefits under a health plan offered through the UT System on th basis of a positive HIV test result.

    X. SPECIAL INSTRUCTIONS FOR IMPLEMENTATION

    None

    XI. FORMS AND TOOLS/ONLINE PROCESSES

    1. UTSA Worker's Compensation General Information
    2. UTSA Risk and Emergency Management Resources
    3. Texas Worker's Compensation Commission
    4. UTSA Worker’s Compensation Form Packet
    5. Housing and Residence Life Handbook
    6. What You Should Know About HIV (texas.gov)

    XII. APPENDIX

    None

    XIII. Dates Approved/Amended

    May 12, 2023 (non-substantive change)
    September 1, 1997