3.1.2 Professional Competence: The HIV Infected Physician
B. Lynn Johnston, MD, FRCPC
- To appreciate the basis, in ethics and guidelines, of the physician’s responsibility to minimize the infectious risk that he/she may pose to his/her patients.
- To understand the responsibility that physicians who care for other physicians infected with a blood borne pathogen have in advising and reporting these individuals.
- To appreciate the privacy rights of the infected health-care worker.
Dr. Leblanc is a 38-year-old surgeon in Halltown, a city west of Toronto (population 150,000). He has a successful practice and is active in the community, coaching a bantam hockey team that has reached the provincial finals for two years in a row. He is in a long-term relationship (8 years) with Jason, a teacher. They were both tested for HIV 10 years ago when each of them got life insurance. Jason was tested again after an episode of multidermatomal zoster; his test came back positive. They have an open relationship and acknowledge that each of them has had casual partners, but they have been careful to have protected sex with those other partners. Dr. Leblanc feels perfectly well and cannot believe that he might be HIV-infected.
After considerable deliberation and soul-searching, Dr. Leblanc goes to an anonymous HIV testing clinic in Toronto. Much to his distress, the test does come back positive. He realizes that this might have a major impact on his practice, let alone his health. However, he currently feels well and knows that it may be several years before his HIV status impacts on his well-being. He is glad that he was afforded the anonymity of the Toronto clinic and wonders if he might just let things ride until he feels that the HIV is affecting his health. After all, no one aside from him and Jason knows their test results.
After some consideration, Dr. Leblanc realizes that he has a responsibility to be checked out medically and to determine whether he might pose a risk to his patients. He makes an appointment to see the family physician that he had when he was a resident in Toronto. Dr. MacDonald confirms that Dr. Leblanc is asymptomatic with respect to the HIV and has no abnormal physical examination findings. Laboratory testing reveals that his T cells are fine (750/cc), but that his viral load is moderately elevated at 150,000 copies/mL. He is immune to the hepatitis B virus (HBV) (from a prior vaccination) and negative for hepatitis C virus (HCV). Dr. MacDonald confers with one of her colleagues to see what she should do about Dr. Leblanc’s work situation. Her colleague tells her that nothing needs to be done, but she is not convinced that is correct.
Dr. Leblanc decides to take a 6-week leave of absence and starts antiretroviral treatment to lower his viral load. He tolerates the medications well, and within 4 weeks his viral load is undetectable. He generally feels well, but is consumed by the thought that if the administrators at his hospital find out about his HIV status they will retract his privileges and make a public notification of his status. He also wonders if, when he goes back to work, he’ll have to divulge his HIV status to his patients.
- Did Dr. Leblanc have any professional obligation to undergo HIV testing?
- Does Dr. Leblanc have a professional obligation to notify anyone that he is infected with HIV?
- Are there any reporting requirements that Dr. MacDonald has to comply with?
- Are there guidelines regarding the workplace management of the HIV-infected physician that Drs. Leblanc and MacDonald could refer to?
- Are there any situations where the public needs to be notified of a physician’s HIV status?
- Does informed consent require Dr. Leblanc to tell his patients that he has HIV?
There are probably few infections that present as much fear and concern for contagion to patients and physicians alike as HIV,1,2 despite evidence that it is rarely transmitted from patient to health care worker (HCW) and extraordinarily rarely transmitted from HCW to patient. To date, there are only four instances where HIV has been attributed to care provided to patients by an HIV-infected HCW. One of these is the famous case in the early 1990s of the Florida dental surgeon.3 In that instance, the mechanism of transmission was not determined and may have been related to poor infection-control practices. The other instances include one patient who acquired HIV from an infected orthopaedic surgeon during a prolonged surgical procedure4 and one patient who acquired HIV during a Caesarean section during which the obstetrician suffered a needle-stick injury.5 The fourth transmission was attributed to an HIV-infected nurse who was not involved in an invasive procedure, leaving the transmission route unclear.6 In addition to these reports, there have been a number of look-backs that have tested tens of thousands of patients cared for by HIV-infected HCWs, including a number of surgeons.7–9 In none of these studies was transmission identified.
We can therefore say with some confidence that the transmission of HIV from HCW to patient is extremely low. However, it is recognized that there is a risk for transmission of blood-borne pathogens from HCWs to patients.10 To maintain the public confidence in the safety of health-care environments, it is important that we identify where risks for transmission do exist and take appropriate measures to reduce those risks.
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- Nelson R. Canadian hospital recalls patients for HIV testing. The Lancet Infectious Diseases 2004; 4: 133.
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- Mallolas J, Arnedo M, Pumarola T, Erice A, Blanco JL, et al. Transmission of HIV-1 from an obstetrician to a patient during a caesarean section. AIDS 2006; 20: 285–7.
- Goujon CP, Schneider VM, Grofti J, Montigny J, Jeantils V, et al. Phylogenetic analyses indicate an atypical nurse-to-patient transmission of human immunodeficiency virus type 1. Journal of Virology 2000; 74: 2525–32.
- Mishu B, Schaffner W, Horan JM, Wood LH, Hutcheson RH, McNabb PC. A surgeon with AIDS. Lack of evidence of transmission to patients. Journal of the American Medical Association 1990; 264: 467–70.
- Robert LM, Chamberland ME, Cleveland JL, Marcus R, Gooch BF, et al. Investigations of patients of health care workers infected with HIV. The Centers for Disease Control and Prevention database. Annals of Internal Medicine 1995; 122: 653–7.
- Donnelly M, Duckworth G, Nelson S, Wehner H, Gill N, et al.; Incident Management Teams. Are HIV lookbacks worthwhile? Outcome of an exercise to notify patients treated by an HIV infected health care worker. Communicable Disease and Public Health 1999; 2: 126–9.
- Johnston BL, Conley JM. Nosocomial transmission of bloodborne viruses from infected health care workers to patients. The Canadian Journal of Infectious Diseases 2003; 14: 192–6.
- Canadian Medical Association (CMA). CMA code of ethics. Ottawa: CMA; 2004. Available from: http://policybase.cma.ca/dbtw-wpd/PolicyPDF/PD04-06.pdf.
- Canadian Centre for Occupational Health and Safety (CCOHS). HIV infection in the workplace. Hamilton: CCOHS; 2017. Available from: https://www.ccohs.ca/oshanswers/diseases/aids/aids.html.
- Health Canada. Proceedings of the consensus conference on infected health care workers: Risk for transmission of bloodborne pathogens. Ottawa: Public Health Agency of Canada, 1998. Available from: http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/98vol24/24s4/index.html.
- Keeling RP. Health science students with blood-borne pathogen diseases. Journal of American College Health 2001; 50: 101–4.
- Public Health Agency of Canada. HIV/AIDS. Epi updates. Ottawa: Public Health Agency of Canada, 2014. Available from: http://www.phac-aspc.gc.ca/aids-sida/publication/epi/2010/1-eng.php.
- Centers for Disease Control. Recommendations for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients during exposure-prone invasive procedures. Morbidity and Mortality Weekly Report 1991; 40: 1–9.
- Gostin LO. A proposed national policy on health care workers living with HIV/AIDS and other blood-borne pathogens. The Journal of the American Medical Association 2000; 284: 1965–70.
- Department of Health. AIDS/HIV infected health care workers: guidance on the management of infected health care workers and patient notification—a consultation paper. Ottawa: Crown Copyright, 2002. Available from: http://www.rki.de/DE/Content/Infekt/Krankenhaushygiene/Erreger_ausgewaehlt/HIV_AIDS/HIV_pdf.pdf?__blob=publicationFile.
- Tuboku-Metzger J, Chiarello L, Sinkowitz-Cochran RL, Casano-Dickerson A, Cardo D. Public attitudes and opinions toward physicians and dentists infected with bloodborne viruses: Results of a national survey. American Journal of Infection Control 2005; 33: 299–303.
- Reitsma AM, Closen ML, Cunningham M, Lombardo PA, Minich HN, et al. Infected physicians and invasive procedures: Safe practice management. Clinical Infectious Diseases 2005; 40: 1665–72.
- Gostin LO. Rights and duties of HIV infected health care professionals. Health Care Analysis 2002; 10: 67–85.
- Cook RJ, Dickens BM. Patient care and the health-impaired practitioner. International Journal of Gynecology and Obstetrics 2002; 78: 171–7.
- Commission for Labor Cooperation. Guide to employment discrimination laws in Canada. Washington: Commission for Labor Cooperation. Available from: http://www.naalc.org/migrant/english/pdf/mgcanemd_en.pdf.