French surgeon case renews debate over testing

AMA awaiting more information before responding

The recent report of an HIV-positive health care provider infecting a patient with the virus — only the second case ever documented worldwide — raises concerns that policy changes may be promoted in the United States. So far, however, the report is too sketchy to provoke much response.

The French government announced in January that a surgeon suffering from AIDS is likely to have infected a patient during a hip operation outside Paris four years ago. The case was issued in a report from the Pasteur Institute, and has not been published in a medical journal. The New York Times reported that the doctor believes he was infected while operating on an HIV-positive patient in 1983. However, he did not receive an HIV test until he became ill in 1994.

The surgeon, who no longer performs surgery, had operated on about 5,000 patients since 1983. One of 986 patients who were contacted and agreed to testing for HIV tested positive. The virus closely matched the surgeon’s, and further documentation showed a "high probability" that the surgeon infected the patient while cutting himself during a hip operation, the Times reported.

In a public statement, the surgeon urged both patients and health care workers to find out their HIV status.

In France, the report has opened a debate over whether surgeons should be tested for HIV, and whether those who test positive should avoid surgeries where they are at risk of being cut. The Ministry of Health responded by recommending that surgeons voluntarily be tested for HIV, but it has opposed blanket testing for patients or health care workers because that could delay surgeries. However, the French Order of Doctors, a 220,000-member association that sets medical standards in the country, voted to recommend that HIV-positive surgeons refrain from operating.

The American Medical Association in Chicago is eager to receive more information about the case before considering whether it should make any changes to its guidelines. Those recommendations urge health care workers to know their HIV status. Those who test positive and who perform invasive procedures should either inform their patients of their status, or refrain from invasive procedures.

"Our view thus far has been that we don’t have enough particulars about the case to see if it warrants a change in our policy," says AMA spokesman Dan Maier.

CDC favors peer review over mandatory tests

Following documentation of the first provider-to-patient HIV transmission case in 1990, the federal Centers for Disease Control and Prevention chose against recommending mandatory testing of health care workers in favor of establishing peer review panels to determine whether infected health care workers should limit their practices. The CDC’s position is a well-balanced one that has, in most case, proved adequate, says the CDC’s Harold Jaffe, MD. Jaffe headed the agency’s investigation of Florida dentist David Acer, who was shown to have infected six of his patients through an undetermined mode.

The French Ministry of Health consulted with the CDC, but did not involve it in the investigation, Jaffe says. While not surprising, the case doesn’t seem to warrant any policy changes, he says.

"Our feeling all along was that there was some small risk of health care worker-to-patient transmission and eventually there would be a second case," he tells AIDS Alert. The CDC is unaware of any other cases in this country, and no new findings have emerged from the Acer case, he adds.

Unlike the Acer case, the U.S. media’s response to the French case has been relatively low-key, possibly because the details of the case are not known. However, once they are known, some experts predict the issue of mandatory testing of health care workers to be raised again, as in the Acer case.