unfair for interns and residents or student nurses, all of whom could anticipate greater salaries later in their careers (Brennan, 1987; Cooke and Sande, 1989; Hauptman and Feinberg, 1990).

HIV-Infected Practitioners and Risks to Patients

It is not just caregivers who are worried about HIV transmission in health care settings. HIV-positive health care workers can transmit the virus to patients in the course of rendering care. Even remote or theoretical possibilities of caregiver-to-patient transmission can spark a great deal of concern. A Texas pediatrician was forced to close his practice within days after it became known through local news stories that he was HIV positive (Applebome, 1987).

The death of Dr. Rudolph Almarez, a breast cancer surgeon who had operated on as many as 2,000 patients before he died from AIDS, generated considerable concern in Baltimore. Soon after his case was made public in 1990, a Baltimore law firm began to solicit clients to seek legal advice whether they were infected or even knew their serostatus. Clients were advised that emotional distress might be grounds for recovery against the hospital where Dr. Almarez practiced, and lawsuits were filed. In two separate cases, however, a Baltimore judge dismissed complaints based on fear of exposure to AIDS. The judge noted that there were no allegations that Dr. Almarez had not followed recommended infection control procedures or that any accident had occurred during surgery. The plaintiffs did not allege Dr. Almarez had infected them. A "look-back" study failed to uncover any HIV-positive patients (Rossi v. Almarez, Faya v. Almarez, Baltimore City Cir. Ct. Nos. 90344028 CL 123396; 90345011 CL 12345g, May 23, 1991).

Of the 202,843 cases of AIDS reported as of 1990, less than 5 percent are known to have been among health care workers. This is a slightly smaller fraction than is proportional to their number in the population at large. The attention to occupational risk for health care providers has overshadowed the fact that many more health care workers have become infected off the job, through unprotected sex or intravenous drug use. Health care workers with AIDS have included 679 physicians, 42 surgeons, 156 dentists and dental hygienists, and 1,199 nurses (Barnes et al., 1990). Many of the infected workers are HIV positive but have yet to develop AIDS. A number of look-back studies have been conducted of patients of infected health care workers to develop approximations of patient risk, but they are expensive to conduct and fraught with methodologic difficulties (Danila et al., 1991). The only alternative to developing estimates of risk of transmission is the development of theoretical models (Office of Technology Assessment, 1991).

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