The Human Immunodeficiency Virus is a pandemic surrounded by questions and uncertainties. After almost 3 decades since the emergence of the virus, knowledge on its epidemiology and pathology has increased dramatically. The impact of HIV has also lessened from a once terminal infection to a manageable chronic illness (Gutierrez & Decker, 2010). Evidently, with the increase in manageability, athletes are living and competing with HIV. There is a growing debate concerning the participation of HIV-positive athletes in all levels of sports ranging from the high school level to professional arenas. The negative publicity towards HIV and HIV-positive athletes is focused on the potential for transmission of the virus through the blood or bodily fluids. During competition, the blood or bodily fluid of a seropositive athlete may contaminate the skin or mucous membranes of other athletes or team staff. This likelihood is greatly increase in contact and combat sports like hockey and boxing where exposures to blood spills are greatly increased (AAP, 1999).The question under research is whether or not it's safe for HIV-positive athletes to participate in sports. In order to answer the above question, this article will address current knowledge regarding the prevalence of HIV-positive athletes in sports, the method and probability of transmission within the sporting arena, current policies regarding HIV in Major athletic governing bodies, legal and universal precautions to take in order to stem the spread of HIV.
The first issue under focus is the prevalence of HIV-positive athletes in sports. HIV had an estimated incidence rate of 0.30% in the North American population in 2009 (CDC, 2009). The prevalence is greater at 0.40% in the adult (18-49) population (IBID). The prevalence of HIV has stabilized in the past 10 years and the number of incidences per year has greatly decreased since the early 1990s (IBID). Currently, there is no published information on the prevalence of HIV infections in any sporting groups. However, a survey conducted in 1991 by Mcgrew, Dick, Schniedwind, & Gikas (1995) stipulated a very small number of HIV-positive athletes in the NCAA. The result of the survey estimated that around 250 student athletes are HIV-positive from a sample of approximately 270,000 students competing in the NCAA (Mcgrew at el, 1993). The data however does show a relatively small increase in prevalence rate between the general student body control group (0.08%) and the athletic student body (0.10%). Mcgrew at el (1993) however contributes the difference of prevalence rates to "off-field" behaviours categorized by risky lifestyle that includes alcohol and inconsistent contraceptive use that are more commonly found in the athletic student body. Currently, the USA boxing Association is the only sport governing body in the United States that enforces mandatory HIV testing and prohibition of HIV-positive athletes (AAP, 1999). The AAP (1999) reported the number of boxers testing positive is no more than a handful. Based on the data collected by the NCAA (1993) and the AAP (1999), there is a very small number of HIV-positive athletes to start with. The potential for HIV transmission is determined by the prevalence of HIV in the population and the relative ease of transmission. Without consideration of possible modes of transmission, the minute ratio of HIV-positive athletes to the total athletic body makes transmissions a rare incident (IBID).
The second issue is the risk of HIV transmission during competition. The risk of HIV transmission can be examined through a theoretical and an applied approach. According to Mast et al (1995), the transmission of blood borne pathogens such as HIV requires several hypothetical elements. 1) HIV transmission is only possible with a relatively large quantity of an infectious substance usually in the form of blood. 2) there must exist a mode of transportation between the infectious reservoirs to the host.3) the infectious substance can only enter if the host has an available portal of entry. 4) The host must also be susceptible to the infection without the ability to fight off the virus. All four variables must be present for transmission to occur. Applying the above principles to the sporting arena, HIV transmission requires 1) a HIV- seropositive Athlete, 2) the presence of a HIV-seropositive blood spill 3) that comes in contact with a permeable membrane on a HIV-seronegative athlete and 4) prolonged exposure to the blood. Mast at el (1995) argues that the four hypothetical variables greatly reduce the risk of HIV transmission and likely to occur together only in a limited number of sporting activities, specifically contact and combat sports. Lacerations and bleeding injuries are more common in sports like hockey, football and boxing. These injuries increase the likelihood of transmission by opening a portal of entry and exit (Feller & Flanigan, 2000). A national football league study measured the potential incidence rate of HIV transmission in the NFL regular season. In the descriptive prospective study, Brown, Drotman, Chu, Brown, & Knowlan (1995) looked at Professional football players from 11 teams of the National Football League during 155 regular season games from September through December 1992. Brown at el (1995) stipulated from prevalence of HIV among college men and relative rates of HIV transmission, the risk for HIV transmission to each player was estimated to be less than 1 per 85 million game contacts. Putting the numbers in context, a survey conducted by the CDC in 1994 reported a total of 38 documented incidence of infectious disease outbreak linked to sports participation over the previous 28 year period (Stacey & Atkins, 2000). Of the 38 cases, there is no conclusive report of a single HIV transmission during sporting activities. Stacey and Atkins (2000) argues that the low prevalence rate of HIV- infected athletes coupled with a minute chance of transmission shows that participation of HIV-positive athletes should not be restricted or restricted only in situations where the chance of transmission is greatly increased.
HIV has garnered increasing media attention. With the increasing media exposure of HIV in sports; many governing organisations have produced policies regarding HIV in athletic competition. The American medical society for sports medicine (AMSSM) and the American academy of sports medicine (AASM) have published a joint statement in which various issues regarding participation, confidentiality, testing, universal precaution and legal considerations for HIV-positive athletes are addressed (Stacey & Atkins, 2000). Stacey and Atkins (2000) argues that a decision concerning athletic participation of HIV-positive athletes requires an assessment of risk versus discrimination and based on the medical judgement of the American medical association (ASM), American academy of sports medicine (AASM), and the Center for Disease Control (CDC), neither mandatory testing nor prohibition of athletes is justifiable. It is however important for the education of athletes, coaches and other staff members on the risks and prevention of HIV transmission in their respective sports (Stacey & Atkins, 2000). Currently, the census amongst sport and medical governing bodies such as the AMA, CDC and the NCAA is that routine HIV testing of athletes is not necessary and HIV-positive athletes should not be prohibited from any competition (Mcgrew at el 1993). A survey conducted by the NCAA sampled athletic trainers from all NCAA institutions (860) to find 1) the prevalence of HIV testing and 2) policies on participation (IBID). Responses to the survey showed of the 548 institutions that responded, only 2 (0.4%) schools have mandatory HIV testing for athletes while 20 others had testing on a voluntary bases (IBID). The survey shows that the majority of NCAA institution does not have routine HIV testing (IBID). Of the 548 institutions to respond, 33 (6%) restricted HIV-positive athletes from participation in inter-collegiate competition, 9 prohibited only contact sports while 6 prohibited all competition. Consistent with the consensus of major sports medicine governing bodies (AMA, CDC and NCAA), the large majority of NCAA institutions do not have mandatory HIV testing for athletes (IBID). This is also true for professional athletes. Most professional governing bodies in North American enforce random drug testing policies but those policies do not extent to HIV testing (Gutierrez & Decker, 2010).
The Canadian and US legal system have not considered HIV-seropositive status as grounds to prohibit athletes from competition (Feller & Flanigan, 2000). The responsibility of determining suitability falls mainly on the athlete and their primary health-care provider (IBID). Since the justice system have advocated for the right for HIV-positive athletes to participate, sport governing bodies have began to implement guidelines and policies focused on preventing the possibility of HIV-transmission (IBID). Stacey and Atkins (2000) argue that the risk of blood-borne infections can be minimized if there are strict rules over the removal of players with bleeding wounds and maintaining a sterile standard of treatment when tending to the injuries. The NCAA and most professional sport governing bodies regard bloody jerseys or open wounds as warrant for immediate removal from the playing surface until a jersey change or appropriate bandaging is applied (IBID). These guidelines form the basic principles of universal precautions. Universal precaution can be accomplished by implementing standard policies regard injuries and bleeding and practicing standard precaution with everyone at all times (IBID). This includes the wearing of sterile gloves, use of antiseptic for wounds, cleaning of facilities and appropriate reporting of blood injuries to the medical physician (IBID). Universal precautions protects the confidentiality of athletes as while as the safety of athletic training staff and physicians by ensuring the same standard procedures are upheld at all times (AAP, 1999). The current policy of the AAP states that the physician should respect the right of the patient to confidentiality unless an informed consent form is signed by the appropriate party for the release of confidential information (IBID). It is also the responsibility of the primary care physician to educate the athlete on the possibility of infecting others and to make appropriate recommendation for the athletes to participate in sports where the likelihood of transmission is minimal (IBID).
HIV statistics are often approximations of reality. Overall HIV prevalence cannot be measured directly because a fraction of new incidences have not been diagnosed or reported to local surveillance programs (CDC, 2009). However, the data collected from most of the studies on HIV in sports support two critical pieces of information. Firstly, the risk of HIV transmission during athletic participation appears to be extremely rare and secondly, the prevalence of HIV athletes is very small (Feller & Flanigan, 2000). Based on the above information, the consensus of major sport and medicine governing bodies is that HIV-positive athletes should be allowed to participate in all competition under standard guidelines that ensures universal precaution.
