Immunodeficiency Virus (HIV) Infection
College of Physicians\and\Infectious Diseases Society of America*.
February 1994 | Volume 120 Issue 4 | Pages 310-319
Knowledge about the
epidemiology, diagnosis, and treatment of human
immunodeficiency virus (HIV) infection gained since 1988 has
necessitated an update of our previously published policies. Important
advances have been made in the treatment of HIV infection and
the acquired immunodeficiency syndrome (AIDS), resulting in
a prolongation of the symptom-free period. Transmission of HIV
infection from a dentist to several of his patients is believed
to have occurred. Heterosexual transmission of HIV infection
is increasing in importance.
emphasizes the ethical imperative to care for all patients;
the need for health care professionals to adhere scrupulously
to universal precautions because of the low but definite risk
for transmission of HIV in the health care setting; the
expanded recommendations for HIV testing to identify infected
persons as early as possible; and the need for national leadership
in public education, public policy development, and health care
*This position paper
was authored by Theodore C. Eickhoff, MD, and was developed
for the Infectious Diseases Society of America (IDSA) and the
American College of Physicians (ACP) Health and Public Policy
Committee by the Clinical Practice Subcommittee: David J.
Gullen, MD, Chair; Whitney Addington, MD; Louis M. Aledort,
MD; Sandra Adamson Fryhofer, MD; Edgar B. Jackson, Jr., MD;
Nicole Lurie, MD; Bruce J. Sams, Jr., MD; John P. Tooker, MD;
Constance M. Winslow, MD, MBA. Members of the Health and
Public Policy Committee were: Clifton R. Cleaveland, MD, Chair;
Cecil O. Samuelson, Jr., MD, Vice-Chair; Robert A. Berenson,
MD; Christine K. Cassel, MD; John M. Eisenberg, MD; David J.
Gullen, MD; Woodrow A. Myers, Jr., MD; Steven A. Schroeder,
MD; Harold C. Sox, Jr., MD; Gerald E. Thomson, MD; Quentin D.
Young, MD. Members of the IDSA HIV Committee were: King K. Holmes,
MD, PhD, Chair; Donald Armstrong, MD; Donald Burke, MD; Julie
Gerberding, MD, MPH; Daniel F. Hoth, MD; Newton E. Hyslop, Jr.,
MD; Harold W. Jaffe, MD; Henry Masur, MD; John P. Phair, MD;
Philip A. Pizzo, MD; Jack S. Remington, MD; Merle A. Sande,
MD; Edmund C. Tramont, MD; Catherine M. Wilfert, MD; Constance
B. Wofsy, MD. Members of the IDSA Council were: Merle A. Sande,
MD, President; Gerald L. Mandell, MD; Vincent T. Andriole, MD;
Catherine M. Wilfert, MD; R. Gordon Douglas, MD; Ward E. Bullock,
MD; Ellie J. C. Goldstein, MD; Adolf W. Karchmer, MD; Dennis
G. Maki, MD; Allan R. Ronald, MD; Walter E. Stamm, MD. The paper
was approved by the ACP Board of Regents on 23 March 1992 and
by the IDSA Council on 21 March 1993.
The American College
of Physicians and the Infectious Diseases Society of America
have jointly published two policy statements on AIDS, the
first in 1986 and the second, revised and expanded, in 1988. Since the last statement, new developments suggest
the need for a re-examination and restatement of our policies
relating to HIV infection and AIDS. First, advances have been
made in the treatment of AIDS and HIV infection, including the
capability of substantially prolonging the presymptomatic period
in HIV-infected persons. Second, concerns about HIV transmission
in health care settings have been heightened in the minds of
both the public and health care professionals. Third, more
attention is being paid to some of the unique manifestations
of AIDS in women. Finally, heterosexual transmission of HIV
infection is steadily increasing.
In this statement,
we emphasize the ethical imperative to care for all patients;
recognition of the very low but definite risk for
transmission of HIV in the health care setting and of the
need for HIV-infected health care professionals to adhere scrupulously
to universal precautions; expanded recommendations for HIV testing
of patients to identify infected persons who might benefit from
early treatment; and the need for stronger national leadership
in public education, public policy development, and health care
June 1991 marked the end of the first decade of the worldwide
epidemic of human immunodeficiency virus (HIV) infection and
the acquired immunodeficiency syndrome (AIDS). As of that date,
l82 834 cases of AIDS had been reported in the United States. The Centers for Disease Control and Prevention (CDC) has
estimated that there are approximately 1 million HIV-positive
persons in the country, most of whom are asymptomatic and many of whom are
unaware of their seropositivity. Homosexual and bisexual men
and intravenous drug abusers have accounted for most of the
cases, but in recent years the rate of increase in the number
of new cases among homosexual and bisexual men has slowed and
has increased among injecting drug abusers. The number of cases of AIDS resulting from
heterosexual transmission of HIV has been increasing
steadily. Minority populations are disproportionately
represented, with 44% of cases of AIDS having occurred among
African-Americans and Hispanics. The CDC has estimated that
the cumulative number of patients with AIDS since the
beginning of the epidemic will be between 390 000 and 480 000
by the end of 1993.
of reported patients have died. The acquired immunodeficiency syndrome is now the
second leading cause of death among men ages 25 to 44 years
and the sixth leading cause of death among women in that age
The World Health
Organization estimated that there were 8 to 10 million
HIV-infected persons worldwide in 1991, with heavy
concentrations in developing countries in Africa and Southeast
Asia. The World Health Organization re-estimated this number
at 12 to 14 million in 1993. No reliable estimates of total
deaths are available on a worldwide basis, but the number probably
exceeds 1 million. It is estimated that more than 1 million
people worldwide are living with symptomatic AIDS.
These raw numbers,
however large, do not begin to reflect the human tragedy
caused by this pandemic. The numbers do make it clear that
the AIDS epidemic will continue to challenge the health care
professions and society well into the 21st century.
Recent advances in
AIDS research have enabled physicians to prolong symptom-free
intervals, to prolong productive life span even after an
AIDS-defining illness, and to improve treatment of
opportunistic infections. For example, alternative drugs are
now available for the prevention and treatment of Pneumocystis
carinii pneumonia. New antiviral drugs (ganciclovir and foscarnet)
are available for the treatment of cytomegalovirus infection,
and two new antiretroviral drugs, dideoxyinosine (ddI) and
dideoxycytidine (ddC), have been approved by the Food and
The natural history
of HIV infection is now better understood. The "latent period" may be less than 1 year in some
persons or longer than 10 years in others; the reasons for such
broad differences are not yet understood. Most persons remain
asymptomatic for 6 to 10 years. The infection, although
asymptomatic, is not truly latent because this period is
characterized by a gradual reduction in CD4 cell counts. The
antiretroviral drug presently available, zidovudine (AZT), is
now known to be effective in prolonging the asymptomatic
state even longer in patients whose CD4 cell counts have
declined to 500/mm3 or less.
have extended the survival time of persons with AIDS. In the
early years of the epidemic, the average time from diagnosis
of AIDS to death was less than 12 months. More recent
estimates place the Figure atabout 20 months. Further improvements in antiretroviral therapy
and treatment of opportunistic infections are expected to
increase overall survival even more.
The number and
character of opportunistic infections seen in patients with
AIDS have changed. The striking success of prophylactic
therapy for P. carinii pneumonia has resulted in a decrease
in the number of cases of P. carinii pneumonia seen in many
medical centers. Before such preventive treatment was introduced, P.
carinii pneumonia was by far the most common AIDS-defining
illness encountered in HIV-positive patients. That is often
no longer the case, and other opportunistic infections of the
lung and lymphatic system are becoming relatively more prominent.
In addition to
Mycobacterium avium-intracellulare infections, Mycobacterium
tuberculosis infection is increasingly recognized as a major
hazard in severely immunocompromised patients. Outbreaks of
tuberculosis have occurred in hospitals in New York and Miami, traceable to highly immunosuppressed patients with AIDS
in hospitals in which other patients had unrecognized or
inadequately treated cases of tuberculosis. These outbreaks
have resulted in transmission to health care personnel as
well. The multidrug-resistant nature of the mycobacteria
responsible for recent outbreaks has enormously complicated their management and control
and has sharply increased mortality rates.
The increased life
expectancy of HIV-infected patients comes with a price. Many
of the new treatments are expensive, and many HIV-infected
patients are unable to afford them. Hellinger
has estimated that the average cost of treating a person
with AIDS is $32 000 per year, with an average lifetime cost
of $85 000. The total cost of treating all persons with HIV
infection in the United States for the year 1991 was estimated
to be $5.8 billion. Thus, the successes of biomedical research
and improved therapies for HIV-infected patients exacerbate
the serious problems of access to and financing of care for
Other areas of AIDS
research have also had successes, although the improvements
are perhaps less immediate. Newer generations of confirmatory
tests have virtually eliminated falsely positive results.
Highly sensitive tests using polymerase chain reaction
technology are now available that detect the presence of the
virus by identifying minute amounts of HIV nucleic acid. Vaccine development continues steadily, and
progress in this area is more promising now than ever before.
A new AIDS case
definition by the CDC, introduced in 1993, has broadened the
definition to include asymptomatic HIV-infected persons with
CD4 cell counts less than 200/mm3. In addition, cervical cancer, pulmonary tuberculosis,
and recurrent pneumonia have been added as AIDS-defining illnesses
in HIV-positive patients. These changes have resulted in a sharp
increase in the number of reported patients with AIDS but have
not affected the overall rate of increase of new patients.
In 1990, the CDC
reported the first case of apparent transmission of HIV
infection from a health care provider--a Florida dentist--to
a patient. In subsequent investigations of the patients in
this dentist's practice, four additional cases were identified. It is not known how transmission occurred, whether
from direct contact with the dentist's blood or through indirect
transmission via contaminated instruments or equipment. This
widely publicized outbreak has heightened public concerns about
transmission in the health care setting.
cases of HIV-infected health care providers have been
identified, either after they have died or left practice, and
have prompted retrospective patient notification programs, or
"look-back" studies. In these studies, HIV testing was
offered to former patients of the HIV-positive provider.
Some of these
investigations have revealed serious gaps in the observance
of universal precautions by health care professionals.
Infection control procedures in the office of the Florida dentist,
for example, were identified as having been seriously deficient.
In another instance, an HIV-positive physician continued to
have direct patient contact despite having open exudative lesions
on his hands and arms.
professionals need to understand and appreciate public
concerns about this issue and not simply dismiss those
worried as being uninformed about the nature or level of risks.
All reasonable steps must be taken to reassure the public and
to ensure that no clinically significant risk for transmission
of HIV infection occurs in the health care setting.
Much work remains to
be done to address the serious social, ethical, and public
health implications of this catastrophic disease. Persons
with HIV infection continue to face discrimination, including
loss of employment, exclusion from the community, denial of
insurance, eviction from housing, ostracism of children in
school, and difficulty in obtaining medical and dental care.
Persons infected with HIV face substantial barriers in obtaining
access to basic care. These barriers are greatest for minority
groups, especially minority women. Injection drug users who
are infected with HIV may have problems obtaining drug
treatment. Seropositive women may have difficulty finding
appropriate prenatal and perinatal care, particularly if they
also use injecting drugs.
Thus, the need is
compelling for an expanded national program emphasizing
public education, prevention, and coordinated services that
can be managed at the local level. These programs should
focus on preventing infection through education and behavior
The American College
of Physicians and the Infectious Diseases Society of America
believe that physicians, other health care professionals, and
hospitals are obligated to provide competent and humane care
to all patients, including HIV-infected patients. The denial
of appropriate care to a class of patients for any reason is
ethically obligated to provide high- quality, nonjudgmental
care without regard to personal risk, real or perceived. It
is inappropriate for any health care professional to
compromise the treatment of a patient on the grounds of unacceptable
personal risk. This fundamental principle of medical ethics
cannot be compromised.
relationship is established by a patient requesting a
physician to provide care and the physician agreeing to do
so. The physician thereby incurs a moral responsibility to
provide the best care possible. If a physician feels inadequate
or incapable of providing such care in a given circumstance,
the physician must refer the patient to a competent colleague
who is able and willing to provide care. Refusal of a physician
to care for a specific category of patients, such as patients
who have AIDS or who are HIV positive, is morally indefensible.
principle of providing care to all patients with HIV
infection is not universally accepted. Increasing numbers of physicians training in
internal medicine and other primary care disciplines would
prefer not to care for HIV-infected patients. Half of the
respondents in a 1990 survey of primary care physicians in
the United States indicated that they would not, if given a
choice, provide care to HIV-infected patients. Two thirds of the respondents, however, believed
that they had a responsibility to do so.
The choice of
specialty training by medical students has also been affected
by the AIDS epidemic. The proportion of patients with AIDS seen in
residency training programs is increasingly influencing
students' ranking of training programs in the National
Resident Matching Program. These manifestations of disinterest
or disincentive in providing care to patients with AIDS may
be based on judgmental attitudes toward homosexual and bisexual
men and intravenous drug abusers or may be related to perceived
personal risk for transmission of the disease in the health
care setting. In a 1989 survey of 1745 senior residents in family
practice and internal medicine training programs, 9% reported
a needle-stick exposure to HIV-positive blood, and 20% more
had a needle-stick exposure to blood from persons at risk but
of unknown antibody status. Twenty-three percent of the residents indicated
that, if given a choice, they would not care for patients
with AIDS, and 38% indicated they were "very concerned" about
the risk for occupational transmission.
The public is not
likely to be reassured about the low risk for transmission of
HIV from an infected physician or surgeon in the health care
setting (Position 3) if a substantial number of health care
professionals avoid caring for HIV-infected patients because
they themselves fear transmission.
We believe that
primary care physicians are obligated to become competent in
the diagnosis and management of HIV-infected persons.
Complicated opportunistic infections or malignancies associated
with AIDS may require referral to subspecialists, but the
magnitude of the problem alone dictates that HIV infection
and AIDS be in the realm of competence of primary care
physicians. Primary care physicians need to know how to gain
access to clinical trials, experimental therapies, and
"compassionate use" protocols. We recognize that there are
parallel obligations to provide educational support in the
form of publications and postgraduate courses to enable
primary care physicians to gain and maintain competence in
caring for HIV-infected patients. In addition, we must be
able to counsel professional colleagues in any health care
discipline who may have unwarranted perceptions or fears
about risks involved in providing care to HIV-infected persons.
The practice of
medicine is a societal trust and carries with it a societal
responsibility. If medicine wishes to retain its respected
status as the healing profession, each of us must continue to
provide care to all our patients, regardless of personal
risk. To do less threatens the very nature of the patient-physician
relationship, makes a mockery of our professional heritage,
and violates the essence of being a physician.
Testing for HIV
antibody should be strongly recommended when it will benefit
the patient or the patient's contacts or when it will
minimize the risk for transmission of the virus or protect
the public health.
The first enzyme
immunoassay to detect antibody to HIV was licensed in March
1985. Because the goal of such testing initially was to
identify HIV-positive blood and thereby protect the safety of
the nation's blood supply, the tests were designed to be
highly sensitive. This purpose has been served, and
transfusion-associated HIV infection has occurred only in
rare instances of blood donated during the "window" of up to
3 months between HIV infection and the ability to detect HIV
antibody. The estimated risk for acquiring HIV infection via
transfusion of screened blood is about 1:60 000 units of
blood. Screening for HIV has become more specific as
improved confirmatory tests have become available. The
confirmatory tests are highly specific when strict criteria
are used to interpret the test results. The full testing sequence
consists of repeatedly reactive enzyme immunoassay tests, coupled
with a positive confirmatory test. A patient should not be
considered infected nor should a patient be informed of a
positive test result until the full test sequence, including
the confirmatory test, is completed.
In the United
States, all blood donors and donors of organs, tissue, semen,
and ova are tested for obvious and sound reasons. All
military personnel, federal prisoners, and immigrants are
required to be tested, although the appropriateness of such
testing has been questioned. There is need for a systematic
review of the costs and benefits of existing mandatory screening
programs. Although we support offering HIV testing to immigrants
entering the United States, particularly if they come from
countries with high rates of HIV in fection, we oppose
current federal policies that bar HIV-positive visitors from
entering this country. Such policies have no scientific
foundation, serve no demonstrable social purpose, and are
therefore unwarranted. They serve only to heighten public
anxiety about the transmissibility of HIV infection.
Most HIV testing in
the United States is currently done only after the person to
be tested has given informed consent. This is in contrast to
most other diagnostic tests, which generally do not require
individual informed consent unless an invasive surgical
procedure is involved. The unusual nature of HIV testing
evolved out of the concerns of homosexual men about confidentiality
of their health data and the discrimination encountered at all
levels of society. Thus, HIV infection and AIDS were perceived
initially more as civil rights issues than as public health
issues. Over the course of the last decade, the pendulum has
shifted in the direction of treating HIV infection and AIDS
increasingly as a public health issue. When discrimination against persons infected with
HIV has been eliminated and when seropositive persons are
assured access to care, then HIV antibody testing can be
treated more like other noninvasive diagnostic tests. Testing
should continue to be closely linked to counseling.
consent may be appropriate in certain circumstances, such as
after accidental exposure of a health care provider to a
patient's blood or testing of an unconscious or incompetent
patient in the absence of a responsible decision maker. Some
states have enacted legislation that permits testing without
individual informed consent in such situations. In states where
informed consent is mandated by law, some hospitals have
incorporated into their admission consent forms a provision
indicating that, in case of accidental exposure, the
patient's blood may be tested for both hepatitis B virus and
HIV infection. In such circumstances, patients should be
informed and counseled before testing.
The most important
reasons for HIV testing are to diagnose current illness and
to identify asymptomatic HIV-infected persons who could
benefit from treatment or prophylactic regimens. Other
justifiable reasons for testing include enabling therapeutic
decision making, minimizing the risk for transmission in health
care settings, providing reassurance for the worried well, and
allowing large-scale anonymous testing in epidemiologic studies
to define the extent of HIV infection in various population
usefulness of HIV testing is self-evident in the presence of
generalized lymphadenopathy; unexplained dementia; chronic
unexplained fever, diarrhea, or weight loss; or infections
such as tuberculosis. There are now compelling reasons to identify
asymptomatic HIV-infected persons as early as possible in the
course of their infection. First, antiretroviral therapy initiated
when CD4 cell counts fall below 500/mm3 is now known to
result in an increase in CD4 cells and prolongation of the
symptom-free period of the infection. Prophylactic therapy
directed against P. carinii is highly effective in persons
with CD4 counts of less than 200/mm3 and in those
who have recovered from an episode of symptomatic P. carinii
pneumonia. Thus, the HIV-infected person gains direct benefit
in learning that information as soon as possible. Second,
early identification of HIV-infected persons gives physicians
the opportunity to provide counseling, education in safe
sexual practices, and other ways of minimizing the risk for
transmission of the virus through genital secretions or
blood. Third, knowledge that a patient is HIV positive may
change the management of other medical problems, such as treatment
of syphilis or prevention of tuberculosis.
We strongly support
testing for early identification of HIV infection in patients
who may have been exposed in the past. This includes persons
with sexually transmitted diseases, intravenous drug abusers,
homosexual and bisexual men, persons who identify themselves
as at risk, women of child-bearing age with identifiable
risks for HIV infection, persons who received blood transfusions
between 1978 and April 1985, and sexual contacts of persons
who have had multiple sexual partners in the past or are in
other known risk groups. Because many patients may not recall
or may deny risk behaviors, physicians might consider offering
HIV testing to all their patients, whether or not specific risk
factors are known to be present.
circumstances, HIV testing may be used to minimize the risk
for HIV transmission in the health care setting. For example,
preoperative testing of patients would be appropriate, after
consent, if a surgical procedure could be modified to
minimize the risk for nosocomial transmission of HIV from patient
to health care provider (but only if the modifications were
too time-consuming or expensive to be carried out for all
patients). Examples might include use of special
puncture-resistant gloves, use of other kinds of protective
gowns or hoods, or avoidance of hand passage of sharp
Testing of patients
for the HIV antibody in any health care setting raises
several concerns. First, the patient must be appropriately
informed and consent to be tested. Second, testing must be
linked to and accompanied by counseling provided by properly
trained persons. Third, the provision of medically
appropriate care must not in any way be contingent on consent
to be tested or on the results of the test. Finally, safeguards
must be in place to limit knowledge of the test results to those
directly involved in the care of infected patients, to contacts
who may have been exposed, or as required by law or regulation.
Physicians and other
health care personnel are obligated to use all reasonable
measures to minimize the risk for transmission in the health
The risk for
transmission of HIV infection in the health care setting is
bidirectional; that is, there is a risk for transmission from
a patient to health care personnel and a risk for transmission
from health care personnel to a patient. The former risk has
been extensively studied and is now well quantified; quantitative
information about the latter risk does not exist.
studies of accidental HIV exposures in the health care
setting, taken together, document that the risk for HIV
transmission from a single percutaneous exposure to
HIV-positive blood is about 0.3% to 0.4%. The risk for transmission after
mucous-membrane or skin exposure to HIV-infected blood has
also been reported but appears to be substantially lower than
the risk from percutaneous exposure.
theoretic risk for transmission of HIV from health care
provider to patient was recognized early in the epidemic, no
such transmission was documented until the cluster of cases
was identified in the practice of a Florida dentist. During
the period in which transmission is believed to have occurred,
the dentist was HIV positive, had Kaposi sarcoma in the mouth,
and was intermittently taking zidovudine. He himself was a patient
of a dental hygienist in his office. It seems likely that
transmission occurred in the dental practice, presumably in
the office, but the precise mechanism of transmission is not
and probably never will be known. These five patients
represent the only known instances of transmission of HIV
infection from a health care provider to a patient.
A number of
"look-back" studies have been reported, particularly
involving former patients of surgeons with AIDS and, to date,
no instances of nosocomial transmission of HIV infection to
patients have been documented. Such negative information is not
conclusive, however, since the denominator of about 19 000
potentially exposed patients is still small in relation to
even the highest risk estimate (1:42 000).
In July 1991, the
CDC published recommendations for the prevention of
transmission of HIV and hepatitis B virus to patients during
exposure-prone invasive procedures. These recommendations underscored the importance of
continued use of universal precautions and indicated that
health care professionals who carry out invasive procedures
defined as "exposure prone" should know their HIV and
hepatitis B virus serologic status. If infected, it was
recommended that they refrain from doing such procedures unless
advised otherwise by a local expert panel. Additionally, the
guidelines recommended that if the infected provider continued
to do exposure-prone procedures, patients be notified of the
provider's HIV or hepatitis B virus status. The CDC recommended
against mandatory testing of health care workers and against
restricting the practice of health care workers infected with
HIV or hepatitis B virus who do invasive procedures not identified
as exposure prone.
In October 1991,
Congress passed legislation that requires each state public
health officer to certify to the Secretary of Health and
Human Services within 1 year that the state has implemented
the CDC guidelines or their equivalent. Many health care and professional organizations,
including the National Commission on AIDS, have expressed
serious reservations about certain components of the CDC
guidelines, and many state health departments have
promulgated their own recommendations on HIV-infected health
care professionals within their jurisdictions. The CDC has discontinued
its efforts to identify "exposure-prone" procedures and will
instead assess the equivalency of individual state health
As part of the
development of recommendations for preventing transmission of
HIV and hepatitis B virus to patients during exposure-prone
invasive procedures, the CDC constructed a mathematical model
to estimate the risk for transmission of HIV and hepatitis B
virus during invasive procedures. The elements of the model included the probability
of an HIV-positive surgeon having an accidental exposure to a
sharp instrument during a surgical procedure, the probability
of that sharp instrument recontacting the patient's blood or
open wound, and the probability of transmission after one
such exposure to the surgeon's HIV-infected blood. The high
estimate of risk for seroconversion after an invasive
procedure by an HIV-positive surgeon was 24 per million (1:42
000), and the low estimate was 2.4 per million (1:420 000).
This risk is substantially less than the risk for anesthesia-associated
mortality and is of the same order of magnitude as the risk
for death because of penicillin anaphylaxis or of HIV
seroconversion after the transfusion of appropriately
screened blood. This is a mathematical model, however, based
on estimates and extrapolations; data on which to base a
precise estimate of risk simply do not exist.
We base our policies
on the HIV-infected physician on the following principles:
that we are committed to preserving and enhancing the health
of the public and our patients; that the risk for HIV
transmission from an HIV-positive health care professional is
extraordinarily small, so small that it cannot presently be
measured; that this very low risk is further reduced by strict
adherence to universal precautions; and, finally, that sound
public health policy should be based on scientific data, not
on unwarranted fear and anxiety.
therefore make the following four recommendations to minimize
the risk for HIV transmission to patients in the health care
1. All physicians should become thoroughly familiar with the
principles and practices of universal precautions through periodic
infection control training. Health care institutions must take
steps to assure strict adherence to these basic infection control
policies and procedures.
2. All physicians
should undergo a voluntary self-assessment of HIV risk to
identify any risk of HIV exposure, either in personal life or
in the workplace. Physicians who may have been exposed should
be tested to ensure prompt medical assessment and care if HIV
positive and to minimize the likelihood of transmission
through sexual activity.
3. Physicians who
are HIV positive should seek appropriate medical care and
periodic evaluations of health status from their own personal
physicians. In addition, counseling should be sought, as
needed, about the advisability of continuing to work in the
health care setting. Such counseling should be conducted periodically,
based on, for example, changing health status or emergence of
new information about the risks for HIV transmission in the
health care setting. The physician's personal health status,
the ability of the physician to perform his or her professional
duties, and the demonstrated ability to comply with infection
control policies should be the sole determinants of decisions
about practice alterations or limitations. There is no evidence
of cognitive impairment during the asymptomatic period of HIV
infection in adults
[63,64,65,66]; therefore, HIV positivity alone does not
justify restriction of an otherwise competent health care
professional. Practice restrictions or work modification, if
any, should be based on individualized assessment of the
physician's ability to comply with universal precautions and
infection control procedures, and on professional competence
and judgment. For the HIV-infected physician who does not do
invasive procedures, monitoring by his or her own personal physician
should suffice. For the HIV-infected physician who does invasive
procedures, the personal physician may wish to consult public
health officials and other experts. Individual state health
departments have varied in their recommendations for implementing
the CDC guidelines. In New York, for example, local and state
review panels are established under health department auspices.
In Michigan, major responsibility is placed on personal
physicians. The relevant state health department guidelines
for HIV-positive health care professionals should be
confidentiality safeguards must be instituted and maintained.
We emphasize the
ethical obligation of physicians who may have been exposed to
be tested. This is in the best interest of both physicians
and their patients. There is clearly a need to balance the
right to privacy and livelihood of the seropositive health
care worker with the need to protect patients. We recognize
our obligation to support efforts to help HIV-infected health
care workers continue to work productively should practice alteration
become necessary or to assist in career redirection. For those
who are unable to work, we must assure the availability of
adequate disability insurance.
reason for health care professionals to be tested is the risk
to HIV-positive health care personnel of continuing to work
in an environment in which they may be exposed to various
opportunistic infections. The recent outbreaks of nosocomial
multidrug-resistant tuberculosis make this risk particularly
grave. Health care professionals who are HIV positive may need
to make difficult decisions about remaining in a health care
environment that may present substantial risk to their health.
clinically significant exposure of a patient to a provider's
blood or body fluids occurs, that exposure should be managed
in the same way as exposure of a health care professional to
a patient's blood. The patient should be apprised of the
exposure and the source health care professional should be tested
for HIV and hepatitis B virus.
We do not recommend
mandatory testing of health care professionals for HIV or
hepatitis B virus, nor do we believe it should be required
for employment, credentialing, licensure, or liability
insurance. Such mandatory testing programs, if carried out annually,
would cost up to $1 billion each year , without any assurance that a single case of HIV
infection would be prevented. The observance of universal
precautions by HIV-positive health care professionals,
including physicians, will minimize any risk for transmission
of HIV to patients. We believe that HIV-positive physicians
and other health care professionals who comply with universal
precautions and are not physically or cognitively impaired
present virtually no risk for HIV transmission to patients
and should not be restricted in the practice of their profession.
recommendations on minimizing the risk for transmission in
the health care setting are based on current knowledge. We
strongly support the need for comprehensive studies to define
the risks, if any, of HIV transmission from provider to patient
in the health care setting. As further scientific information
becomes available, these recommendations will be reconsidered
and revised if appropriate.
about HIV infection, with particular emphasis on the limited
mechanisms by which the virus can be transmitted, should
guide public policy and should serve to alleviate discrimination
against those who become infected with the virus and to limit
the further spread of infection.
Persons in positions
of public responsibility, such as elected leaders, employers,
community service organizations, welfare agencies, public
housing authorities, prison officials, and school officials,
are urged to become knowledgeable about the basic concepts of
HIV transmission and to educate their constituencies
accordingly. Physicians bear a special responsibility to assist
persons in public leadership positions in understanding these
basic concepts of the epidemiology of HIV infection.
indicates that transmission of HIV requires parenteral,
broken skin, or mucous-membrane contact with contaminated blood
or body fluids. Compelling evidence shows that even close and
prolonged familial exposure to persons infected with HIV will
not transmit the virus (68; see Addendum). Because the virus
is not transmitted by casual contact, restricting social or
professional relations with HIV-infected persons is not justified
when transmission of blood or body fluids is not likely.
educational efforts, rather than policies promoting physical
restriction or quarantine, are needed to control the spread
of HIV infection. Effective health education regarding the
hazards of engaging in risk behaviors is presently the single
most important approach to controlling the epidemic. Public
education should include an emphasis on activities and behaviors
that do not transmit HIV, as well as those that do.
We believe that
public health officials and others in positions of public
leadership bear an obligation to minimize the risk for
transmission in all settings, including ensuring the wide
availability of condoms as well as education on using them properly.
Similarly, needle exchange programs should be evaluated in various
settings and, if effective in decreasing transmission, should
be encouraged. We disagree with the view that such practices
serve only to encourage risk behaviors.
Public policy on
HIV-infected persons in areas of patient care, employment,
housing, institutionalization, and education should be based
on knowledge of the actual risks for infection and not on
speculation or unwarranted fears. Once fully informed,
persons in positions of public responsibility will be able to
educate their own constituents, and those likely to come into
contact with HIV-infected persons will be able to respond in
a humane fashion without jeopardizing their own health and safety.
This is particularly important for police, firefighters, emergency
medical technicians, and others in similar positions.
against HIV-infected persons is a public problem that
threatens the fabric of society and should evoke concerned
responses from all sectors of society. The health care professions
have a special responsibility to ensure that such prejudice
does not occur in the health care setting.
of patients infected with HIV should be protected to the
greatest extent possible consistent with the duty to protect
others and to protect the public health.
professionals should be sensitive to the concerns about
confidentiality and privacy. Patients with AIDS risk societal
ostracism and, in many cases, loss of employment and housing
if their disease status is known. The potential discriminatory
effect of public knowledge of a person's HIV seropositivity
is, therefore, enormous. Physicians and hospitals have the
obligation to review and, if appropriate, to strengthen
procedures to assure the confidentiality of their medical
records and to disclose information only with the patient's
situations, however, in which the health and welfare of other
persons may take precedence over the responsibility to
maintain confidentiality. Physicians have a concurrent duty to inform
identifiable persons at risk for grave harm; examples might
include present or recent sexual contacts and persons with
whom an HIV-infected person has shared intravenous needles.
In many instances, HIV-infected patients will recognize and
accept the responsibility to inform their sexual or other
contacts. Indeed, patient counseling should reinforce the concept
that the HIV-infected patient is obligated to inform his or
her partners. If the HIV-infected patient refuses to inform
others, the physician should consider how to protect the health
and welfare of the patient's spouse or other partners. The
physician may either notify the partner directly or arrange
to have public health officials do so. Clear guidelines on
this sensitive issue do not exist, but under some
circumstances the duty to warn may override confidentiality.
Physicians should inform themselves about applicable laws in
their practice locations.
where reporting of positive tests for HIV antibodies is
mandated by law, public health authorities will assume the
responsibility of partner notification. Cooperation of the index
case is essential, however, and standard practice with other
sexually transmitted diseases is to protect that person's
confidentiality. When a physician acts in good faith under
the law to disclose test results for the protection of
partners, he or she should be protected against legal
challenge by the seropositive person.
Many state health
authorities now require reporting by name of patients with
confirmed HIV-seropositive tests, and others are moving in
this direction. Such reporting may be epidemiologically
useful, but the confidentiality of seropositive persons must
be properly protected. Established public health techniques,
including identification of persons at risk; epidemiologic analysis
by time, place, and person; health education; and skillful contact
tracing are useful in limiting HIV infection.
obtain complete sexual histories on their patients and should
assume responsibility for candid communication with, and
education of, persons at risk for HIV infection. The need to
modify sexual practices in order to prevent transmission of
infection should be stressed.
provide information about the risks for HIV transmission to
their patients in a timely and accurate manner. Because of
the complex nature of the disease and the regular emergence
of new information, physicians must keep well informed, even
if they do not currently have patients with AIDS or HIV
infection in their practices. Discussions with patients should
convey an understanding of the basic concepts of infection
transmission in general; the nature of HIV transmission;
behaviors that might result in HIV transmission and those
that will not; the significance of a positive test for HIV
antibody; and the guidelines for risk reduction, including
the concepts of "safe sex," that have been promoted within
Physicians are often
reluctant to discuss sexual preferences and practices with
their patients. However, HIV infection is predominantly a sexually
transmitted disease, and this fact emphasizes the importance
of learning the sexual history of all, particularly new,
patients. The infectious nature of the disease, its causes,
and the steps to be taken to prevent transmission must be
discussed candidly with each patient known or suspected to be
at risk regardless of how the physician personally views the
subject. We recall the comments of former Surgeon General
Koop, who wrote: "Some of you find it unpleasant to recommend
condoms to young people. So do I. Acquired immunodeficiency
syndrome is an unpleasant disease and recommending condoms to
those who need protection is preferable to treating AIDS".
Guidelines on "safe
sex" are widely available, particularly within risk groups.
These guidelines are reasonable and sensible and are believed
to minimize the risk for HIV transmission. It should be
noted, however, that although the use of condoms during
intercourse reduces the risk for HIV transmission, it does
not totally eliminate it. "Safe sex" is certainly safer sex,
but it is not risk free. Only in a monogamous relationship in
which neither partner is infected is sexual activity free of
continued research into the causes, prevention, and treatment
of HIV infection and AIDS. In addition to biomedical aspects,
research into psychosocial and economic issues related to
AIDS should be increased. Studies of the effectiveness of
various types of educational interventions on behavior modification
are critically important.
The explosive growth
in knowledge about HIV infection and AIDS in the past 10
years is astonishing. This knowledge will have profound
application in human biology, specifically with regard to
human retroviruses and oncogenesis. The response of the biomedical
research community to the challenge of AIDS and the leadership
roles of the National Institutes of Health and the CDC should
be acknowledged and commended. Nevertheless, it is apparent
that most of the task remains to be completed and that
considerable research must yet be done before this disease is
fully understood and controlled.
should be given to prevention of HIV infection. Educational
efforts, more effective barrier protection, and psychosocial
research that focuses on improving preventive strategies are
presently the most promising avenues toward that goal. Particularly
important are the development of techniques for promoting "safer"
sexual practices and for limiting illicit drug- related
activities, especially among adolescents, young adults, and
hard-to-reach minority groups.
vaccines are being developed, and some are undergoing phase
I-II clinical trials. Phase III trials of potential HIV
vaccines present difficult methodologic and ethical problems
but nonetheless must be done. Although progress has been rapid
in the development of potential vaccine candidates, most
authorities believe that an effective pre-exposure HIV
vaccine will probably not be available before the year 2000.
The second priority
is to develop an efficient and responsive system to provide
care to all patients with AIDS. Special efforts must be made
to reach women and minority groups. A major research effort
is needed to explore all aspects of the care of patients with
AIDS, not just the purely clinical care of the hospitalized
patient. Long-term efforts to understand and favorably influence
the sociologic, psychiatric, and economic consequences of HIV
infection and AIDS are also needed. The goal should be
out-of-hospital care that maintains a patient as a productive
individual within the community for as long as possible,
coupled with a supportive environment with an emphasis on
comfort and human dignity when independence is no longer
possible. Public and private sector funding must be increased
to provide social and home services, housing, hospice care,
and continuing health care to persons with AIDS.
The third priority
is the development of improved antiretroviral therapies and
therapeutic and prophylactic regimens for the opportunistic
infections and malignancies that affect persons with HIV
infection. Although substantial strides have been made in the
development of effective chemotherapy, the development of
more effective and safer chemotherapeutic agents remains a
priority. Further, therapies that can safely and effectively
be provided on an ambulatory basis or in the home need to be
developed and evaluated. The need for inclusion of women and
minority groups in clinical trial groups must be emphasized.
postgraduate training programs, and continuing medical
education programs must educate present and future physicians
to care for HIV-infected patients and patients with AIDS with
compassion, understanding, and a thorough knowledge base. Sexual
history taking and counseling must be given major emphasis.
The challenge is
clear. Support from both the public and private sectors is
needed for public education, basic and applied research,
health services research, and health care delivery. Federal,
state, and municipal governments are encouraged to fill the
existing leadership gaps in these areas. We believe that the
resources and skills of all segments of our society will be
required to control this disease. Such an effort will require
enormous financial resources and the expertise of many disciplines.
To do less will risk catastrophic morbidity and mortality well
into the future.
Since this statement was written, we have become aware of several
instances of household transmission of HIV infection. Recently,
Fitzgibbon and colleagues
 reported transmission of HIV infection from one
child to another without documented sexual, percutaneous, or
demonstrable blood contact. Sequence analysis of the HIV
proviral DNA from the two isolates showed a high degree of
relatedness. Numerous opportunities existed for unrecognized
blood contact, because the source child had frequent nosebleeds,
bleeding from the mouth, and lacerations. These rare instances
of household transmission emphasize that HIV infection is a
blood-borne pathogen and that accidental blood exposure can
occur within home settings. No new or previously unsuspected mechanisms of
transmission have been identified.
Author and Article Information
& Article Info
Reprints: Linda Johnson White, Director, Department of
Scientific Policy, American College of Physicians, Independence
Mall West, Sixth Street at Race, Philadelphia, PA 19106-1572.
& Article Info
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