Experts Still Baffled Over HIV Infection by Dentist

They still don’t know how it happened.

A decade ago, Kimberly Bergalis stepped forward to announce that she had AIDS. The pretty Floridian had none of the known risk factors for the disease; she had not had sex, she did not share needles, she had not had blood transfusions.

But she had gone to a dentist to have two teeth pulled, and somehow he gave her AIDS.

It was the first documented case of AIDS transmission from a health care professional to a patient, stunning the public and confounding the experts.

There were efforts to make AIDS testing mandatory and other attempts to force infected doctors to reveal their disease; in 1991 the government issued guidelines designed to protect patients from HIV-infected health workers.

“It really created a whole aura of suspicion of health care providers that hadn’t existed before--the perception that your health care provider could be dangerous to your health,” said Dr. Kenneth Mayer, director of a Brown University AIDS program.

Ultimately, health officials traced AIDS infections in five other patients to the same dentist, Dr. David Acer; he died four days before Kimberly Bergalis went public. For the last 15 months of her life, she pleaded for mandatory testing of health care workers and patients before invasive procedures.

The AIDS landscape has changed dramatically since Bergalis sat back in Acer’s dental chair in December 1987. Powerful drugs have been developed that make AIDS less virulent, and the number of new AIDS cases reported nationwide each year has stabilized.

U.S. Centers for Disease Control and Prevention guidelines still recommend barring HIV-infected doctors from performing certain invasive procedures without patient consent and approval from an expert review panel.

But the CDC--urged on by groups ranging from gay activists to the American Medical Assn.--is thinking about loosening those rules. Because nearly a decade later, the Acer cases remain the only known instances of clinician-to-patient AIDS transmission nationwide.

Some experts said that shows how tiny the risks are. Others said they illustrate the success of increased infection control practices prompted by Acer’s trail of misery.

But to this day, no one can say just how Acer infected his patients with the deadly virus.

It is a mystery that most AIDS experts acknowledge may never be solved.

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Now 44 and living in the lakeside town of Empire, Mich., Lisa Shoemaker is one of two survivors among the patients Acer infected. There are two reasons she is still alive, she said: luck and medical advances.

Her disease has remained relatively dormant. Each day, she takes 14 pills, including a protease inhibitor that wasn’t available until 1997. Combined with other anti-AIDS drugs, it can bolster the immune system and reduce the level of virus in the blood to undetectable levels.

In 1988 she was suffering from two abscessed teeth. She was new to Stuart, Fla., and didn’t have a dentist; she picked Acer on the basis of the “painless dentist” promotional magnet she had received from a welcome wagon-type group.

“I went in very naive and very trusting. I’m not like that anymore,” she said.

Her memories of that office visit are still vivid. Acer “was wearing gloves and a mask,” she recalled. “He was very skeletal-looking. I thought he had cancer.” She never suspected AIDS.

Her face swelled from the Novocain, but Shoemaker said the visit was otherwise routine.

When she had an AIDS test the next year, it had nothing to do with her visit to the dentist; she suspected that her fiance had engaged in unsafe sex. And when the result was positive, it was a thunderclap. She blamed her boyfriend.

The couple split up, and Shoemaker moved home to Michigan. It was only in 1990 that she learned the real source of her infection, after her father saw an article about Acer.

She became an activist. She went to schools to speak about the disease. She testified before Congress, supporting measures to force HIV-infected patients to reveal their disease to their sexual partners, and urging that AIDS testing become mandatory for doctors and part of yearly routine checkups for others.

Shoemaker and Sherry Johnson, the other survivor among those infected by Acer, oppose relaxing the CDC guidelines. Infected health care workers should not hide their disease from patients, they said.

“You’re kind of putting your life into their hands,” said Johnson. She is 25 now; she was about 11 when Acer filled her cavities.

Both women feel a moral obligation to tell doctors that they are infected.

“To me, not revealing my status would be like holding up a revolver to their heads with one bullet and spinning it, playing Russian roulette,” Shoemaker told Congress in 1998. “Those who are uninfected need to be given their rights back.”

That the risks of doctor-to-patient transmission are so slim is small consolation.

“They’ll always say it only happened once,” Shoemaker said. “Well, it’s like six people were in that ‘once.’ ”

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Dr. Robert Wood--gay and HIV-infected--was disturbed by the alarm over the Acer cases. His reaction turned to “profound dismay and some depression” when the CDC adopted its restrictive guidelines.

“Most of us who had followed those issues felt that those guidelines were really knee-jerk responses that sort of were below the level of scientific scrutiny,” Wood said.

Scientific evidence has only bolstered his opinion, the Seattle-area resident said.

He learned he was HIV-positive in 1985, but didn’t worry that he might pose a risk to his patients--many of them were also HIV-infected, and he didn’t perform invasive procedures. Wood didn’t tell patients about his disease until he was interviewed by a reporter in 1993, because “no one needed to know and it would only stimulate fear.”

Wood served on an advisory committee that in 1998 urged the CDC to soften its guidelines and scrap the recommendation that HIV-infected providers abstain from “exposure-prone” procedures unless they have patient consent and approval from a panel that includes a state or local public health official.

A board member of the Gay and Lesbian Medical Assn., Wood helps answer calls to a telephone hotline established by the group in 1990 in response to the Florida cases. As many as 400 calls came in annually during the first couple of years. They have dwindled to fewer than about 50.

One recent hourlong caller stood out--a gay doctor-in-training at a major hospital in a large city who had just learned he was infected.

The man had started himself on antidepressants and a triple-drug AIDS cocktail. He didn’t know a doctor he could trust, even in his large city, and though he wasn’t going to do any surgery, he didn’t want to tell his supervisors.

“He was very scared because he was in a training program [and feared] it would ruin his credibility and people would wonder if he could continue to practice,” Wood said. “There’s still an incredible amount of stigma associated with this disease.”

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The CDC offers no estimate of how many health care workers are HIV-infected; of all the cases reported through 1999 in which an occupation is known, about 5% worked in health care. Other experts said the percentage probably is tiny, and only a fraction perform procedures that potentially could put patients at risk.

The CDC issued universal infection control precautions in 1987 designed to protect health care workers from contracting AIDS from patients, which happens rarely but is more common than doctor-to-patient transmission. Those precautions included wearing gloves, masks and goggles whenever contact with bodily fluids is anticipated.

The Acer cases raised awareness about the importance of those precautions, said John Molinari, chairman of the biomedical sciences department at the University of Detroit’s dentistry school and a spokesman for the American Dental Assn.

“You see people nowadays doing things that would have been almost unheard of,” Molinari said. “Gloves, masks, protective eye wear, sterilized and wrapped instruments--now, quite frankly, it’s taken for granted.”

Dr. John Nelson, a Salt Lake City obstetrician and American Medical Assn. trustee, said the fact that the Acer patients remain the only known U.S. cases suggests that stringent precautions and practices are working.

“We sure hope that’s what it means,” Nelson said.

In a 1998 report, the AMA’s Council on Scientific Affairs noted that advancements in medical techniques have reduced the risks of transmission even in invasive procedures. They include the use of blunter needles in suturing and using instruments rather than fingers to load and unload scalpels and needles.

“The health care worker should be permitted to provide health care services as long as there is no significant risk of patient infection,” the report said.

The report also recommended that the CDC consider amending its guidelines so that practice restrictions apply only to infected health care workers who pose “a significant risk” to patients.

Brown University’s Mayer said advances in AIDS treatment since the Acer cases have further reduced such risks.

“The presumption is now that if you’re a health care worker you’re sophisticated enough to know that the medications we have now can make you less infectious,” Mayer said.

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Would advancements in treatments or technique have prevented the Acer AIDS cases? No one knows, because no one knows how he infected his patients.

“No one will ever really know,” said Florida attorney Robert Montgomery, who represented Bergalis and some other Acer patients.

Although some have theorized that Acer intentionally infected his patients, Montgomery disagreed. He noted that Acer cooperated with the CDC’s investigation. Prosecutors decided in 1993 not to pursue a criminal investigation.

George Bergalis, Kimberly’s father, said suggestions that Acer tried to infect his patients were a cop-out, “just an easy way of saying it can’t happen unless they do it intentionally.”

With a bitter edge to his voice, Bergalis said he still doesn’t believe the risks of doctor-to-patient transmission are as small as experts suggest, even given all the changes since his daughter was infected.

“One of the reasons why [Kimberly] got infected was because we in our wildest dreams weren’t aware this could happen, because our government told us it couldn’t happen,” Bergalis said, adding, “Accidents can happen. We’re probably more at risk today because of the fact that the heightened awareness has gone away.”

Bergalis and Shoemaker believe, as others have suggested, that Acer accidentally infected patients with dental instruments he had used on himself.

“He had full-blown AIDS before any of us went into his office. He was working on himself, working on his own teeth,” Shoemaker said. “I think he genuinely cared about people, but I also think he was so far gone with AIDS and was afraid of people finding out that he was gay. I would hate to have been in his shoes.”

But her sympathy is tinged with frustration.

“I did everything to protect myself,” she said. “But I still got it and all I did was sit in a chair.”

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Government: www.cdc.gov

Gay and Lesbian Medical Assn.: www.glma.org

AMA: www.ama-assn.org