Despite the theoretical risk to patients of HIV transmission in health care settings, there was little discussion in the late 1980s among professional associations and government officials about actions to be taken should a case of practitioner-to-patient transmission occur.6 Nor were there guidelines as to what kind of procedures HIV-infected health care workers should be permitted to perform or who among colleagues, employers, or patients should be apprised of their HIV status. In the absence of clear policy guidelines, cases were handled on an ad hoc basis. An HIV-positive dental student from Washington University St. Louis was dismissed; a Chicago neurologist obtained a consent decree from a federal court that allowed him to practice but limited his involvement in certain invasive procedures; a director of anesthesiology was denied contact with patients and then disciplined when he personally assisted a patient who had vomited and was in immediate danger of aspirating; a gynecologist was forced to abandon a lucrative medical partnership despite his offer to do no work requiring physical contact with patients (Gostin, 1990:2091).
It became apparent that risks to patients in health care settings, if exceedingly remote, was more than theoretical when the CDC reported the possible transmission of HIV to Kimberly Bergalis, a patient in the Florida dental practice of David J. Acer, who died of AIDS. In 1991 the CDC announced that five patients had likely become infected in the course of treatment by Dr. Acer.7 Ms. Bergalis's case sparked a firestorm of controversy and intense public policy debate concerning HIV testing in health care settings and possible strictures on practicing by HIV-positive health care workers. Ms. Bergalis, who died from AIDS in December 1991, blamed her illness on public health officials in a highly publicized letter published in Newsweek (Kantrowitz, 1991). In media appearances and in congressional testimony, the Bergalis family launched a campaign calling for mandatory testing of health care workers and disclosure of test results.
The issue of disclosure of caregivers' HIV status to patients is a critical policy concern. In a Gallup poll conducted among 1,014 adults in May 1991, 87 percent of the general public believed that doctors and dentists should be tested for AIDS, and 84 percent believed that nurses should be tested. In another study, more than one-half of patients surveyed said they would seek care elsewhere if they found out their physicians were caring for people with HIV disease (Gerbert et al., 1989).
In July 1991, largely as a result of the Bergalis case, the CDC published new guidelines reiterating the need for strict adherence to universal precautions and infection control procedures (Centers for Disease Control, 1991). The guidelines also stated that health care workers who perform "exposure-prone invasive procedures" should know their HIV status. Infected health care workers were directed not to perform such procedures unless they sought counsel from an expert panel as to the circumstances, "if any," under