Medical students, their electives, and HIV

Most medical students go overseas on their electives—97% from one medical school¹—and many go to Africa. The attractions are obvious: adventure, travel, new cultures, and a depth and range of medical experience that may never be gained at home. However, like any travel experience, electives can be dangerous. British medical students doing electives overseas often go to areas with high HIV prevalence, work in settings with poor infection control practices, and are exposed to HIV and other bloodborne viruses.² The reports by Moss and Beeching (p 161) and Gamester et al (p 158) in this week’s issue provide shocking data that help to quantify these concerns.¹,³

In their questionnaire survey of British medical schools Moss and Beeching show that only half the schools provide written advice about health and safety on electives.¹ Most rely on the normal curriculum for providing information on personal risks of acquiring HIV, and only two schools make postexposure prophylaxis for HIV exposure available to students going overseas on their electives. Schools vary greatly in the quality of advice and support given. By studying and working in high prevalence settings students are clearly at risk, and many schools seem to be sending them away unprepared and ill advised.

Gamester et al sent a questionnaire to 220 final year students at one medical school who had recently returned from their electives.³ Although only 67% replied, the data are illuminating. Many students (44%) had worked in what was defined as a high HIV prevalence setting, but many (42%) had been unaware of even this. What does “high prevalence” really mean? About 60% of patients admitted to the acute medical service at Hlabisa hospital, South Africa, in early 1998 had HIV infection (A Reid, personal communication), and, by the end of 1998, 41% of pregnant women in the district were infected with HIV (unpublished data). Any invasive procedure in this setting is potentially dangerous, and as a result provincial and national health authorities have established HIV postexposure prophylaxis telephone hotlines.

Four students (3%) reported percutaneous or mucosal exposure on their elective.³ Most of these incidents seem not to have been well managed or followed up when the students returned home. Written guidelines to help prevent and manage these incidents were provided by their medical school, but it is worrying that the guidance was often not heeded—even by students’ advisers. For example, against policy, some students did attachments in obstetrics and surgery in Africa, and among those visiting high prevalence settings only 34% took a zidovudine starter pack with them.

At the University of Adelaide Medical School, about 45% of fifth year students taking electives travel to potentially high risk settings, and this proportion is likely to rise as the school has accepted a programme of extended placement in South Africa as an alternative path to the sixth year exam. Already, one student working there has experienced a needlestick injury, representing one incident in about 80 weeks of clinical work. Preparation for electives varies from nothing beyond normal undergraduate course content to an integrated programme for those on the South African programme. Notices seeking applicants for this programme raise the issue of HIV; the selection panel checks that students understand the risks; and after selection the students receive a tutorial with a doctor experienced in HIV medicine. No drugs have been sent to date, and no restrictions are placed on activity, but debriefing does occur on return to Australia. Today’s articles will, however, lead to important changes. Counselling about levels of clinical responsibility will be upgraded, and from 1999 students will receive a handbook indicating what to do if an incident occurs that places them at risk. All students will be supplied with postexposure prophylaxis.

Where does all this leave us? It would indeed be tragic if medical students were restricted or discouraged from going to Africa and other places where HIV and other bloodborne viruses are hyperendemic. They risk missing important educational opportunities. Medical schools need a system that ensures that the risk to students’ health, especially from occupationally acquired HIV, can be kept to a minimum during electives. Students need accessible, regularly updated, and evidence based guidance on how to go on electives safely. Such advice would include how to reduce risks from malaria,⁴ unprotected sex,⁵ and road traffic accidents,⁶ as well as occupational HIV. In the United Kingdom the BMA is committed to educating medical students in this regard (D Morgan, BMA, personal communication). In addition to the BMA booklet AIDS and You⁷ an interactive CD Rom on bloodborne viruses is now available,⁸ and in response to the findings in today’s BMJ the BMA is developing a new booklet aimed at helping medical students travel on electives more safely, which will be available later this year. Finally, individual medical schools (whether inside or outside the United Kingdom) cannot escape their responsibility for providing their students with postexposure prophylaxis for occupational HIV exposure.¹

Papers pp 158, 161