HIV scare story

Dr Mike Fitzpatrick is worried about the implications of the General Medical Council's decision to strike off a doctor who delayed an HIV test

Yesterday's decision by the General Medical Council to strike Dr Patrick Ngosa off the medical register, on the grounds that he delayed in seeking HIV testing when he had reason to believe such a test might be positive, is absurd and unjust. It reveals the irrationality of the GMC's guidelines rather than unethical conduct by Dr Ngosa.

The key fact here - that renders every point of the GMC guidelines absurd - is that the risk of HIV transmission from doctor to patient is negligible. That is not to say it is zero: the case of the Florida dentist remains the single confirmed case of transmission, though its exceptional character raises some doubt about whether other modes of infection might have been involved. A negligible risk is one that, for all practical purposes, can be ignored.

There is a large body of evidence to justify confidence about the negligible risk of doctor/patient transmission of HIV. In more than a dozen scares about HIV positive doctors in Britain, tens of thousands of patients have been tested: not a single one has turned up positive. Though theoretically the risk of transmission in the course of invasive procedures, such as surgical operations, might be thought to be higher, this has not been borne out in practice. The risk of HIV transmission in invasive procedures also appears to be negligible.

If the risk of transmitting HIV from doctor to patient is negligible, then:

• There is no reason why doctors should be under any PROFESSIONAL obligation to seek testing or advice if they think they may be HIV positive; (there may be good reasons why such a doctor would be advised to get tested, but the protection of patients is not one of them);

• There is no reason why a doctor who is HIV positive should notify the authorities or desist from invasive procedures; (he or she would be advised not to have unprotected sexual intercourse with a patient, or to inject drugs with the same needle as a patient, but such activities are precluded under existing GMC regulations);

• There is no reason why former or current patients of a doctor who is HIV positive should be notified and offered reassurance, counselling and testing. What is the point in notifying somebody that they face a negligible risk of something?

In 1993 a public health physician in Scotland wrote to the British Medical Journal to express his horror at the consequences of following the official guidelines in dealing with a local case of an HIV positive doctor. The media gained access to the doctor's confidential file and his family were hounded out of their home. Nearly 1000 worried people phoned a special helpline. He condemned the guidelines as a concession to 'political expediency': 'If we are forced to carry them out I believe that we will fail in our professional duty of care to patients, their families, former patients, and the public. We will waste resources, cause undue anxiety, and impair health education about HIV and AIDS. We are likely also to sabotage the other main objective , which is to ensure that health care workers who believe themselves to have been exposed to HIV infection seek appropriate advice'. (David S G Sloan, 'Confidentiality for doctors with AIDS', BMJ, 28 August 1993)

The case of Dr Patrick Ngosa confirms Sloan's warning in every particular.