The following revised statement regarding the surgeon and HIV infection was approved by the College's Board of Governors and subsequently by the Board of Regents at its meeting in October 2003. The Regents approved the first College statement on this issue on October 19, 1991. Revisions to the statement were approved by the Board of Governors at its meeting on October 12, 1997, and were subsequently approved by the Executive Committee of the Board of Regents.
In 1980, the human immunodeficiency virus (HIV) was identified as the causative organism of acquired immunodeficiency syndrome (AIDS). Since its discovery and characterization, HIV infection has attained extraordinary attention among surgeons and other health care workers (HCWs) as a potential source of occupational infection. Epidemiological information has not been easily accessible because of barriers to testing that have arisen out of the stigma and socioeconomic consequences if an individual tests positive.
Because the disease is blood-borne and transmissible, and due to the nature of surgical work, a concerned surgical community has become involved and has offered leadership in developing enhanced sterile surgical barriers, and improved surgical techniques and procedures. Surgeons are at-risk for exposure to HIV and are concerned about this risk. Patients have been concerned about their potential risk of exposure to HIV infection from blood transfusions, other patients, health care workers, and surgeons.
In the U.S. and Canada, the only identified HIV transmission from a health care worker to patients occurred in a dentist's office in Florida. Proof does not exist as to how this transmission of infection occurred. The differences between sterile technique in a dentist's office and that in a surgical environment are enormous, and they must be differentiated in any epidemiologic analysis. There has been no documented transmission of HIV infection in the performance of surgical treatment from a surgeon to a patient to this date.
Reasons for the low risk of HIV transmission from the surgical team are readily available and include routine utilization of sterile surgical technique and universal precautions. The surgical team is continually aware of the dangers of transmission of infections, which is inclusive of, but not limited to, HIV infection. In addition, we now know that the blood concentration of viral particles in patients who are infected with HIV is low. Surgical barriers and surgical techniques should be further developed whenever possible to avoid intraoperative injury and to further diminish any possible risk of transmission of HIV or other pathogens.
Guidelines published in July 1991 by the Centers for Disease Control and Prevention (CDC) have been widely distributed and have not been amended or changed since that time. The College has expressed concern that these actions were not based upon direct scientific data, were not cost-effective, and were intrusive to the extreme. We continue to feel that the recommendations of defining "risk-prone procedures," as was recommended by the CDC, cannot be determined in a scientific or rational way. We have felt, and continue to feel, that these recommendations were irrelevant and counterproductive. In formulating these guidelines, the CDC ignored the overwhelming testimony of the scientific community, and the fact that all currently available data indicate that transmission from surgeon to patient in a hospital setting continues to be a hypothetical event.
While basic, clinical, and epidemiological research continues, a number of issues remain unresolved. The surgical community emphasizes that available scientific data indicate that transmission of HIV infection from physician, surgeon, or nurse to patient is extremely rare. The overall risk of transmission of HIV from infected surgeons to patients appears to be so low that costly measures, such as testing and limiting of work, are not justified. This is especially true now that antiretroviral therapy has advanced to a level to make many infected individuals virtually free of virus in their blood.
We continue to believe in operating room behavior that will minimize the risk of transmission of HIV or any other blood-borne or environmentally transmissible pathogen. We believe in enforcing a high standard of infection control and universal precautions, which remain the best strategy for protecting patients and surgeons from accidental exposure. We should continue to emphasize the absence of scientific data about any transmissions in the operating room environment, so that a healthy atmosphere can be maintained in the minds of patients and the public regarding the problem of HIV transmission. Any regulatory efforts should be based solely on documented scientific data and not on unfounded hysteria.
When a high-risk exposure event has occurred to a surgeon in the performance of a surgical procedure, the CDC recommends postexposure antiretroviral chemoprophylaxis. There is statistical evidence that indicates possible prevention of occupational infection, which has been observed from hollow needlestick exposures and has been extrapolated to have potential benefits following solid needle and other percutaneous or mucous membrane exposures to HCWs.
While therapy for HIV infection has not resulted in eradication of the disease, effective combination antiretroviral therapy is available that reduces antigenemia from the infection, improves quality of life, and appears to significantly improve life expectancy. Surgeons should know their HIV serologic status in the same way that they would want to have knowledge of any other disease about which they may have personal concerns. This personal and confidential information about HIV infection would allow the surgeon to obtain important treatment and counseling for his or her own personal health, and should not be used for any determinations of credentialing or privileging for surgical practice.
Based on data that are currently available, we make the following recommendations:
- Surgeons have the same ethical obligations to render care to HIV-infected patients as they have to care for other patients.
- Surgeons should utilize the highest standards of infection control, involving the most effective known sterile barriers, universal precautions, and scientifically accepted infection control practices. This practice should extend to all sites where surgical care is rendered and to all patients who receive surgical care.
- Based on data in the current literature, HIV-infected surgeons may continue to practice and perform invasive procedures and surgical operations unless there is clear evidence that a significant risk of transmission of infection exists through an inability to meet basic infection control procedures, or the surgeon is functionally unable to care for patients. These determinations are to be made by the surgeon's personal physician and/or an institutional panel so designated for confidential counseling. Such a panel should be composed of infectious disease specialists, surgeons, and other health care professionals who are knowledgeable about blood-borne infections.
- Postexposure prophylaxis with antiretroviral chemotherapy is recommended. Counseling and recommendations for surgeons are available through the National Clinicians' Postexposure Hotline at 1-888-448-4911 or at www.ucsf.edu/hivcntr.
- Surgeons should know their own status for HIV infection, as they would be knowledgeable about any other disease or illness that is of concern to them personally. Treatment of HIV infection, while not curative, has been effective and is recommended. Knowledge of the HIV infection status of the individual is not to be used in the determination of suitability of the surgeon for surgical practice. The HIV status of a surgeon is personal health information and does not need to be disclosed to anyone.
- Various College committees should continue to consider the concerns and problems of HIV- infected surgeons and their families in their deliberations. The College committees will continue to monitor new developments in HIV infection and its treatment to optimize patient safety and safety in surgical practice.
Reprinted from Bulletin of the American College of Surgeons
Vol.89, No. 5, May 2004