French incident reopens debate about testing health-care workers for exposure to HIV
Chris Miller, PHD
The French government released information in January indicating that an orthopedic surgeon with HIV likely spread the disease to a patient during a hip operation near Paris in 1992 or 1993.
The surgeon was diagnosed with AIDS in early 1995 and indicated that he probably was infected while performing an operation on an HIV-positive patient in 1983. The tests for HIV disease were not available until after 1985, but the physician was not tested until 1994 after he experienced several unexplained illnesses. The physician informed the French Health Ministry that he had operated on about 5,000 patients since 1983. The Ministry attempted to inform these patients, and, of the 2,458 patients contacted, 986 agreed to be tested.
One HIV-positive patient was found in this group. This patient had had hip surgeries in 1992 and 1993 during which the HIV-positive physician apparently cut himself through his gloves, apparently spreading the virus.
The co-discoverer of HIV, Dr. Luc Montagnier at the Pasteur Institute, was asked by the French Health Ministry to compare the viruses isolated from the physician and from the patient. After several months of very careful work, Dr. Montagnier stated that it was Ohighly probableO that the virus was transmitted from the physician to the patient. The two viruses Oare indeed very similar.O While Dr. Montagnier is a well-respected HIV scientist, this work has not yet been peer-reviewed for publication in a scientific journal.
This is the second incident of probable transfer of HIV from a health-care worker to patients, the first involving an HIV-positive Florida dentist and six of his patients in the late 1980s. Investigations of at least 63 other HIV-positive physicians and dentists have not identified any other cases of HIV spread to patients, and this has involved testing of about 23,000 patients treated by these HIV-positive doctors.
This second incident has reopened discussions about HIV testing and the responsibilities of HIV-positive health-care workers and patients. The French Health Ministry recommended that surgeons be tested for HIV. The French Order of Doctors is considering announcing that doctors who are HIV-positive should stop operating in the interest of patients. The current CDC recommendations for the U.S. health-care workers (HCWs) were published in 1991 (ORecommendations for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients during expose-prone invasive procedures,O Morbidity and Mortality Weekly Report-MMWR 40 [No. RR-8], July 12, 1991).
They state that:
* All HCWs should adhere to universal precautions, including use of hand washing, protective barriers and care in the use and disposal of needles and other sharp instruments. HCWs who have exudative lesions or weeping dermatitis should refrain from all direct patient care and from handling patient-care equipment and devices used in performing invasive procedures until the condition resolves itself.
HCWs also should comply with current guidelines for disinfection and sterilization of reusable devices used in invasive procedures.
* Currently available data provide no basis for recommendations to restrict the practice of HCWs infected with HIV or HBV who perform invasive procedures not identified as exposure-prone, provided the infected HCWs practice recommended surgical or dental techniques and comply with universal precautions and current recommendations for sterilization/disinfection.
* HCWs who perform exposure-prone procedures should know their HIV-antibody status. HCWs who perform exposure-prone procedures and who do not have serologic evidence of immunity to HBV from vaccination or from previous infection should know their HBsAg status and, if that is positive, should also know their HBeAg status.
* HCWs who are infected with HIV or HBV (and are HBeAg positive) should not perform exposure-prone procedures unless they have sought counsel from an expert review panel and have been advised under what circumstances, if any, they may continue to perform these procedures. Such circumstances would include notifying prospective patients of the HCW?s seropositivity before they undergo exposure-prone invasive procedures.
* Mandatory testing of HCWs for HIV antibody, HBsAg, or HBeAg is not recommended. The current assessment of the risk that infected HCWs will transmit HIV or HBV to patients during exposure-prone procedures does not support the diversion of resources that would be required to implement mandatory-testing programs. Compliance by HCWs with recommendations can be increased through education, training and appropriate safeguards.
The AMA and ADA support the CDC guidelines, and this reported incident in France has not yet caused these organizations to change their recommendations concerning HIV-positive HCWs.
Chris Miller is director of Infection Control Research and Services and professor of oral biology at Indiana University.
