In 1980, the identification of the human immunodeficiency virus (HIV) as the causative agent of acquired immunodeficiency syndrome (AIDS) fundamentally shaped medical understanding of the disease and subsequent policy. Over the decades, HIV has continued to receive significant attention from surgeons and other healthcare workers, not only due to its occupational implications but also because of evolving clinical management and social attitudes.
Advances in HIV testing, treatment, and prevention have dramatically changed the landscape since the early years of the epidemic. Modern antiretroviral therapy can effectively suppress the virus, often rendering the viral load undetectable and “untransmittable” through sexual contact. This has significantly reduced risk—both for healthcare workers and patients.
For surgeons, the risk of occupational exposure remains low, especially when rigorous infection control practices and universal precautions are followed. Evidence confirms that transmission of HIV from healthcare professionals to patients is exceedingly rare, with only a handful of documented cases worldwide and none occurring in a surgical setting. Continued vigilance, use of protective barriers, and adherence to established protocols are the best approach to maintaining safety.
Patients and surgeons alike have benefited from improvements in blood screening, surgical technique, and post-exposure prophylaxis (PEP). Today, when high-risk exposure does occur, prompt administration of PEP is known to significantly reduce the likelihood of infection. Furthermore, stigma and barriers to testing have lessened with societal progress and improved confidentiality protocols, encouraging more open discussions and knowledge of serologic status among healthcare workers.
It is now widely recognized that HIV positivity should not restrict a surgeon’s practice or professional opportunities, provided they follow recommended precautions and maintain an undetectable viral load. There are published recommendations that surgeons avoid performing exposure-prone procedures unless approved to do so after consultation with an expert review panel. Although descriptions and tables of exposure-prone procedures have been published, no direct data exists as to the appropriateness of the inclusion of the list of procedures in these examples. In addition, such lists are likely to change frequently as surgical knowledge and techniques continue to evolve.
Advancements in the understanding and management of HIV have significantly improved the lives and outcomes of patients living with the virus. The ethical obligation to provide care to all patients—including those living with HIV—remains unchanged and central to surgical practice.
Recommendations
Based on currently available data, the ACS recommends the following:
- Surgeons have the same ethical obligations to render care to HIV-infected patients as they have in rendering care to 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.
- When elective surgery is planned in patients with HIV, the surgeon should work with the patient's HIV clinician to achieve viral suppression in advance of the planned procedure, if needed. Viral suppression—low to undetectable viral load, higher CD4 cell count—is associated with lower incidence of postoperative bacterial complications.
- 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 designated for confidential counseling. Such a panel should be composed of infectious disease specialists, surgeons, and other healthcare professionals who are knowledgeable about bloodborne infections.
- HIV-infected surgeons who perform procedures that involve high-exposure risk should continue to do so if they meet the following criteria in addition to the criteria previously outlined in recommendation 3.
- Obtain advice from an institutional panel as described in recommendation 3 regarding continued practice and techniques to minimize the risk of exposure.
- Undergo follow-up routinely and testing to demonstrate maintenance of an acceptably low viral load by a provider or personal physician who has expertise in the management of HIV infection and who is allowed by the provider to communicate with the expert review panel about the provider’s clinical status.
- As direct data is lacking as to the definition of high-exposure risk procedures, these should be agreed on by local experts.
- PEP with antiretroviral therapy is recommended. Counseling and recommendations for surgeons are available through the National Clinician Consultation Center’s (NCCC) Postexposure Hotline at 844-275-6222 or on the NCCC website.
- 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 the 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.
- There is no need or justification for routine notification to patients regarding surgeons living with HIV who are being managed with the guidance of an oversight panel.
- The ACS should continue to monitor and update guidance on HIV infection as it relates to surgeons and surgery to optimize the care and safety of surgical patients.
