After 18 Years, Will the CDC Reconsider Its Restrictions on HIV-Positive Health Care Workers? (2009)

Given what we know about the near-zero risk of HIV transmission from health care worker to patient, even during so-called exposure-prone procedures, it’s past time that the nation’s public health authority acknowledges that their own guidelines are too restrictive.

In the January 9, 2009, issue of Morbidity and Mortality Weekly Report (MMWR), the Centers for Disease Control and Prevention (CDC) reported on an investigation into the practice and patients of an HIV-positive Israeli cardiothoracic surgeon who had performed about 150 surgeries a year for more than two decades. Israeli health officials’ extensive investigation of the surgeon’s patients revealed not a single case of HIV transmission. Based on its investigation and the review of existing literature on transmission risk in the health care setting, the Israeli Ministry of Health allowed the surgeon to return to work with no restrictions on his practice or procedures, and no requirement that patients be notified of his HIV status, as long as the surgeon monitored and maintained his health and infection control procedures.

The CDC concludes that an HIV-positive surgeon, even one engaged in invasive procedures such as cardiothoracic surgery, poses “a very low risk” of HIV transmission to patients. This is hardly news. Repeated studies of patients of health care providers with HIV have produced evidence of only one such transmission in the U.S. in the history of the epidemic—HIV transmission among several patients of an HIV-positive dentist twenty years ago. Frankly, considering that the CDC is describing the risk of an event that apparently hasn’t occurred over the last two decades, describing the exceedingly unlikely occurrence as a “near-zero risk” would seem more accurate.

Those who have studied transmission risks know that there is a big gap between the average person’s perception of risk of certain types of especially feared events occurring and the actual risk that those events—in this case, the transmission of HIV from a surgeon to a patient—will occur. In fact, we also know that in attempting to avoid a negligible risk you can actually wind up increasing your overall risk—for example, by focusing on the HIV status of a physician rather than on, say, the physician’s experience or success with a particular procedure.

That’s why we need our public health experts to talk straight to us about the real risk that events affecting individual and public health will occur. This way, we can focus our attention and resources on the things that will give us the most protection. Unfortunately, since 1991, in response to a CDC directive, many states have maintained laws or policies restricting the practice of health care workers on the basis of HIV serostatus rather than skills. Despite advances in what is known about HIV transmission, and calls for a revision to the national policy on HIV-positive health care workers, the CDC has up to now refused to revisit the issue. The CDC’s unwarranted guidelines in turn have provided cover to federal courts that have concluded that only a zero risk of transmission—a standard applied to no other aspect of health care delivery—will allow a fired physician to regain a job when HIV status is the reason for the termination.

So the real headline here is that, finally and after nearly two decades, the CDC is acknowledging, in effect, that perhaps it’s time for their guidelines to catch up with the scientific facts.

In the editorial following the MMWR article, CDC now states that:

“The data in this and other studies published since the CDC guidelines of 1991, considered together, argue for a very low risk for provider-to-patient HIV transmission in the present era and could form the basis for national and international public health bodies to consider issuing revised guidelines for medical institutions faced with HIV infection in a health-care worker performing exposure-prone procedures.”

The call for a long-overdue revision of these outdated guidelines also happens to be one of the “asks” in a CHLP coalition document for the Obama Administration, entitled “Critical Civil Rights Issues for People Living with HIV/AIDS in the United States: A To-Do List for the New Administration’s First 100 Days,” that has been in circulation since last November. The call for the guidelines’ revision also was recently reiterated by public health commentator and Georgetown professor Larry Gostin, who has joined CHLP in calling for some meaningful federal action on this issue.

Will the CDC’s recent acknowledgement lead, finally, to some official movement on the revision of a national policy that unnecessarily stigmatizes an entire class of workers? Stay tuned—change is certainly overdue. In the meantime, CHLP will continue the call for an end to this and all forms of government-sponsored discrimination that keep the official seal of approval on HIV-related stigma.