Heart Surgery Patients at Cedars-Sinai Asked to Take AIDS Blood Test
Cedars-Sinai Medical Center is asking all its heart surgery patients to have pre-operative AIDS antibodies blood tests, The Times has learned.
The new policy, in effect since May, is likely to trigger renewed debate over the uses and abuses of blood tests for infection to the human immunodeficiency virus, or HIV.
Some cardiac and orthopedic surgeons have publicly advocated wider testing so that they can better care for their patients as well as protect themselves from exposure to the virus.
But Cedars-Sinai heart surgeons and orthopedic surgeons at San Francisco General Hospital are the only two groups of surgeons in the state that are known to be seeking routine HIV testing for all their patients before surgery. “We are HIV testing everybody and have been doing it for a while,” said Dr. Jack M. Matloff, chief of cardiac surgery.
At other California hospitals, such routine testing is either discouraged or the decision is left to individual surgeons. “A lot . . . are doing it, but most aren’t publicizing it,” said David Langness, a spokesperson for the Hospital Council of Southern California.
Many AIDS specialists and patient advocacy groups have expressed concerns that routine pre-operative testing may lead to breaches of confidentiality and an increasing number of instances where doctors refuse to operate on infected individuals. In addition, they say negative test results may create a false sense of security and that physicians should take the same safety measures against exposure to blood and body fluids regardless of a patient’s HIV infection status.
Under a 1985 California law, one of the toughest in the nation, an individual must give written consent before being tested for HIV infection. The test results must be kept confidential; an individual must give explicit consent for test data to be shared among health care workers. Unauthorized disclosure of the results is punishable by a fine, imprisonment or both.
Cedars-Sinai physicians said that the major reason for recommending pre-operative HIV blood tests is their conviction that in infected individuals who have no symptoms, the stress of cardiac surgery may hasten the onset of the fatal acquired immune deficiency syndrome.
Temporary Effects
According to Dr. Richard Gray, director of surgical cardiology at Cedars-Sinai, the “heart-lung machine” that takes over the functions of the heart and lungs during cardiac surgery has a “temporary deleterious” effect on the function of white blood cells and other components of the disease-fighting immune system.
His theory is that if the immune system is weakened, HIV-infected patients will be at greater risk of developing AIDS-related problems. Such patients would not necessarily be discouraged from undergoing the surgery, but Gray said they might receive closer post-operative follow-up.
“There is a risk of potentially activating AIDS in HIV positive individuals,” Gray, a cardiologist, said in a telephone interview. “We haven’t said that (open-heart surgery) produces AIDS, we have just said that it might. It seems to us to be a reasonable extension of current medical knowledge to be concerned about this.”
But a leading AIDS expert said there was no scientific data to support the hospital’s stated reasons for recommending routine pre-operative testing. “This is folklore among the surgeons,” said Dr. Harry Hollander, the chief AIDS physician at the UC Medical Center, San Francisco. “Some surgeons have anecdotal stories that they have seen this happen but I can tell you that there is nothing written.”
Dr. Neil Schram, a Kaiser internist and member of the Los Angeles County Medical Assn. AIDS Committee, said he was “unaware of any scientific data” showing that major surgery can cause a worsening of the condition of asymptomatic HIV-infected individuals. (A major exception is procedures such as organ transplants, which involve the long-term post-operative use of drugs that suppress the immune system. Cedars-Sinai, however, does not have a heart transplant program.) The Cedars-Sinai policy covers both elective and emergency surgeries. So far, none of the more than 100 patients asked has refused to be tested, according to Gray. “Several” have tested positive.
No Patient Refused
Gray added, however, that no patient had been refused surgery or treated differently based on their test results or a decision not to be tested and that heart surgery had been performed at the hospital in recent years “on many patients who are HIV positive.”
The test results are made available to the patient’s personal physician and primary surgeon. “Sharing beyond that is up to the patient,” Gray said. The actual test records are being kept in a “separate, secure pathology file,” not in the patient’s official hospital chart, according to Ron Wise, a hospital spokesperson.
UCSF’s Hollander suggested that Cedars-Sinai surgeons were simply offering a “rationalization” for their desire to protect themselves by learning which of their patients were infected with the virus. “I think it is ludicrous. It is all self-interest and potentially very, very dangerous to the patients,” he said.
Asked to respond to this view, Gray said that self-protection was “not a factor” in implementing the new policy. “Standard universal precautions (such as the use of protective clothing as recommended by the U.S. Centers for Disease Control) are used regardless of test results,” he said. Hollander and Dr. Jared Spotkov, chairman of Kaiser Permanente’s regional AIDS committee and an infectious disease specialist, both expressed concerns that surgical patients undergoing pre-operative HIV testing might be inadequately counseled about the pros and cons of voluntary HIV testing and the meaning of their test results.
“(Kaiser) has discouraged routine presurgical testing because it misleads the surgeon and the patients,” Spotkov said. He cited the fact that the test results are sometimes inaccurate and difficult to interpret.
The Times asked about a dozen hospitals in the state about their pre-operative HIV testing policies. Orthopedic surgery patients at San Francisco General Hospital are routinely asked to consent to HIV testing, said Dr. Lorraine Day, the hospital’s chief of orthopedic surgery and an outspoken advocate of the role of testing in protecting health care personnel from exposure to the virus.
“I want to know what I am dealing with,” Day said in a telephone interview. “They are asking me to take risks and I want to know what the risks are. We get cut all of the time because of the tools that we use.”
Orthopaedic Hospital in Los Angeles has no official policy, but some surgeons ask all their patients to be tested, a spokeswoman said. Pre-operative patients are not tested routinely at Kaiser Foundation Hospitals, UCLA Medical Center, the Hospital of the Good Samaritan in Los Angeles, Brotman Medical Center in Culver City and St. Joseph Medical Center in Burbank, officials at those facilities said.
UC Medical Center San Francisco says that decisions should be made on a case-by-case basis, according to Dr. John E. Conte, the chairman of the hospital’s infection control committee.
