Expert: Terry B - 3/28/2007

Question
Dear Terry B,
We have found a nanny which we believe would be perfect for our child. Because we are flying her out to our home we requested a full medical as she will be away from family for a year and we are responsible for her medical expenses. She has now told us that her Elisa test has come back positive and they are retesting her. She feels quite sure that she wouldnt be HIV positive.
Main questions are. What are the risks of false positives? Secondly, we really do like this person but are worried about a few things such as having responsibility for her health during this year in a much more harsh climate than she is used to (damp and cold).
Also, what is the risk of infection in our home? Would it be irresponsible to employ her knowing her status?

Answer
Dear Charley:

Peace and all good things.  Depending on the country of origin for your prospective nanny, the antibody test procedures might be different from the international standards, where a reactive (positive) ELISA would be immediately followed by a Western Blot test.  

A positive ELISA means the presence of HIV antibodies OR SOMETHING SIMILAR.  The Western Blot is used to determine if the positive result is due to HIV or the something similar.  Simply, the Western Blot is a more expensive test, so the ELISA is used to eliminate samples that have neither HIV nor something similar (thus containing costs).  In testing terms, this means the ELISA is Highly Sensitive (meaning it will catch almost all reactive tests - including a small number of false positives); the Western Blot is Highly Specific - meaning it is used to differentiate HIV from other conditions.
Some factors, including multiple pregnancies, cause a reactive ELISA and an indeterminate Western Blot.  Thus her being retested is appropriate.

Now to your other question - I respect your inquiry and consideration of retaining her employment even if she is HIV infected, and for asking for facts rather than exhibiting prejudice.  With necessary information (such as the absence of risk of transmission through sharing a household, or in providing care, as evidenced by 25 years of history among health care workers), you can approach your decision-making using ethical guidelines appropriate to your situation and culture.  Questions you ask about responsibility for her health (and care) are appropriate and some would recommend you look at goods that can be accomplished, harms that can be avoided, whether you would treat her case differently than a similar one, and lastly what your preference would be in dialogue with her.  This is a longer discussion in which I would be happy to work with you or refer you to an appropriate resource in your area.

Lastly, because the law has impact on your decision making, be advised that some immigration policies prohibit granting a work permit for someone known to be HIV positive.  On the other hand, some laws prohibit discrimination against a person simply because of their HIV status.

I suggest you wait for a confirmative test and in the meantime check your area's regulations and restrictions on work visas.  

The very best to you, and thank you so much for your question.

Sincerely,

Terry