U.S. Seen Urging Voluntary AIDS Tests for Surgeons

The long-awaited federal recommendations regarding AIDS-infected surgeons, due out this week, are expected to urge health professionals to take voluntary actions to protect their patients, but numerous public health groups and others predict they will instead prompt widespread restrictive policies, including mandatory testing.

The Centers for Disease Control, in guidelines scheduled to be released Thursday, are expected to recommend that all surgeons and other health professionals who perform “seriously invasive” procedures voluntarily undergo testing to determine whether they are infected with the human immunodeficiency virus and refrain from practicing if they are. The guidelines also suggest that those who find they are infected seek counseling from a local medical review panel.

“Seriously invasive” procedures are defined as those where a sharp instrument is present inside a highly confined anatomic site and/or where visibility is poor.

The language of the guidelines is more moderate than in earlier drafts, and it emphasizes that the scientific evidence of doctor-to-patient transmission “is inadequate,” according to one source who helped negotiate the final language. But “the essence remains the same,” as earlier drafts, which is that surgeons and others who perform invasive procedures should know whether they are infected and probably should not practice if they are, another knowledgeable source said.

Many medical and public health groups have criticized the federal government for what they see as responding to public fears rather than relying on available scientific evidence, which indicates that the chance of doctor-to-patient transmission is remote.

There is only one known case of a health care worker with AIDS apparently transmitting the virus, which triggered a national debate over the professional fate of infected surgeons.

A Florida dentist with AIDS is believed to have infected five of his patients. Initially, when only two infected patients had been identified, the mode of transmission was believed to be blood-to-blood contact, that is, an accident where the dentist’s infected blood somehow became mixed with the blood of his patients.

But, as additional patients have been identified, the evidence increasingly points to a breakdown in infection-control procedures, such as the use of contaminated equipment, in the transmission of the virus.

Critics attack the government’s approach, saying that a policy directed toward infected physicians fails to address what they believe to be the real source of the potential problem: infection-control procedures. Such procedures, for which guidelines already exist, include sterilizing equipment and wearing protective clothing.

“What’s disappointing about these guidelines is that they focus on a theoretical mode of transmission--i.e., blood-to-blood--and don’t address reinforcing adherence to universal precautions,” said Jeff Levi, director of government affairs for the AIDS Action Council.

“There are so many risks in the world that are so much more real to the average American citizen than this one, it makes no sense to be so worried about this when we don’t worry about the other ones,” said Dr. Michael Callaham, chairman of the task force on AIDS of the American College of Emergency Physicians and the director of the emergency department at UC Medical Center in San Francisco. “I understand why they are playing to the public mood on this, but I believe it is a significant mistake.”

Many groups believe that the current climate is such that once federal health officials recommend that surgeons learn their HIV status, hospitals and other medical facilities--anxious about potential liability--likely will move beyond the guidelines and require certain physicians, such as surgeons, to undergo periodic testing before allowing them to practice.

“Unfortunately, the impact of the recommendations will be driven by how the insurance companies react, which is not what we would like to see occur,” said Katherine McCarter, associate executive director of the American Public Health Assn.

Thomas B. Stoddard, an adjunct professor of law at New York University and executive director of the Lambda Legal Defense and Education Fund, agreed.

“These recommendations will be interpreted by every liability lawyer in the United States to require health professionals to disclose their HIV status,” he said. “The idea that these guidelines are voluntary is totally illusory. What is voluntary at this moment will, within six months, become mandatory. And in another year, we will see testing for patients as well.”

There have been several dozen cases of patient-to-doctor transmission of the virus.

There are growing signs that the American public believes it has a right to know whether its doctors have AIDS or are HIV-infected. A recent poll conducted by Newsweek magazine of a representative sample of 618 adults showed that 95% believed that surgeons should be required to tell their patients if they are HIV-infected, and 90% believed this rule should apply to all health care workers.

Further, Sen. Jesse Helms (R-N.C.) has introduced legislation, scheduled for Senate action Thursday--the same day the CDC guidelines are expected--that would make it a crime, punishable by 10 years in prison or a $10,000 fine, for any health care worker who knows he or she is HIV-infected to treat a patient without first disclosing his infection.

In the House, Rep. William E. Dannemeyer (R-Fullerton) has authored a bill that would require states to test certain health care professionals for HIV and would also give doctors, dentists and other health care providers the right to order involuntary AIDS testing of some of their patients.

The American Medical Assn. and the American Dental Assn. have made recommendations similar to those expected from CDC. They have called upon their HIV-infected members to voluntarily stop practicing or disclose to their patients that they are infected.

“The whole testing approach gives a false sense of security,” Callaham said. “We (emergency physicians) get exposed to blood daily. Suppose I was negative yesterday; I could become infected today.”