17 August 2017

Administrative Order No. 18 s. 1995

  
21 November 1995


ADMINISTRATIVE ORDER
No. 18 series 1995


REVISED GUIDELINES IN THE MANAGEMENT OF HIV/AIDS PATIENTS IN THE HOSPITAL


I.     BACKGROUND


The HIV/AIDS pandemic has been declared a worldwide emergency by the World Health Organization. This situation has serious health, social, economic and political implications for all countries. The Philippines is not spared of the problems brought about by this pandemic as evidenced by the current national statistics on AIDS.

In response to the emerging needs for standardized procedure in the OPD consultation and/or hospitalization of HIV/AIDS patients, the Department of Health through the Hospital Operations and Management Service in collaboration with the National AIDS/STD Prevention and Control Program issued Administrative Order No. 27 last March 1994. Since then, the guidelines had been disseminated to concerned hospitals through orientation seminars, and even through other training workshops conducted by the National AIDS program.

More than a year after its issuance, experience in field implementation had gradually accumulated. With lessons learned, the need for the revision of this guideline became evident.


II.    OBJECTIVES


General Objective:

To strengthen the capability of the hospital in the prevention and control of HIV infections / AIDS.

Specific Objectives:

1. To organize an HIV/AIDS Core Team.
2. To formulate standardized guidelines in the management of HIV/AIDS.
3. To provide holistic care to HIV–infected/AIDS patients, their families and significant others including referrals and networking with NGOs and GOs.
4. To develop human resources necessary to carry out the provisions of this guidelines.
5. To implement and operationalize HIV/AIDS–related programs in the hospital.


III.   ORGANIZATIONAL STRUCTURE

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IV.    COMPOSITION AND FUNCTION OF THE HACT


Each DOH hospital shall organize an HIV/AIDS Core Team (HACT) which shall directly report to the Chief of Hospital. It shall be composed of, but not limited to the following: doctor(s), dentist(s), nurse(s), medical social worker(s), and medical technologist(s) and have the following functions:

1. Formulate hospital guidelines on the comprehensive care and management of HIV/AIDS patients.

2. Provide care and counseling to HIV/AIDS patients.

3. Promote prevention and control measures/strategies such as health education and hospital infection control.

4. Facilities inter– and intra–departmental/agency coordination including referral system and networking.

5. Performs training and research activities on HIV/AIDS.

6. Provide recommendations in hospital planning and development related to HIV/AIDS.

7. Monitor compliance of ethico–moral guidelines for HIV/AIDS including confidentiality of records and reports and release of information.

8. Update records and submit reports to concerned offices.

9. Conduct monitoring and evaluation activities.

A. SPECIFIC FUNCTIONS OF EACH HACT MEMBER

1. PHYSICIAN

1.1.Acts as chairperson of HACT as designated by the Chief of Hospital.
1.2.Coordinate with the Hospital Infection Control Committee in the strict
Implementation of prevention and infection control measure within the hospital.
1.3.In–charge of the medical management.
1.4.Ensures follow–up of patients and referral to other specialties as
necessary.
1.5.Conducts training and research.
1.6.Submits reports of HIV infection/AIDS to the National AIDS Registry.
1.7.Provides post–test counseling.

2. DENTIST

2.1.Coordinates with Hospital Infection Control Committee in the strict
Implementation of prevention and infection control measures within the dental clinic.
2.2.In–charge of the oral care and management.
2.3.Disseminates oral health information and counseling.
2.4.Ensures follow–up of dental patients and refers them to specialist when
necessary.
2.5.Conducts training and research related to dental field.

3. NURSES

3.1.In–charge of the nursing management.
3.2.Coordinates patient referrals within the hospital.
3.3.Promotes health education activities.
3.4.Manages training and research activities for nurses and auxiliaries.
3.5.Ensures implementation of infection control guidelines.

4.  MEDICAL SOCIAL WORKER

4.1.Provides psychosocial support services including counseling to HIV–
infected/AIDS patients and their families.
4.2.Coordinates and establishes linkages with GOs and NGOs in order to:
4.2.1.     Identify existing resources for efficient networking.
4.2.2.     Assist in providing alternative source of income.
4.2.3.     Provide continuing psychosocial support.
4.3.Provides health education.
4.4.Conducts home visits/follow–ups.
4.5.Conducts training and research related to social work activities.

5. MEDICAL TECHNOLOGIST

5.1.        Ensures that pre–test counseling is provided with an oral
or written informed consent.

5.2.        Performs appropriate laboratory procedures according to
set technical standards.

5.3.        Ensures proper laboratory waste disposal.

5.4.        Implements guidelines on laboratory safety and preparations.

5.5.        Ensures that test results are reviewed and duly signed by
the Laboratory Chief before releasing to HACT physician.


V.     APPROACH TO MANAGEMENT


1. Suspected or known HIV–infected patients shall be referred to the HACT.

2. Initial assessment shall be done by HACT physician.

3. Suspected HIV cases shall undergo HIV antibody testing with an informed consent after pre–test counseling. Post–test counseling shall be provided to all patients who underwent HIV antibody testing.

4. The decision to admit known HIV–infected/AIDS case shall be determined by the HACT doctor and shall be admitted to the appropriate ward according to the presenting manifestation.

5. A multidisciplinary approach to the care and counseling of HIV – infected patients shall be carried out by the HACT.

6. All HIV–infected/AIDS patients for discharge shall be provided with written discharge instructions on home care and management.

7. Asymptomatic patients shall be followed–up every 3 months. Symptomatic patients shall be followed–up as necessary.

8. Referrals/networking with other hospitals/agencies shall be done as necessary.


VI.   RECORDS AND REPORTS


1. HACT shall observe and monitor implementation of the ethico–moral guidelines in record–keeping and release of information of HIV/AIDS patients.

2. HACT shall ensure that the records of HIV/AIDS patients are complete and regularly updated.

3. HACT shall submit to the Medical Records Office the records of HIV/AIDS patients with coded names. The name should remain with HACT for safekeeping. However, information related to such record shall be released only upon authorization of Chief of Hospital unless otherwise delegates to the HACT chairman.

4. HACT shall submit updated reports to concerned offices for statistical purposes (DOH–National AIDS Registry).


VII.  MONITORING AND EVALUATION


1. HACT shall formulate monitoring tools and guidelines for the HIV/AIDS program of the hospital.

2. HACT shall conduct annual evaluation of program implementation and make necessary recommendations.

3. HACT shall submit annual report to NASPCP.

4. HACT shall conduct regular review of HIV/AIDS clinical management protocol.


VIII.  GENERAL PROVISIONS


1. Confidentiality

All HACT members shall ensure that all medical data and information of HIV/AIDS patients are maintained with utmost confidentiality. HACT physicians are required to report using the official HIV/AIDS reporting form (See ANNEX 3) any HIV infection/AIDS case the HACT members attended to. In order to protect the fundamental right of privacy of an individual with AIDS or infected with HIV, the reporting must be limited to the number of AIDS cases and other statistics without divulging the identity of the person unless the patient agrees in writing to disclosure.

2.  Counseling

All HACT members should be able to provide counseling to all patients including pre – and post–test counseling.

3.  Right to health care services

HIV/AIDS patients have the right to avail of health care services in any health care facility. One who has HIV infection/AIDS shall not be denied his right to medical treatment.

4. Hospital Implementing Procedure

The HACT shall be responsible for formulating the implementing procedure of this guidelines and such procedure shall be in accordance to the objectives and provisions of this Administrative Order. The scope and limitations of the Hospital
Implementing Procedure shall be concurrent to the hospital set–up and capacity.

5. Case Definition

Any person with or without overt signs and symptoms of opportunistic infection and gives a confirmed positive HIV antibody test result is diagnosed to be HIV–infected. On the other hand, an AIDS case has one or more of the AIDS–defining conditions (see ANNEX 1).

6. Universal Precaution

Universal precautions assume that blood, blood products and other body fluids of all patients are potential sources of infection independent of diagnosis or perceived risk. It is, therefore, mandatory for all hospital personnel to practice precautionary measures (see ANNEX 2) to prevent transfer of HIV and other infectious agents.

7. Post–mortem care

All dead bodies shall be considered potentially infected with HIV. Procedures that would entail physical contact with blood and other body fluids shall be carried out with precautions. Cadavers should be properly placed inside a non–permeable material such as plastic bag before burial or cremation. Physical barriers to prevent exposure of skin and mucous membranes to potentially infected body fluids during post–mortem procedures shall be utilized. Patients who die of AIDS shall be buried un–embalmed within 24 hours or cremated.


IX.   PENALTY CLAUSE


Any individual who does an act in violation of the foregoing provisions or fails to do an act provided hereof, shall be subject to appropriate action by proper authorities after due notice and process.


X.    EFFECTIVITY


This order supersedes Administrative Order No. 27, s. 1994 (Guidelines on OPD Consultation and/or Hospitalization of HIV/AIDS Patients) and shall take effect immediately.



HILARION J. RAMIRO, JR., MD, MHA
Secretary of Health


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ANNEX 1

US Center for Disease Control (CDC), AIDS Defining Conditions

Opportunistic Infections

        Candidiasis of bronchi, trachea or lungs
        Candidiasis, esophageal
        Coccidioidomycosis, disseminated or extrapulmonary
Cryptosporodiosis, chronic intestinal (>1 month’s duration)
Cytomegalovirus disease (other than liver, spleen or nodes)
Cytomegalovirus retinitis (with loss of vision)
Herpes simplex: chronic ulcers (>1 month duration), or bronchitis, pneumonitis or esophagitis
Histoplasmosis, disseminated or extrapulmonary
Mycobacterium avium complex or M. kansasii, disseminated or extrapulmonary
Mycobacterium tuberculosis, any site (pulmonary or extra–pulmonary)
Mycobacterium, other species or unidentified species, disseminated or
            extrapulmonary
Pneumocystic carinii pneumonia
Pneumonia, recurrent
Progressive multifocal leukoencephalopathy
Salmonella septicemia, recurrent
Toxoplasmosis of brain

Malignancies

Kaposi’s sarcoma
Lymphoma, Burkitt’s (or equivalent term)
Lymphoma, immunoblastic (or equivalent term)
Lymphoma, primary of brain
Cervical cancer, invasive

Encephalopathy, HIV–related
Wasting syndrome due to HIV
Advanced immune deficiency (CD4 cell count <200/ul)


ANNEX 2

            Universal Precautions

a. Standard hygienic procedures, especially handwashing, should be followed at all times.

b. Hospital or medical center guidelines for disinfection and sterilization should be consulted and followed faithfully.

c. Any skin disease or injury should be adequately protected with gloves or impermeable dressing to avoid contamination with a patient’s body fluids.

d. Any spills of blood or other potentially contaminated material should be liberally covered with household bleach (dilution 1 to 10), left over 30 minutes then carefully wiped off by personnel wearing gloves.

e. Needles and sharp object should be discarded in puncture–proof containers. Do not bend or break needles by hand. Do not recap used disposable needles.

f.  Reusable needles and syringes should be handled with extreme care and safety stored prior to cleaning and sterilization or disinfection.

g. Linen soiled with blood or other body fluids should be handled as little as possible. Gloves and a protective apron should be worn while handling soiled linen.



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