Policy Number: 158

Bloodborne Pathogen Infection Control


Bloodborne pathogen infection control


Health care worker as defined in this policy

Date Reviewed: April 2009

Responsible Office: Human Resources; Environmental Health & Safety; The University of Texas Student Health Clinic; The University of Texas Health Services; Applicable Student Affairs Office

Responsible Executive: Vice President and Chief Human Resources Officer; Vice President, Safety, Health, Environment, and Risk Management; Associate Dean for Student Affairs (Medical School)


The University of Texas Health Science Center at Houston (“university”) works to help safeguard the health and safety of students, employees, patients and the general public against the contact and spread of infectious diseases. The university is also sensitive to the needs and rights of any of its employees or students who have contracted diseases that might be infectious. In recognition of Human Immunodeficiency Virus ("HIV"), Hepatitis B Virus ("HBV"), and Hepatitis C Virus ("HCV") as serious public health threats, the university has adopted the following policy and procedural steps both to protect the rights and well-being of those employees or students who may be infected with HIV and HBV, and to prevent the spread of HIV, HBV, HCV and other bloodborne pathogens.

The university has adopted the Universal/Standard Blood and Body Fluid Precautions and a Bloodborne Pathogens Exposure Control Plan. It is the responsibility of each employee and student to acquaint himself/herself with and abide by these guidelines in the conduct of employment and educational activities. Failure to do so may result in disciplinary action.

The university will not use a person’s HIV, HBV or HCV status to decide employment status or service delivery or to deny services. Refer to HOOP Policy 183 Equal, Opportunity, Discrimination and Harassment.


Exposure-prone procedure: Procedure(s) determined by the Infectious Diseases Review Committee to pose a direct and significant risk of transmission of bloodborne pathogens from an infected health care worker to a patient.

Health care worker: 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 under the auspices of the university. This includes students assigned to work in clinical and/or laboratory settings where there may be contact with patients' blood, body fluids, body cavities, subcutaneous tissues or mucous membranes. In the context of this policy, "health care worker" can refer to faculty, staff, students, residents, fellows or other individuals performing direct patient health care services under the auspices of the university.

Infectious Diseases Review Committee: A subcommittee of the Biological Safety Committee whose members are appointed by the President to review instances of HIV or HBV infection in health care workers, to identify exposure-prone procedures, and to determine those circumstances, if any, under which a health care worker who is infected with HIV or who is infected with hepatitis B virus and is HBeAg positive may perform such procedures.


A. Health Care Workers Infected with HIV or with Hepatitis B Virus who are HBeAg Positive

A health care worker infected with HIV or infected with HBV who is HBeAg positive may not engage in activities that might require him or her to perform exposure-prone procedures unless the Infectious Diseases Review Committee has prescribed the circumstances under which he or she may perform such procedures. Health care workers infected with HIV, HBV, or who are HBeAg positive must report their status to the Infectious Diseases Review Committee prior to performance of exposure prone procedures.

Health care workers whose practices are modified due to infection with HIV or HBV should be offered opportunities to continue appropriate patient-care activities, if practicable; receive career counseling and job retraining; or, to the extent reasonable and practicable, be counseled to enter an alternative curriculum, if the health care worker is a student.

A health care worker whose practice is modified because of HBV infection may request periodic redeterminations by the Infectious Diseases Review Committee based on change in the worker's HBeAg status resulting from resolution and/or treatment of the infection.

The appropriate supervisor should advise health care workers that failure to comply with the preceding precautionary measures and limitations will subject the workers to disciplinary procedures by their licensing entities where applicable, and/or by the university, in accordance with HOOP Policies 187 Discipline and Dismissal of Classified Employees, 133 Faculty Termination and 186 Student Conduct and Discipline.

B. Work or Educational Activity-Related Exposure to HIV, HBV and HCV

Any incident that may be regarded as having potential HIV, HBV, or HCV exposure implications must be reported immediately to the appropriate supervisor; or for students, to the appropriate supervisor, attending clinician, or to UTHS/UTSHC who will follow the guidelines for reporting exposures as stated in the Institutional Biosafety Manual.

If a health care worker reports unverified possible exposure to HIV while performing the duties of employment or while performing duties of his or her educational assignment, that individual will be informed that he or she may request HIV testing and counseling at the university’s expense, if:

If a health care worker is exposed to another individual's ("Individual" in this paragraph) blood or body fluid in the course of the health care worker's assignment, the university, at its expense, may test that Individual for HIV, HBV and HCV infection with or without the Individual's consent, provided the test is performed under the post exposure protocol which provides criteria for testing and which respects the rights of the person being tested. If the test is done without the Individual's consent, the guidelines 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. All testing, whether with or without consent, and their results will be done in accordance with existing state and federal law.

Any employee who claims Workers' Compensation Insurance (WCI) benefits as a result of alleged bloodborne pathogens exposure must provide a written statement of the date and circumstances of the exposure and document that, within 10 calendar days after the exposure, the employee had a test result that indicated absence of HIV, HBV and HCV infection. An employee who may have been exposed to bloodborne pathogens while performing duties of employment may not be required to be tested, but refusal to be tested may jeopardize workers' compensation benefits.

An employee will be ineligible for unemployment compensation benefits if the Texas Employment Commission finds an employee leaves his or her job voluntarily rather than provide services within the course and scope of employment to an individual infected with an infectious disease, including HIV and HBV, or that an employee was discharged based on a refusal to provide services included within the course and scope of employment to an individual infected with an infectious disease, including HIV and HBV.

The UTHS/UTSHC offers or refers employees and students for confidential and anonymous HIV, HBV and HCV counseling and testing following workplace exposures. Health care workers may also contact the Texas HIV/STD InfoLine, 1-800-299-AIDS, which is a toll-free HIV/AIDS and STD information and referral service.

C. HIV Testing

The university will not test students or employees for HIV infection without their informed consent unless required by law or court order or as specified in section II of this policy. It shall, however, encourage employees and students who have HIV infection or who have been potentially exposed to HIV to inform UTHS and/or UTSHC. These employees and students are also encouraged to seek counseling and testing either from the UTHS/UTSHC or from any other appropriate resource. (For work-related exposure, refer to section II of this policy.)

The university will report HIV, HBV and HCV test results in compliance with all applicable statutory requirements.

Except when a release is required or authorized by law, information concerning the HIV, HBV or HCV 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, HBV or HCV status in workers' compensation files will remain confidential and have the confidentiality status of medical records. HIV, HBV or HCV status information will not be placed in an individual’s personnel or student file.

D. Educational Efforts

1. Employees: Human Resources will provide to each new employee during new employee orientation an educational pamphlet about methods of transmission and prevention of HIV infection. The Office of Institutional Compliance will provide the educational pamphlet to current employees annually. Employees who are involved in hands-on patient care and/or research with HIV-exposed tissue must complete an educational course about bloodborne pathogens annually.

2. Students: Upon request, the UTSHC will provide information on the prevention of HIV infection, including the value of abstinence and long-term mutual monogamy, information on the efficacy and the use of condoms, state laws relating to HIV transmission, and conduct that may result in HIV transmission.

The deans of each school, in coordination with faculty, will structure the curricula of their respective schools to include information about methods of transmission and methods of prevent of HIV infection; federal and state laws, rules, and regulations concerning the HIV infection and AIDS; and standard precautions if a potential for bloodborne pathogens exposure exists for the school’s students as part of their educational experience.


ContactTelephoneEmail/Web Address
Human Resources - Equal Opportunity ( employees who have questions about their rights in relation to HIV, HBV and HCV infection) 713-500-3130 http://www.uth.edu/hr/department/equal-opportunity/index.htm
Environmental Health and Safety (safety related information regarding bloodborne pathogens) 713-500-8100 http://www.uth.edu/safety/
The University of Texas Health Services (voluntary testing and counseling information, employees) 713-500-3267 http://www.uthealthservices.com/healthservices/about/contact.htm
The University of Texas Student Health Clinic (voluntary testing and counseling information, students) 713-500-5171 http://med.uth.tmc.edu/administration/stud_health/index.html
Applicable Student Affairs Office (students who have questions about their rights in relation to HIV, HBV and HCV infection)