AIDS-Infected Doctors to Get New Guidelines

WASHINGTON —  Rather than endorse mandatory restrictions, federal officials appear likely to recommend that AIDS-infected health care professionals voluntarily refrain from performing surgery and other invasive procedures or seek expert advice before continuing to do so.

Draft guidelines prepared by the Centers for Disease Control stress that doctors and dentists have a professional responsibility to determine whether they are infected with the human immunodeficiency virus and, if so, to take appropriate steps to protect their patients.

The issue has been hotly debated for much of the past year, ever since the first case was reported last summer of a dentist with AIDS who apparently infected three of his patients. It is the only known instance in which such transmission may have occurred, although there have been several dozen documented cases of transmission from infected patients to health workers.

Overall, experts believe that the risk of transmission in either direction is extremely low in health care settings.

The latest proposed guidelines, dated April 5, have been submitted to Assistant Secretary of Health James O. Mason by Dr. William L. Roper, director of the CDC, but have not been made public. A copy of the draft was obtained by The Times.

While Mason has asked for some revisions, the substance of the recommendations is expected to remain unchanged.

The latest guidelines reflect a softening in the position of Roper, who earlier this year appeared ready to propose that health care facilities prohibit HIV-infected surgeons, dentists and others from performing invasive procedures, and to routinely screen them for infection.

The current recommendation “takes advantage of professional responsibility of health care workers and the expertise of professional societies and institutions,” the draft says.

Once the guidelines are approved by Mason and by Health and Human Services Secretary Louis W. Sullivan, they will be subject to public comment for 60 days. The recommendations are not binding, but they are expected to wield considerable influence on public health policy.

Invasive procedures include surgery and other operations in which bleeding is involved and sharp instruments are used, whether in a hospital surgery center, a delivery or emergency room or outpatient setting, such as a dentist’s office.

The guidelines also would apply to the transmission of the hepatitis B virus, which causes a potentially life-threatening liver ailment.

The guidelines appear similar to those already issued by the American Medical Assn. and the American Dental Assn., which have called on their members to either stop practicing invasive procedures or inform their patients that they are infected.

Nevertheless, the new guidelines are expected to draw fire from AIDS lobbying groups and others who believe health care workers infected with HIV should not be subject to such restrictions.

“There are no data to support restriction of HIV-infected health care workers,” said Jeff Levi, director of governmental affairs for AIDS Action Council, a Washington-based lobbying organization.

“That is making policy based on fear, not on data,” Levi said. “There are so many other riskier situations that the CDC does not attempt to restrict--health care workers who drink too much, or take drugs, for example--that the only conclusion we can draw is that this is pandering to public fear.”

In addition, Levi said that approval of the voluntary guidelines by federal officials probably would lead to mandatory restrictions at the local level, in part to reduce the potential financial liability of health care facilities.

The guidelines emphasize that infected health care workers who are unwilling to stop practicing should seek counsel from an expert review panel. The panel “should address the question of whether an . . . infected health care worker can continue to perform exposure-prone invasive procedures with the informed consent of the patient,” the draft says.

The panel should be composed of the health care professional’s personal physician, state or local public health officials, an infectious disease specialist with expertise in AIDS transmission and a health professional with expertise in the procedures performed by the health care worker, according to the draft. If the professional works in an institution, such as a hospital, the panel should also include a member of its infection control committee, the draft recommends.

Dr. Alvin Novick, professor of biology at Yale University and chairman of the ethics committee of the American Assn. of Physicians for Human Rights, said it was “inflammatory” to suggest that infected surgeons seek informed consent from patients before operating on them.

“Surgeons and others who perform invasive procedures never seek consent from patients for ways in which they are incompetent,” he said. “There are many ways in which surgeons can be incompetent that are enormously more dangerous to patients than the immeasurably small risk of HIV infection, such as substance abuse, psychological difficulties, even clumsiness.”

The recommendations urge that HIV-infected health care workers whose practices are hurt “should, whenever possible, be provided opportunities to continue appropriate patient-care activities.” Further, they say, “career counseling and job retraining should be encouraged to promote the continued use of the health care worker’s talents, knowledge and skills.”