Response to Mallolas et al. ‘Obstetrician-to-patient HIV transmission’
Jagger, Janine; Perry, Jane L
International Healthcare Worker Safety Center, Division of Infectious Diseases, Department of Internal Medicine, University of Virginia Health System, Charlottesville, Virginia, USA.
Received 16 February, 2006
Accepted 26 May, 2006
The report of Mallolas et al.  is an important confirmation that, although uncommon, HIV can be transmitted from an infected healthcare worker (HCW) to a patient via a needlestick injury during an exposure-prone procedure. The actions of the obstetrician in this case raise some important issues.
First, although the obstetrician was in a known risk group for HIV infection, he declined to know his HIV status before infecting a patient, in contradiction to recommendations cited by the authors. By knowing his HIV status he could have eliminated or reduced his risk of infecting a patient by refraining from performing invasive procedures or by eliminating the use of sharp-tip suture needles from caesarean and other obstetric procedures (substituting blunt suture needles instead), and also by receiving antiretroviral therapy, which can reduce the viral load in the blood of an infected individual.
In addition, the obstetrician did not report the needlestick injury he sustained while operating on the patient he infected. HCWs who report exposures to patients' blood are offered postexposure follow-up, and, if the patient is HIV positive, chemoprophylaxis to reduce their risk of HIV infection. The obstetrician deprived his patient of chemoprophylaxis that might have prevented her infection.
The authors state that ‘it is not necessary routinely to perform retrospective patient notification’, citing a 1992 publication by authors from the Centers for Disease Control and Prevention. We maintain that look-back studies are important. The majority of documented cases of HCW-to-patient transmission of HIV, hepatitis B and hepatitis C have been identified through look-back studies. For example, six out of nine (66.6%) such HIV infections were identified during retrospective investigations [2–5]. Is there not a responsibility to offer all patients infected by the HCW the opportunity to receive treatment for their infections?
The actions of this obstetrician and his institution before and after the exposure incident are by no means unique. The general mindset in healthcare settings regarding patient exposures to HCWs blood is one of avoidance: HCWs performing invasive procedures avoid being tested for bloodborne pathogens and reporting patients' exposures to their blood; and institutions avoid investigating whether additional patients have been infected. This too often results in a situation in which patients are deprived of the protection and treatment that we mandate for their caregivers.
1. Mallolas J, Arnedo M, Pumarola T, Erice A, Blanco JL, Martinez E, Gatell JM. Transmission of HIV-1 from an obstetrician to a patient during a caesarean section. AIDS 2006; 20:285–299.
2. Ciesielski C, Marianos D, Ou CY, Dumbaugh R, Witte J, Berkelman R, et al. Transmission of human immunodeficiency virus in a dental practice [see Comment]. Ann Intern Med 1992; 116:798–805.
3. Ciesielski C, Marianos DW, Schochetman G, Witte JJ, Jaffe HW. The 1990 Florida dental investigation: the press and the science. Ann Intern Med 1994; 121:886–888.
4. Lot F, Seguier JC, Fegueux S, Astagneau P, Simon P, Aggoune M, et al. Probable transmission of HIV from an orthopedic surgeon to a patient in France. Ann Intern Med 1999; 130:1–6.
5. Goujon CP, Schneider VM, Grofti J, Montigny J, Jeantils V, Astagneau P. Phylogenetic analyses indicate an atypical nurse-to-patient transmission of human immunodeficiency virus type 1. J Virol 2000; 74:2525–2532.
© 2006 Lippincott Williams & Wilkins, Inc.