The HIV-Positive Surgeon: Weighing the Risks

The recent report on 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 (MOH) conducted a fairly rigorous investigation of the surgeon. HIV testing was performed for 545 patients on whom the surgeon operated in the previous decade.¹ The sample represented roughly one-third of the surgical cases performed in the preceding 10 years, and none of the patients were found to be HIV-positive. In addition, none of the 1669 patients on whom the surgeon operated in the past decade were listed in Israel’s National HIV Registry, indicating that none had tested positive for HIV in Israel. After test results on the surgeon’s patients became available, an expert panel was convened to review the matter and make recommendations about the surgeon’s ability to practice.¹

As recommended by Israel’s MOH, the surgeon was allowed to resume his surgical practice with no restrictions on the types of surgeries he could perform if he agreed to the following conditions:

• Adhere to standard infection control precautions and hand hygiene requirements.
• Double-glove for all surgeries.
• Report immediately any cuts in gloves or finger sticks.
• Undergo quarterly HIV medical monitoring visits.
• Adhere to his prescribed antiretroviral drug regimen.
• Maintain an HIV RNA level below 50 copies/mL (the threshold of detection) and a CD4+ cell count above 200/µL.

He was not required to notify patients of his HIV status, which is counter to the CDC’s position on the issue,2 but the MOH does require him to receive HIV therapy and adhere to that treatment regimen in order to maintain viral load suppression.

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

Looking Back
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 the agency’s words, “exposure-prone” procedures.² The guidelines were vague about the specific procedures subject to restriction. The CDC sought guidance from professional societies about the types of procedures that might carry the highest risk, but those societies declined to respond.⁴ As a result, the CDC asked members of a local expert review panel to determine which if any restrictions should apply by using a case-by-case evaluation of a health care provider’s specific work situation.

The CDC’s guidelines offer general characteristics of exposure-prone procedures, such as 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

Available data support the Israeli MOH’s decision to allow the surgeon to continue to operate. Since the publication of the CDC’s guidelines, a number of retrospective studies and mathematical models have helped clarify the risk of provider-to-patient HIV transmission and put it into perspective. Briefly, the risk of hepatitis B and hepatitis C transmission in exposure-prone settings is considerably higher than the risk of HIV transmission.^3,5,6 Regarding cardiothoracic surgery, previous retrospective studies have revealed transmission of hepatitis B virus and hepatitis C virus⁵ but no transmission of HIV.⁶

When the CDC published its guidelines in 1991, little evidence existed that would allow an accurate assessment of the risk of provider-to-patient HIV transmission. Instead, the risk of such HIV transmission and the need for practice restrictions were based on “fear of contagion.”⁴ Data from reported cases, retrospective investigations, and national HIV/AIDS surveillance reports dating back to 1991 have shown that the risk is remote. Since the beginning of the HIV pandemic more than 2 decades ago, few cases of HIV transmission from health care workers to patients have been documented. In addition to 6 transmission events attributed to a Florida dental surgeon in 1990,^7,8 a single case in France in 1997 involved an orthopedic surgeon with advanced symptomatic but undiagnosed HIV infection.^9,10 This surgeon performed at least 3 exposure-prone procedures on a 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. A possible case of nurse-to-patient HIV transmission in France was reported in 2000.¹¹

Comprehensive retrospective investigations, particularly among physicians engaged in invasive procedures, have not identified additional cases of provider-to-patient HIV transmission.^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 found 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 were found to be HIV-positive.¹² Finally, US state health department follow-up of reported cases of HIV infection or AIDS have failed to confirm additional cases of provider-to-patient transmission.¹⁴

In 1999, Gerberding¹⁵ offered in an editorial what at the time became the standard infection control guidance on how to keep provider-to-patient HIV transmission low. Gerberding’s points, all of which are reasonable, were based on the assumption that surgical personnel are at risk for occupationally acquired HIV infection (Table). However, these recommendations have been unevenly implemented, particularly 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 editorial is that the relative risk of HIV infectivity depends on the degree of viral load suppression. Initially, our understanding of HIV infectivity based on viral load suppression came from results of studies of preventing mother-to-child transmission of HIV in the Pediatric AIDS Clinical Trials Group Protocol 076 trial.^16,17 It showed that the risk of mother-to-child transmission increased as viral load increased. Studies of discordant couples showed an increased risk of sexual transmission of HIV from partners with higher viral loads and genital ulceration.¹⁸

The debate on HIV infectivity and viral load level was reignited when senior HIV physicians and researchers in Switzerland issued a statement that persons who receive effective antiretroviral therapy and have an undetectable plasma HIV RNA level for at least 6 months are not sexually infectious to their heterosexual partners, provided that they adhere to treatment and do not have a sexually transmitted infection.^19-21 A clinical trial is under way in an effort to provide evidence to support this hypothesis.²²

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

Gostin⁴ suggests strengthening the infection prevention safety net for patients by increasing surgical staff awareness of prevention of blood-borne pathogen transmission, encouraging health care workers to manage their own health care more effectively, discontinuing expert review panels that impose unnecessary practice restrictions, no longer requiring mandatory disclosure to patients, and imposing restrictions that are more relevant to patient safety.

In an editorial response, Fost²³ agrees in general 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 and ethical framework of Gostin’s argument does not provide a proper balance between the interests of patients and those of clinicians.

The case of the HIV-positive cardiothoracic surgeon in Israel adds to our understanding of the low risk of HIV transmission in surgical settings and provides some guidance that incorporates emerging concepts of HIV infectivity based on viral load levels into the standard infection prevention approach. In the end, the primary issues are proper balance, emerging evidence, and patient safety.

References:

References
1. 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 February 9, 2009.
2. Recommendations for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients during exposure-prone invasive procedures. MMWR Recomm Rep. 1991;40(RR-8):1-9. http://www.cdc.gov/ mmwr/preview/mmwrhtml/00014845.htm. Accessed February 9, 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? maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=adapted& searchid=1&FIRSTINDEX=1650&resourcetype=HWFIG. Accessed February 9, 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 hu- man immunodeficiency virus to a patient during an invasive dental pro- cedure. MMWR. 1990;39:489-493. http://www.cdc.gov/mmwr/preview/ mmwrhtml/00001679.htm. Accessed February 9, 2009.
8. Centers for Disease Control and Prevention. Update-transmission of HIV infection during an invasive dental procedure-Florida. MMWR. 1991;40:21-27, 33. http://www.cdc.gov/mmwr/preview/mmwrhtml/ 00001877.htm. Accessed February 9, 2009.
9. Lot F, Séguier JC, 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. Centers for Disease Control and Prevention. HIV and its transmission. July 1999. http://www.cdc.gov/ hiv/resources/factsheets/PDF/transmission. pdf. Accessed February 25, 2009.
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. Division of HIV/AIDS Prevention. Surveillance of occupationally acquired HIV/AIDS in healthcare personnel, as of December 2006. http://www.cdc.gov/ ncidod/ dhqp/ bp_hcp_ w_hiv.html. Accessed February 27, 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 February 9, 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. 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. HIV transmission under ART. Presented at: XVII International AIDS Conference; August 3-8, 2008; Mexico City. Symposium SUSAT41. http://www.aids2008.org/Pag/PSession.aspx? s=485. Accessed February 27, 2009.
20. Vernazza P, Hirschel B, Bernasconi E, Flepp M. Les personnes séropositives ne souffrant d’aucune autre MST et suivant un traitement 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 February 9, 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. Presented at: XVII International AIDS Conference; August 3-8, 2008; Mexico City. Abstract THAC0505. http://www.aids2008.org/ abstract.aspx?elementId=200721126. Accessed February 27, 2009.
22. HIV Prevention Trials Network. 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 27, 2009.
23. Fost N. Patient access to information on clinicians infected with blood-borne pathogens. JAMA. 2000;284:1975-1976.