Communicable diseases in the recreation community: how do you include HIV-positive participants in public sports?

A three-year-old cuts himself in your public swimming pool. While the child receives treatment for the injury, his mother tells the lifeguard that the child, who was bleeding in the pool, is HIV-positive.

A fight breaks out on the sidelines of your sporting venue. One of the spectators is bleeding and discloses his HIV status.

During registration for your youth basketball program, a child's mother discloses his HIV status to your staff.

An injured soccer player walks off the field with an open, bleeding wound. No one knows, but this child is HIV-positive.

These real-life scenarios occur in public recreation complexes and programs on a regular basis. If they happened at your facility; or at one of your programs, would your agency be prepared? If not, then you need to develop appropriate policies and procedures that minimize the risk of disease transmission during play.

In developing a policy, a primary concern should be to ensure that the person who is or who is perceived to be infected with the human immunodeficiency virus (HIV) receives equal access to programs and services. This concern, while humanitarian in nature, is also a requirement of the Americans with Disabilities Act. Additionally, the American Academy of Pediatrics, the National Collegiate Athletic Association (NCAA), the National Football League and the World Health Organization, among others, all recommend that athletes with HIV infection should be permitted to participate in competitive sports at all levels.

Not an Isolated Case

The Centers for Disease Control and Prevention (CDC) reports that, by the end of 2001, an estimated 161,976 Americans were living with HIV, and an additional 344,178 were living with AIDS. People with HIV infection can lead productive and active lives for many years following infection, and are likely to continue participating in sport and recreation programs for the health benefits they offer.

Knowing that people with HIV are likely to participate in your recreation programs, and that not all will disclose their status, what policies do you have in place to address issues of education and training, treatment of injuries, and appropriate clean-up and disposal of potentially infectious materials and soiled uniforms?

Let's start with pre-event planning. The NCAA recommends certain pre-event planning before allowing an athlete with HIV into play. These precautions, applicable to all athletes, include medical consultation, proper care for wounds, and proper training, equipment and supplies.

The decision whether to participate in a recreation or sport program is best made on an individual basis by the HIV-positive person in consultation with his or her physician. In the case of a minor, the child's parent or legal guardian would play a key role in the decision-making process.

Wounds, including abrasions, cuts and weeping wounds, may serve as a source for bleeding or as an entry site for germs or pathogens. All such wounds should be covered with an occlusive (air-tight) dressing that will withstand the rigors of play. Additionally, healing wounds and dermatitis should also be securely covered.

Ensuring that all coaches and other persons anticipated to render care have properly equipped first aid kits, in compliance with universal precaution standards, is an important element of recreation programming. Required items include latex or nitrile gloves, bandages, adhesive strips, appropriate biohazard bags for soiled uniforms, supplies and equipment, and appropriate clean-up and disinfection material for spills.

There's a small trend to move away from latex gloves in favor of non-latex nitrile gloves. These gloves provide the same protective barrier as latex gloves but avoid allergic reactions by people coming into contact with latex (either the person administering first aid or the recipient of care).

Training for Coaches

All personnel authorized to render care to an injured athlete should be trained in first aid and CPR as well as in the proper use of protective barriers, including gloves. This recommendation applies to all sporting programs, not just those in which an individual has disclosed her HIV status.

Recreation departments could provide first aid and CPR certification to coaching staff. Many recreation departments are already prepared to conduct such training using existing staff (e.g., lifeguard instructors). Others can work collaboratively with the local Red Cross chapter or fire department to find a first aid instructor. In some cases, booster clubs and community businesses might be willing to "sponsor" the training, as there's a direct benefit to the children of the community. By including the cost of training into uniform or tee-shirt sponsorship programs, you can help defray the costs of training.

Alternatively, you could require that all coaches maintain, at their expense, current certification in American Red Cross Community First Aid and Safety or Sport Safety Training (or an equivalent program) as a condition of their participation in the program. Research has shown that the skills learned in a first aid class are likely to be used at home or at work, given that people spend most of their time in these two settings. Thus, the benefit of certification extends beyond the coaching position. The knowledge learned may be of direct benefit to the coach's family and friends. Thus, asking that coaches (volunteer or paid) assume the cost of certification isn't entirely unreasonable. It may, however, reduce the pool of eligibility, as some individuals may not be able to afford the cost of training.

As a final alternative, if full first aid and CPR certification is cost-prohibitive, and if the coaches aren't willing to assume the costs of certification, then a non-certification program could be offered by someone qualified to provide such training. Although not the ideal option, some training is better than none. If your department chooses to develop its own first aid program, proper documentation of the material covered is an important element of the risk-management strategy.

The final training component for those expected to render care to an injured athlete includes bloodborne pathogens training, such as the "Preventing Disease Transmission" course offered by the Red Cross. This two-hour program could be offered as an in-service program for all recreation and park staff and volunteers. The program highlights diseases of concern (including HIV) and provides strategies for preventing disease transmission while rendering care. Another benefit of the program is that it educates participants about diseases of concern beyond HIV, including more readily communicable diseases such as hepatitis, tuberculosis and meningitis. Further, training in proper hand washing and avoiding body fluids reduces the spread of illnesses such as the common cold and influenza.

Public Education

If issues surrounding an HIV-infected athlete escalate, the Red Cross has an HIV/AIDS program that provides education and training for a wide variety of audiences, including children. Because this type of training isn't generally a standard recreation department program, providing this training could generate inquiries about why the program is being offered. Thus, recreation departments might consider providing this type of training if the community is in need of general HIV education.

Because we know that recreation and sport directly affect health and wellness, it wouldn't be inappropriate to include health-related information in your brochure rack, including information on HIV issues. Although this is a passive approach to community education, such brochures offer fact-based material designed to better educate the community, thus minimizing the risk of an adverse community response if the presence of an HIV-infected athlete become public knowledge.

Those concerned for the potential negative public reaction to the presence of an HIV-infected athlete might consider the need for community-based education and training. In the unlikely event of a negative community reaction, recreation departments could turn to the Red Cross, the local school department, the board of health and local hospitals to help reinforce facts and reduce fears of HIV infection.

Public Disclosure

Agencies should consult legal counsel regarding the status of HIV laws in their state. As a general rule, only the HIV-positive individual has the option to disclose his status. In fact, some states specifically prohibit disclosure of HIV status by anyone other than the HIV-positive individual or her guardian. State laws could prohibit recreation and park personnel who have knowledge of an injured athlete's HIV status from disclosing that knowledge even to EMS personnel responding to an injury. The rationale behind such laws is that EMS personnel are trained to follow basic guidelines for disease prevention for all patients, regardless of HIV status. Thus, the risk of disease transmission is negligible, provided that caregivers follow their training and use protective barriers.

The CDC has unearthed no documented cases of HIV being transmitted during participation in sports. The low risk of transmission during sports participation would involve sports with direct body contact in which bleeding might be expected to occur. According to the CDC, "There is no risk of HIV transmission through sports activities where bleeding does not occur." For this reason, only one court has upheld the exclusion of an HIV-infected individual from the contact sport of karate.

Because the risk of disease transmission is generally infinitesimal in the sport arena, disclosure of HIV status is discouraged, particularly if training has been provided as outlined above. Local school departments may provide some guidance on how to handle the disclosure of medical information, including HIV status. Consultation between the recreation department and public school officials would be appropriate to help ensure consistency in addressing the issue of disclosure.

HIV-positive students may disclose their status to receive special education services, help with routine medication administration and, in some cases, receive reasonable accommodations to the state's scholastic attendance policy.

During Play

During play, athletes should be aware of any open wounds and should be required to bring them to the attention of the appropriate personnel (coach, trainer, etc.). However, coaches, officials and other players should also remain alert for uncontrolled bleeding, and should call such cases to the attention of the injured athlete as well as an appropriate individual.

Bleeding participants should be removed from play and bleeding should be controlled, following basic precautions to prevent disease transmission, such as the use of gloves. According to the CDC, the player shouldn't be allowed back into play until the bleeding has been controlled and the wound properly cleaned, treated and securely bandaged with an occlusive dressing.

At a minimum, recreation departments should provide coaches, program coordinators and others who are reasonably expected to render care to an injured athlete protective barriers and proper training in their use. This recommendation applies to all agencies, not just those that know an HIV-infected person is participating in one of their programs. Proper documentation of all training programs should be a routine part of the agency's risk-management program.

For More Information

NCAA Guideline 2h: Bloodborne Pathogens and Intercollegiate Sports. Originally crafted April 1988, revised August 2000. www.ncaa.org/sports_ sciences/sports_med_handbook/2h.pdf

NCAA Guideline 1f: Emergency Care and Coverage. Originally crafted October 1977, revised July 2000. www.ncaa.org/ sports_sciences/sports_med_handbook/1f.pdf

Centers for Disease Control and Prevention: Injury Prevention, Frequently Asked Questions. www.cdc.gov/hiv/pubs/faq/ faq30.htm

Shawn DeRosa, J.D., EMT, is NRPA's Northeast Regional Director. He can be reached at [e-mail]