The HIV-Positive Surgeon: An Evidence-Based Approach

The recent report of an HIV-positive cardiothoracic surgeon in Israel has offered a contemporary perspective on the risks of transmission of HIV in health care settings, specifically surgical settings.

In a summary of the case from the CDC, Israel’s Ministry of Health did a fairly rigorous investigation of the surgeon. In a “look-back” investigation, HIV testing was performed on 545 former surgery patients who were operated on in the previous decade.¹ The sample represented roughly one-third of the total surgery cases of the previous 10 years; none of the patients were found to be HIV-positive. In addition, none of the 1669 patients operated on in the past decade were listed in Israel’s National HIV Registry, indicating that none of them had tested positive for HIV in Israel. According to Israel’s Ministry of Health, after test results on the surgeon’s patients became available, an expert panel was convened to review the matter and make recommendations regarding the surgeon’s ability to practice.¹

The surgeon was allowed to resume his surgical practice with no restrictions on the types of surgeries he could perform. Furthermore, in contrast to the United States’ position,² he was not required to notify patients of his HIV status. As recommended by the Israeli Ministry of Health, the surgeon may resume his surgical practice by agreeing to the following:
• Adhere to standard infection control precautions and hand hygiene requirements.
• Double-glove during all surgeries.
• Report immediately any cuts in gloves or finger sticks.
• Undergo quarterly HIV medical monitoring visits.
• Adhere to his antiretroviral drug regimen.
• Maintain an HIV RNA level below 50 copies/mL and CD4⁺ cell count above 200/µL.

Note the requirements in terms of the HIV-positive surgeon’s viral load and CD4 count. In other words, he is required to be on an antiretroviral regimen and be adherent to that treatment to maintain viral load suppression.

The CDC report noted that part of the investigation included a review of the evidence for and against HIV transmission from health care workers to patients, especially the available data in cardiothoracic surgery settings. The overall risk of HIV transmission from health care workers, according to the CDC, is “extremely low” and is echoed in a number of surveys in specific settings, including those related to surgery and dentistry.^2,3

LOOKING BACK
Historically, the CDC’s 1991 guidelines for prevention of transmission of blood-borne pathogens recommended some restriction of HIV-positive health care workers performing invasive or, in their words, “exposure-prone,” procedures.² The guidelines were vague in terms of the specific procedures subject to restriction. According to one source, the CDC sought guidance from professional societies regarding the types of procedures that might carry the highest risk, but those societies declined to participate.⁴ Instead, the CDC’s guidelines placed the final decision in the hands of a local expert review panel to determine what restrictions, if any, should apply, using a case-by-case evaluation of the health care worker’s specific work situation.

The CDC guidelines offer general characteristics of exposure-prone procedures, which include digital palpation of a needle tip in a body cavity or the simultaneous presence of the health care worker’s fingers and a needle or other sharp instrument or object in a poorly visualized or highly confined anatomical site.²

While cases like this surgeon’s are likely to cause sleepless nights for health care administrators and infection control professionals, available data support the Israeli approach of allowing this surgeon to operate. Since the publication of the CDC’s 1991 guidelines, a number of look-back studies and mathematical models have helped clarify the risk of HIV transmission from health care workers to patients and have put it into perspective. Briefly, the risk of hepatitis B and C virus transmission in exposure-prone settings is considerably higher than the risk of HIV transmission.^3,5,6 Regarding cardiothoracic surgery specifically, previous look-back studies have revealed transmission of hepatitis B virus and hepatitis C virus5 but no transmission of HIV.⁶

At the time of the 1991 guidelines, little evidence existed to accurately assess the risk of HIV transmission from health care workers to patients. Instead, the risk of transmission and the need for practice restrictions were based on “fear of contagion.”⁴ Since that time, data from reported cases, retrospective investigations, and national HIV/AIDS surveillance reports have shown that the risk is remote. Few episodes of HIV transmission from health care workers to patients have been documented since the beginning of the HIV epidemic over 2 decades ago.

In addition to a cluster of 6 transmission events attributed to a Florida dental surgeon in 1990,^7,8 a single case, reported in 1997, involved an orthopedic surgeon in France with advanced symptomatic but undiagnosed HIV disease.^9,10 This surgeon performed at least 3 exposure-prone procedures on his patient for insertion and revision of a hip prosthesis and bone graft. Although a thorough investigation was done, the exact mechanism and date of HIV transmission to the patient were not identified. Another possible case of nurse-to-patient transmission in France was reported in 2000.¹¹

Comprehensive retrospective investigations, particularly among physicians engaged in invasive procedures, have not identified additional cases.^12-14 As of July 1999, the CDC had analyzed HIV test results for more than 22,000 patients of 63 HIV-infected health care workers, and no documented case of transmission had occurred.¹² Similarly, in 1997, 1180 surgical patients of an HIV-infected obstetrician/gynecologist were tested in the United Kingdom; none was found to be HIV-positive.¹² Finally, state health department follow-ups of reported cases of HIV infection or AIDS have failed to confirm additional cases of health care worker–to-patient transmission.¹⁴

In 1999, Gerberding,¹⁵ in an editorial, offered what became, at the time, the standard infection control guidance on how to keep the risk of provider-to-patient HIV transmission low. Gerberding’s points, which are summarized in the Table, are based on the assumption that surgical personnel are at risk for occupationally acquired HIV infection, and all of her points make sense. However, these recommendations have been unevenly implemented, even today and, in particular, the appropriate reporting of possible exposures to blood during surgical procedures.

LOOKING FORWARD

One important piece of information not available at the time of Gerberding’s 1991 guideline editorial is our understanding of the relative risk of infectivity of HIV depending on the degree of viral load suppression. Our understanding of HIV infectivity based on viral load has come initially from the results of studies of prevention of mother-to-child transmission (MTCT) of HIV in the AIDS Clinical Trials Group (ACTG) 076 trial^16,17 and from results of studies in discordant couples that showed an increased risk of sexual transmission of HIV from partners with higher viral loads.¹⁸

More recently, the debate on infectivity and viral load level was reignited when senior HIV physicians and researchers in Switzerland issued a statement that persons who were receiving antiretroviral therapy and had an undetectable plasma HIV RNA level for at least 6 months were not infectious to their heterosexual partners, provided they were adherent to treatment and did not have a sexually transmitted infection (STI).^19-21 A clinical trial is under way to provide the evidence to support the hypothesis.²²

In the meantime, we should reexamine the approach taken by the Israeli expert panel evaluating the HIV-positive surgeon. In the current era of viral load suppression as both a standard of HIV care and a surrogate marker for reduced transmission,²¹ Gostin⁴ proposed a national policy for health care workers living with HIV/AIDS. Speaking from an ethical perspective, Gostin believes that the national policy outlined in the 1991 CDC guidelines should be revised. Since the risk of HIV transmission from health care worker to patient is low, he notes that the current national policy poses a significant human rights burden on the health care worker while not necessarily improving patient safety.⁴ Instead, he builds on the general infection control mantra proposed by Gerberding¹⁵ and places the burden of infection prevention responsibility where it belongs: on health care organizations and providers.

He proposes strengthening the infection prevention safety net for patients by increasing the surgical staff’s awareness of prevention of blood-borne pathogen transmission, by encouraging health care workers to manage their own health more effectively, by discontinuing expert review panels that impose unnecessary practice restrictions, by discontinuing mandatory disclosure to patients, and by imposing restrictions that are more relevant to patient safety.

In an editorial response, Fost²³ is in general agreement with Gostin. However, Fost takes issue with Gostin’s conclusion that disclosure does not apply to the “remote risk” of HIV transmission. Fost argues that the legal/ethical framework of Gostin’s argument does not provide a proper balance between the interests of patients and those of clinicians.

For the time being, expert panels that review work practices and possible restrictions of HIV-positive surgeons remain in place. The Israeli case not only adds to our understanding of the low risk of transmission in surgical settings but also provides some guidance that incorporates emerging concepts of transmissibility based on viral load levels with the standard infection prevention approach.

In the end, it is about proper balance, emerging evidence, and patient safety.

References:

References1. Centers for Disease Control and Prevention. Investigation of patients treated by an HIV-infected cardiothoracic surgeon-Israel, 2007. MMWR. 2009;57:1413-1415. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5753a3.htm. Accessed January 14, 2009.
2. Centers for Disease Control and Prevention. Recommendations for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients during exposure-prone invasive procedures. MMWR. 1991;40(RR-8):1-9. http://www.cdc.gov/mmwr/preview/mmwrhtml/00014845.htm. Accessed January 14, 2009.
3. Beltrami EM, Williams IT, Shapiro CN, Chamberland ME. Risk and management of blood-borne infections in health care workers. Clin Microbiol Rev. 2000;13:385-407. http://cmr.asm.org/cgi/content/abstract/13/3/385?matosho=&HITS=10&hits=10&RESULTFORMAT=&fulltext=adapted&searchid=1&FIRSTINDEX=1650&resourcetype=HWFIG. Accessed January 14, 2009.
4. Gostin LO. A proposed national policy on health care workers living with HIV/AIDS and other blood-borne pathogens. JAMA. 2000;284:1965-1970.
5. Puro V, De Carli G, Scognamiglio P, et al; Studio Italiano Rischio Occupazionale HIV. Risk of HIV and other blood-borne infections in the cardiac setting: patient-to-provider and provider-to-patient transmission. Ann N Y Acad Sci. 2001;946:291-309.
6. Babinchak TJ, Renner C. Patients treated by a thoracic surgeon with HIV. A review. Chest. 1994;106:681-683.
7. Centers for Disease Control and Prevention. Possible transmission of human immunodeficiency virus to a patient during an invasive dental procedure. MMWR. 1990;39:489-493.
8. Centers for Disease Control and Prevention. Update: transmission of HIV during invasive dental procedures: Florida. MMWR. 1991;40:21-27, 33.
9. Lot F, Séguier J-C, Fégueux S, et al. Probable transmission of HIV from an orthopedic surgeon to a patient in France. Ann Intern Med. 1999;130:1-6.
10. Blanchard A, Ferris S, Chamaret S, et al. Molecular evidence for nosocomial transmission of human immunodeficiency virus from a surgeon to one of his patients. J Virol. 1998;72:4537-4540.
11. Goujon CP, Schneider VM, Grofti J, et al. Phylogenetic analyses indicate an atypical nurse-to-patient transmission of human immunodeficiency virus type 1. J Virol. 2000;74:2525-2532.
12. Robert LM, Chamberland ME, Cleveland JL, et al. Investigations of patients of health care workers infected with HIV: the Centers for Disease Control and Prevention database. Ann Intern Med. 1995;122:653-657.
13. Rogers AS, Froggatt JW 3rd, Townsend T, et al. Investigation of potential HIV transmission to the patients of an HIV-infected surgeon. JAMA. 1993;269:1795-1801.
14. Centers for Disease Control and Prevention. National Center for HIV, STD and TB Prevention. Division of HIV/AIDS Prevention. Surveillance of health care workers with HIV/AIDS. http://www.cdc.gov/publications.htm. Accessed January 14, 2009.
15. Gerberding J. Provider-to-patient HIV transmission: how to keep it exceedingly rare. Ann Intern Med. 1999;130:64-65. http://www.annals.org/cgi/content/ full/130/1/64. Accessed January 14, 2009.
16. Connor EM, Sperling RS, Gelber R, et al. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. Pediatric AIDS Clinical Trials Group Protocol 076 Study Group. N Engl J Med. 1994;331:1173-1180.
17. Peckham C, Gibb D. Mother-to-child transmission of the human immunodeficiency virus. N Engl J Med. 1995;333:298-302.
18. Gray RH, Wawer MJ, Brookmeyer R, et al; Rakai Project Team. Probability of HIV-1 transmission per coital act in monogamous, heterosexual, HIV-1-discordant couples in Rakai, Uganda. Lancet. 2001;357:1149-1153.
19. Hankins C, Montaner J, Vernazza P, chairs. HIV transmission under ART. 17th International AIDS Conference; August 3-8, 2008; Mexico City. Symposium SUSAT41. http://www.aids2008.org/Pag/PSession.aspx?s=485. Accessed January 14, 2009.
20. Vernazza P, Hirschel B, Bernasconi E, Flepp M. Les personnes séropositives ne souffrant d’aucune autre MST et suivant un traitment antirétroviral efficace ne transmettent pas le VIH par voie sexuelle. Bulletin des médecins suisses. 2008;89:165-169. http://www.saez.ch/html_f/2008/2008-05.html. Accessed January 14, 2009.
21. Attia S, Egger M, Low N. Can unsafe sex be safe? Review of sexual transmissibility of HIV-1 according to viral load, HAART, and sexually transmitted infections. 17th International AIDS Conference; August 3-8, 2008; Mexico City. Abstract THAC0505.
22. The HIV Prevention Trials Network. Study HPTN 052: a randomized trial to evaluate the effectiveness of antiretroviral therapy plus HIV primary care versus HIV primary care alone to prevent the sexual transmission of HIV-1 in serodiscordant couples. http://www.hptn.org/research_studies/hptn052.asp. Accessed February 3, 2009.
23. Fost N. Patient access to information on clinicians infected with blood-borne pathogens. JAMA. 2000;284:1975-1976.