ABSTRACT & COMMENTARY

Only one patient infected with HIV by French surgeon

Findings reassuring but confidentiality a concern

Source: Lot F, et al. Probable transmission of HIV from an orthopedic surgeon to a patient in France. Ann Intern Med 1999; 130:1-6.

Reasonable evidence of possible transmission of HIV from medical personnel to patients has been limited to one well-publicized cluster of cases involving a dentist in Florida reported in 1990. Following the recognition of HIV infection in a 53-year-old orthopedic surgeon practicing in a Parisian suburb who presented with HIV encephalopathy in 1994, Lot and colleagues from France began attempts to contact 3,004 former patients. (See Hospital Infection Control, March 1997, pp. 33-36.) It was believed that the surgeon had likely been infected while performing surgery 12 years earlier. A total of 983 patients responded to letters requesting information regarding their HIV status or were referred for HIV testing. Attempts to contact nonresponders were made by obtaining current addresses through the hospital registry or the French National Health Insurance Registry. In addition, with the agreement of the French Committee on Information and Privacy, all untested patients were matched to the National AIDS case registry.

Only one person with HIV infection (0.1%) was identified — a 67-year-old woman who had undergone a difficult 10-hour hip replacement in 1992, whose retroviral infection was recognized during a preoperative screen in 1994. Phylogenetic analysis revealed that the HIV strain from the patient and surgeon were similar and probably belonged to a unique and as-yet-unidentified HIV-1 subtype. On questioning, the surgeon reported frequent cutaneous blood exposures and almost weekly percutaneous injuries. His orthopedic surgical colleagues reported a similar frequency of percutaneous injuries, especially while suturing in a blind cavity or while placing metal wires or pins. Few, if any, of these exposures were reported. This high frequency of high-risk exposures was common to orthopedic surgeons and was not shared by other surgical subspecialties.

Comment by Carol A. Kemper, MD, clinical assistant professor of medicine at Standard University and an infectious disease physician at Santa Clara Valley (CA) Medical Center.

Although this surgeon performed thousands of surgical procedures — many of them high-risk — during a period when he was probably viremic, only 0.1% of his patients may have gotten HIV. It’s reassuring to note that no other cases of HIV as the result of transmission from health care provider to patient have been documented to date. Still, these data suggest that physicians in specialties with frequent blood exposures should know their HIV status and should take extra precautions to prevent transmission. Improved reporting of percutaneous blood exposures should be encouraged.

A more disturbing aspect of this story was the use of the French National Health Insur ance system to track patients, especially those who had changed addresses or phone numbers or those who did not respond to the first mailing. Also, the French National Committee on Informa tion and Privacy gave Lot et al permission to examine the mandated national AIDS case registry in an effort to match AIDS cases with the surgeon’s list of patients who had not reported for testing.

Not one additional patient was identified by these measures. The ethical and scientific issues around the use of patient databases in this instance should be carefully examined as we, in the United States, contemplate similar (supposedly confidential) systems. One could argue that patients would want to know their potential risk and that the availability of successful therapeutic intervention provides a rationale for early case identification. However, based on the lack of documentation of any similar cases of HIV transmission despite thousands of surgeries and invasive procedures having been performed since the beginning of the HIV epidemic, the justification for the invasiveness of this investigation does not seem warranted.

On the other hand, when is the sacrifice of civil liberties justified? How many lives is it worth? And who decides? I ask myself if I would have seen this article in a different light if, for example, 30 patients had been discovered, none of whom knew they were HIV-infected.