Growing national sentiment for protecting patients from health care workers who carry the AIDS virus has gained momentum in recent weeks amid speculation that it will lead to mandatory testing of patients and care givers.
From New Jersey to Oregon, the debate is being waged in state legislatures, courtrooms, hospital boardrooms and within professional organizations.
In Florida, where an infected dentist apparently transmitted AIDS to three patients, some dentists and hygienists even have begun posting their AIDS test results on their office walls in an attempt to reassure skittish patients.
"Sometimes, I'm really scared," said 16-year-old Marlene See, a high school student from Stuart, Fla., who was treated by the late Dr. David Acer, the infected dentist.
"Sometimes I wonder if there's more people who got it from him. Sometimes I wonder if I could still get it. I'm sorry for what my dentist went through, but I think patients should be informed," Ms. See said.
It seems almost certain that health care workers who have the human immunodeficiency virus, which causes AIDS, will be restricted in their practice in some manner.
The national Centers for Disease Control is expected to issue new federal guidelines sometime soon, but the proposals -- months in the making -- have apparently been caught in political maneuvering between conservatives who favor mandatory testing and more moderate elements who prefer voluntary disclosure.
"The way this is headed, we are going to be fighting this state by state and court by court," said Evan Wolfson, an attorney with Lambda Legal Defense and Education Fund, a national advocacy organization for gay people and for people with AIDS. "Sadly, hysteria seems to be carrying the day."
Public concern over the risk of HIV transmission from a health care worker to a patient was triggered last July when the Centers for Disease Control disclosed that a dentist had probably passed the virus during a tooth extraction to a Florida woman later identified as Kimberly Bergalis, 23.
It was learned later that two other patients were also believed to have contracted the virus from Dr. Acer, who died of AIDS last September. A decade into the epidemic, the three are the only documented cases of a health work passing on AIDS.
As of March 31, 171,876 AIDS cases had been reported in the United States. Of those, 6,436 were known to be health care workers.
Last fall, the public alarms sounded again when Baltimore surgeon Dr. Rudolph Almaraz died of AIDS. He had performed breast surgery on hundreds of women, but it is not known whether he transmitted the disease to any patients.
Johns Hopkins Hospital, where the late surgeon practiced, offered AIDS tests to 1,800 Almaraz patients, but results have not been released.
Since then, at least three dentists -- in Delaware, Florida and North Carolina -- have died or quit their practices after contracting AIDS. Thousands of their patients, many of them children, have been tested, but so far the results either are not known or have been negative.
Even though the Centers for Disease Control has calculated that the risk of contracting AIDS from a health care worker is remote (as little as 1 in 2.6 million from dentist to patient), events of the past three weeks suggest an emerging pattern of restraint:
* In late April, a New Jersey judge ruled that a patient's right to be safe from even the remote possibility of being exposed to the AIDS virus during surgery outweighs an HIV-infected surgeon's right to practice.
The ruling -- the first of its kind in the nation -- suggests that mandatory disclosure will be the wave of the future.
* The Medical Society of New Jersey, meeting on April 30, called for the testing of all hospital patients for the AIDS virus, the first such proposal made by a U.S. medical society. At the same time, the group called for regular testing of all health care professionals.
* The Oregon Medical Association adopted a policy April 28 requiring doctors infected with AIDS to advise the state health division. A group of peers would decide whether an infected doctor posed a risk to patients and whether the doctor's medical practice should be limited.
A doctor choosing not to consult with state health officials would be expected to stop doing "invasive" procedures that produce blood and therefore pose a risk of infection.
(The American Medical Association and the American Dental Association recommend that AIDS-carrying doctors and dentists either tell their patients or refrain from performing such procedures.)
* The Florida Legislature, at the request of Gov. Lawton Chiles, passed legislation earlier this month allowing state regulatory boards to require health professionals with the AIDS virus to report their infection and submit to inspections and safety education. The bill would not require health professionals to be tested, but it does allow the state to more closely supervise those who report their infections.
* At the University of Washington in Seattle, officials are considering a comprehensive proposal to bar health care providers with the AIDS virus from performing surgery at the University of Washington Medical Center. The proposal includes controversial recommendation that would force some medical students who are HIV-infected to change their course of study.
It appears that the public is searching for safeguards: In a survey published in the National Law Journal on May 6, 93 percent of 800 adults said that dentists or doctors with AIDS or HIV should be legally required to tell patients about it.
"When I see Kimberly Bergalis on the TV screen, she's angelic. She's heart-stopping," said Dr. Frank Rhame, director of the HIV clinic at University of Minnesota Hospital in Minneapolis.
"This is a terrible tragedy that has befallen her. But you're talking about something that happens one in a million times. I try to get people not to worry about the things that have a one in a million chance of killing them," he said.
Critics of mandatory testing and forced disclosure say that those measures discriminate against people with AIDS, that they would create a "medical apartheid" that would result in separate classifications of care for those who have the disease and those who don't and that they would force infected professionals out of business.
"The health care workers I know who are HIV have limited their practices. They aren't sick. They've followed current CDC guidelines, and they would do nothing to put their patients at risk," said Jeff Peters, president of the Florida AIDS Legal Defense and Education Fund.
"Many of the people who treat HIV patients have HIV. The pool to treat HIV is small already. What do you think would happen if you get rid of the HIV docs?"
In particular, the critics claim, the economic costs of forced testing far outweigh the risk of transmission.
In Oregon, for instance, officials estimate that it would cost $105 million a year to test patients and doctors to avoid, at most, one case of doctor-to-patient transmission over a 10-year.
"Is it worth it?" asked Dr. Laurence Foster, Oregon's top health official. "No."
However, according to Lambda's Mr. Wolfson, "What many people are really looking for is mandatory testing. Terms like informed consent are just appealing gift wrap. No one wants any more Kimberly Bergalises, but this is not the way to prevent another Kimberly Bergalis.
The Acer case is an instructive lesson, and the real lesson is that despite the risk, the use of infection controls can prevent this from happening to others. That's the lesson learned."