AIDS

After investigating HIV infection among five patients of a Florida dentist, the Centers for Disease Control (CDC) concluded that these individuals were probably exposed to the AIDS virus during invasive dental procedures, although the exact mode of transmission is still unclear. This report examines CDC's handling of this matter. Although GAO identified minor problems, CDC's investigation as a whole was found to have been both thorough and competent. The evidence GAO reviewed supports CDC's conclusions. That the mode of transmission remains unknown means that the case provides little insight into how to prevent similar episodes in the future.

GAO found that: (1) CDC determined that the dental practice was the only potential exposure to the human immunodeficiency virus, for some of the five patients infected; (2) multiple tests indicated that the dentist and the five patients had similar strains of the human immunodeficiency virus, which served as the basis for concluding the dentist was the common source of infections; (3) there is no certainty regarding the mode of transmission, it is most likely that the patients were infected through exposure to the dentist's blood; (4) no evidence, with the exception of one interview with an acquaintance of the dentist, proved that the transmission was intentional; and (5) because CDC was unable to determine precisely how the virus was transmitted, the public policy implications of this outbreak of the human immunodeficiency virus in a health care setting are unclear.

Recommendations

Our recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.

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