So now the question becomes: Do patients have the right to know whether their doctor or dentist is HIV-positive?
Moreover, should we insist on mandatory testing for health-care workers and should those who test positive for HIV or other blood-borne diseases (such as hepatitis B) be barred from doing invasive procedures (largely, those that involve contact with a patient's blood)?
The Centers for Disease Control (CDC) will soon issue new guidelines for prevention of HIV and hepatitis B transmission to health-care providers and patients. Some health professionals have raised concerns about restricting the duties of health-care workers. Others anticipate a severe loss of clients if a health-care worker is known to be HIV-positive.
Clearly, the patient has the right to know the risk of harm from a health- care provider, and vice versa. Decreasing this "risk" should be the key objective in formulating a new public health policy.
According to the CDC, 156 dentists and 42 surgeons have developed full- fledged AIDS. There are also thousands of additional health-care workers infected with HIV and chronic hepatitis B. The actual number of infected health-care workers is probably much higher, but we just don't know because of under-reporting, confidentiality and bureaucratic health practices.
In the Florida cases, investigators were able to link all three patients to the dentist with the help of sophisticated testing techniques. It marks the first time in the 10-year history of the AIDS epidemic that the transmission
from an infected health-care worker to a patient has been documented.
It is certainly reasonable to conclude that similar transmissions of HIV by health-care workers carrying out invasive procedures occurred long before the CDC guidelines were published in 1987 recommending "universal precautions" to prevent HIV and hepatitis B transmission in health-care settings. These precautions advise the use of gloves, masks, gowns and protective eye wear and consider "blood and certain bodily fluids of all patients potentially infectious for HIV, hepatitis B and other blood-borne pathogens."
However, the risks to the patient with regard to HIV have yet to be addressed by the CDC.
The Florida cases came to the attention of the CDC only because of the short (two-year) incubation period of the virus in one patient, Kimberly Bergalis, which allowed the blood of the dentist to be obtained for testing while the dentist was still alive. Had she fallen within the normal five- to eight-year incubation period before developing AIDS, the dentist would have long been dead, and there would be no blood available for testing.
Health-care professionals also run a real risk of contracting HIV from patients. According to the American Medical Association, at least two dozen medical residents become infected with the AIDS virus each year, usually without their ever remembering they came in contact with blood from an HIV- infected patient.
And another report found that 21 percent of medical students were stuck by HIV-contaminated needles during their third and fourth years of medical school.
Unfortunately, universal precautions do not provide universal safety, and nothing in the guidelines refers to the risk of transmission from an HIV- or hepatitis B-infected health-care worker to a patient.
There are 150,000 dentists and about 500,000 physicians in the United States. Even if only 1 or 2 percent of infected health-care workers carry out invasive procedures that allow for the transmission of the virus, there will be many more Kimberly Bergalises. That is unconscionable and cannot be allowed to happen.
We as health-care professionals must first act as role models in developing sound public health policy to protect the health of all Americans. We must do this in a proactive way, rather than in a reactive way, as has been the case. For instance:
* All health-care professionals involved in invasive procedures should have mandatory testing for HIV and chronic hepatitis B and make their status known to their patients. Testing should be linked to professional licensing requirements. Malpractice insurers will probably demand such tests in any event.
* Blood is a two-way street, and the patient undergoing invasive surgery must similarly be tested. Health-care workers also have a right to know.
* The Centers for Disease Control should issue new guidelines recommending that dentists and physicians who test positive for HIV not be allowed to perform any procedure in which they could come in contact with patients' blood.
* HIV reporting should be obligatory in all 50 states and jurisdictions to comply with the necessity to not only report HIV, but also to trace sexual partners, intervene with life-prolonging therapy and guide pediatric and social-support programs. Confidentiality can and must be maintained.
* From a medical, ethical and public health interest, state health officials should immediately summon for testing all patients of AIDS-infected health-care workers practicing invasive medicine and dentistry. (The AMA and the American Dental Association have said that dentists and surgeons infected with HIV have a voluntary ethical obligation to tell patients. That does not go far enough, as evidenced by the three Florida cases.)
* Significant programs must be enacted to ensure the economic safety of occupationally related HIV or hepatitis B injury to medical and dental students, residents, house staff and health-care workers with regard to workers' compensation, disability payments, life-insurance programs and alternative job placement and retraining programs.
* Legislation at the state and federal levels, as well as regulation by the Occupational Safety and Health Administration, must protect health-care providers and patients against the risk of blood-borne pathogens.
A central principle of medical ethics is "First, do no harm." How can a physician or dentist know that he or she will do no harm when he or she is a carrier of HIV, hepatitis B or any other blood-borne disease?