Israeli health ministry says HIV-positive surgeon very low risk to patients: surgeon returns to work

The Israeli Ministry of Health has decided that a surgeon with HIV who is receiving antiretroviral treatment may return to carrying out invasive surgical procedures, providing that he or she maintains an undetectable viral load, follows infection control procedures and uses two layers of surgical gloves when operating.

The decision, published online today in Morbidity and Mortality Weekly, is the first time that a public health body has admitted that an HIV-positive health care worker has been cleared to carry out invasive surgical procedures since the introduction of antiretroviral therapy.

Antiretroviral therapy reduces the level of HIV in the blood and cohort studies show that a lower level of HIV in the blood is associated with a lower risk of sexual transmission.

The decision also emphasises the very low risk of HIV transmission from healthcare workers with HIV.

The Israeli decision follows an extensive look-back exercise in which 545 patients were tested in 2007 after the surgeon was found to be HIV-positive.

1494 patients who had received cardiothoracic surgery at the hands of the surgeon in the previous ten years were contacted; 545 provided blood samples for testing. (Of the remainder who did not agree to testing, none were listed in the national HIV registry.) None of those tested were infected with HIV, despite the fact that the surgeon had a high viral load (above 100,000 copies/ml) and a very low CD4 count at the time of diagnosis, indicating that the surgeon had been infected with HIV for some years. The surgeon did not report any incidents when blood exposure could have placed patients at risk.

These findings prompted the Israeli health ministry to convene an expert advisory group to examine whether the surgeon could return to work.

They decided:

• The surgeon could return to work; his or her infection control compliance would be closely monitored. In particular the surgeon would wear two pairs of surgical gloves.
• The surgeon must maintain good adherence and attend for regular monitoring to ensure that an undetectable viral load and a CD4 count above 200 cells/mm³ is maintained.
• Prospective patients of the surgeon would not need to be notified of the surgeon’s HIV infection because there is an extremely low risk of HIV transmission if these conditions are met.

The findings of the look-back exercise are consistent with the results of most other exercises, which showed no transmission from health care workers to patients after an occupational exposure. Six cases have been linked to a Florida dentist (although the molecular techniques used to link these cases have been criticised) and three further cases of HIV transmission have been identified, one in Spain and two in France, linked to a gynaecologist, a nurse and an orthopaedic surgeon respectively.

The Israeli expert advice that antiretroviral therapy and viral suppression are risk reduction measures for HIV transmission echoes the Swiss Federal AIDS Commission statement in January 2008, which noted that individuals with undetectable viral load on treatment cannot transmit HIV.

The Israeli decision is likely to lead to pressure on bodies regulating healthcare employment to review their guidance on healthcare workers with HIV engaging in exposure-prone, invasive procedures. In the United Kingdom, for example, the General Medical Council and the General Dental Council require that HIV-positive healthcare workers desist from carrying out exposure-prone procedures – anything that involves cutting, suturing, use of needles or delivery of babies using forceps or suction – and all healthcare workers recruited to the National Health Service who will be carrying out these types of procedures are tested for HIV. Many healthcare workers have been forced to retire or move to other jobs within the health service as a result of the guidance.

Further reading

The September 2008 edition of HIV Treatment Update looked in detail at the question of whether HIV-positive health care workers receiving HIV treatment should be required to avoid exposure-prone procedures. Download HIV Treatment Update in pdf form here.