Abstract
BACKGROUND: Despite strong evidence that sustained HIV viral suppression eliminates transmission risk ("undetectable equals untransmittable", U=U), national approaches to managing healthcare workers (HCWs) living with HIV remain heterogeneous. Because such cases are rare but ethically and legally sensitive, clear guidance is needed to ensure consistent patient safety standards while avoiding unnecessary restrictions and stigma. METHODS: A systematic comparative review of international guidance on the management of HCWs living with HIV was performed. A broad PubMed search identified peer-reviewed guideline-type publications, supplemented by a targeted manual search of official websites of public health authorities, occupational health agencies, and advisory bodies across European Union (EU) countries, Anglo-American countries (UK, Ireland, USA, Canada, Australia), and Japan. Identified documents were extracted and compared using a predefined framework: viral load threshold, definition of suppression, monitoring frequency (initial and after stable suppression), handling of viral load "blips," reinstatement to exposure-prone procedures (EPPs), and oversight structure. Information on the need for patient notification and look-back procedures was also recorded. RESULTS: The PubMed search yielded 2,851 records, but only three peer-reviewed recommendations met the inclusion criteria: the updated guidance of the Society for Healthcare Epidemiology of America (SHEA), USA; the recommendation of the German Association for the Control of Viral Diseases (DVV) and Society for Virology (GfV), Germany, and the consensus of the Japan Society for Occupational Health's Research Group on Occupational Health for Health Care Workers. The manual search identified additional national guidance in the UK, Ireland, Canada, Australia, and several EU member states (including Switzerland, Austria, Denmark, the Netherlands, France, and Spain). Three major regulatory patterns emerged. First, multiple countries employ viral-load-based clearance for exposure-prone procedures (EPPs), most commonly using <200 copies/mL (UK, USA, Australia, Spain), while Germany applies the most stringent threshold (=50 copies/mL) with detailed "blip" rules and quarterly monitoring. Second, some jurisdictions adopt non-numerical, autonomy-oriented frameworks: the Netherlands relies on the treating physician's responsibility under U=U without mandatory panels or reporting, while Denmark uses a universal infection-control approach that does not operationalize HIV status for practice restrictions. Japan similarly lacks numeric thresholds and formal oversight, delegating decisions locally while citing UK/US models as references. Third, Switzerland represents a conservative, procedure-heavy model without explicit thresholds, emphasizing external committee involvement and discretionary decision-making. Many other EU states show regulatory silence or only vague discretionary authority without HIV-specific operationalization. CONCLUSION: International guidance has converged on viral suppression as the decisive determinant of patient safety, but implementation differs markedly in thresholds, monitoring intensity, and governance. Most guidelines specifying a numerical criterion align on <200 copies/mL as the operative standard for eligibility to perform EPPs, effectively establishing an international benchmark. Greater harmonization toward transparent, evidence-based standards may reduce regulatory inconsistency and legal uncertainty while preserving patient protection. Future research should assess whether threshold-based models with defined monitoring and reinstatement mechanisms provide a more reliable and evaluable framework for ensuring patient safety than non-numerical approaches.