Provider-to-Patient HIV Transmission: How To Keep It Exceedingly Rare

Abstract

Editorials5 January 1999Provider-to-Patient HIV Transmission: How To Keep It Exceedingly RareFREEJulie Gerberding, MDJulie Gerberding, MDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-130-1-199901050-00012 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail In 1990, epidemiologic data and DNA sequence analyses linked a Florida dentist with AIDS to HIV infection in 6 of his patients (1, 2). Since then, at least 22 759 patients who received medical care from 53 U.S. health care providers with HIV infection (including 29 dental care workers and 15 surgeons and obstetricians) have been evaluated in retrospective studies monitored by the Centers for Disease Control and Prevention (3). Of the 113 patients who were found to have HIV infection, 28 received the diagnosis before they had contact with the infected health care provider, 77 had other defined risks for HIV infection, and 3 are still under investigation. The remaining 5 infected patients did not acknowledge risks associated with HIV infection. Virus isolates from 3 of the 5 pairs of patient and health care provider were not related according to DNA sequence analysis.Despite the enormous effort and expense required to accomplish these retrospective “look-back” studies, no new cases of nosocomial HIV transmission were detected. In addition, investigations of HIV-infected persons with no identified risk reported to the national HIV/AIDS surveillance system have failed to identify additional cases of provider-to-patient HIV transmission in the United States since the dental cases were identified (4). In 1998, the data substantiate what was only suspected in 1990—an infected provider can transmit HIV to a patient during invasive procedures, but the probability of transmission is below the threshold of detection by even very intensive surveillance methods. In short, provider-to-patient HIV transmission is exceedingly rare in the United States.In this issue, Lot and colleagues (5) in France report what they believe to be the first case of HIV transmission from an infected surgeon to a patient during a surgical procedure. The evidence to support this claim is not entirely conclusive. Despite a very thorough investigation, the mechanism and date of transmission could not be established with certainty, and the patient had had dental care in a region where HIV is highly prevalent before her infection was documented. Nevertheless, genetic sequence analyses of HIV isolates from the surgeon and the patient strongly support a close epidemiologic link (5, 6). However tempting it may be to find other mechanisms to account for the patient's infection, provider-to-patient transmission during orthopedic surgery is the most plausible explanation. Taken in this light, the investigation illustrates some very valuable lessons:Surgical personnel are at risk for HIV infection. The surgeon's HIV infection was attributed to an intraoperative injury that he sustained in 1983. Even though serologic testing does not document occupational infection, the surgeon had no nonoccupational risks, the putative source patient had received multiple transfusions of blood products from untested donors and was therefore at increased risk for HIV infection, and the surgeon developed a febrile illness consistent with HIV seroconversion syndrome shortly after the exposure occurred.Intraoperative percutaneous blood exposures should be reported and managed in the same manner as other occupational exposures. Some surgeons derive a false sense of security from the absence of documented occupational HIV infections attributable to suture needle injuries. Even though suture needle punctures probably transmit less blood than do hollow-bore needles, a low-volume exposure can contain blood with a very high titer of infectious HIV (7). Prompt reporting ensures access to appropriate exposure risk assessment, postexposure prophylactic antiretroviral treatment, and source patient testing for HIV and other bloodborne pathogens that affect follow-up care (8). Moreover, unreported exposures can result in undiagnosed infections and subsequent transmission to others.Surgeons and other health care providers who sustain frequent blood exposures should know their HIV status. As was seen with the surgeon in this case report, who sustained more than 10 percutaneous blood exposures per year, failure to seek HIV testing can have dire consequences. Routine periodic testing may be a practical approach to ascertaining the HIV status of providers with frequent blood exposures, but it does not obviate the need for reporting discrete percutaneous exposures.Health care providers who are infected with HIV need ongoing care from a personal physician. Fortunately, in this case, the surgeon's neurologic impairment was diagnosed after he had already stopped practicing and was not cited as a factor contributing to the patient's infection. However, persons with advanced HIV infection are at risk for complications that can affect their ability to work safely. The personal physician has an important role to play in promoting health, providing medical treatment, and monitoring changes in health status that impair fitness for duty. In addition, the physician can encourage consultation with other experts about safe work practices.Patient exposures to blood should be managed in the same manner as occupational exposures to blood. When an intraoperative injury occurs, the accident should be reviewed to determine whether the patient was exposed to the injured provider's blood. Mechanisms associated with such “recontacts” include passing the contaminated needle back through the patient's tissue or sustaining an injury from bone or hardware imbedded in the patient (9-13). If recontact is probable, the provider should be tested for HIV; hepatitis C virus; and, if he or she is not known to be immune, hepatitis B virus, so that the patient can receive appropriate follow-up care (8, 14). Unfortunately, for most patient infections (like the one reported here), the injury or recontact is either not recognized or not reported in time to initiate prophylactic treatment.Most important, injury prevention is the best strategy for preventing intraoperative HIV transmission among surgical personnel and their patients. Perhaps the most alarming aspect of this case report is the continued high frequency of injuries sustained by the infected surgeon and many of his surgical colleagues. These events create an ongoing hazard of bloodborne pathogen exposure and bi-directional transmission between providers and patients. Surgery may not ever be completely free of risk, but it can certainly be much safer than was imagined even a decade ago. In many operating rooms, better hand protection; improved equipment design; and safer techniques for handling instruments, manipulating sutures, and closing wounds are now standard (15, 16). Blunted suture needles are also gaining acceptance for many procedures (17-19). These and many other new interventions promise to reduce the risk for all intraoperative bloodborne infections.The HIV epidemic has been raging for more than 20 years, and this formidable pathogen has infected millions of people. It is reassuring that only two infected health care providers have been linked to patient infections. Rational prevention policies will further reduce this very small risk. Such policies can not only protect patients from infection but also protect their health care providers from unwarranted discrimination.