Pursuant to a congressional request, GAO reviewed the Centers for Disease Control's (CDC) investigation of a woman infected with the human immunodeficiency virus by a dentist with acquired immune deficiency syndrome (AIDS), to determine whether CDC methods were sound and supported the findings.

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.

Status Legend:

Review Pending-GAO has not yet assessed implementation status.

Open-Actions to satisfy the intent of the recommendation have not been taken or are being planned, or actions that partially satisfy the intent of the recommendation have been taken.

Closed-implemented-Actions that satisfy the intent of the recommendation have been taken.

Closed-not implemented-While the intent of the recommendation has not been satisfied, time or circumstances have rendered the recommendation invalid.

• Review Pending
• Open
• Closed - implemented
• Closed - not implemented

Recommendations for Executive Action

Recommendation: The Director, CDC, should ensure that all relevant expertise is used when investigating new potential sources of human immunodeficiency virus infection.

Agency Affected: Department of Health and Human Services: Public Health Service: Centers for Disease Control

Status: Closed - Not Implemented

Comments: The agency has indicated its intent to implement the recommendation but does not expect to conduct other investigations of this type except in very rare instances.

Recommendation: The Director, CDC, should avoid potential bias in its analyses regarding human immunodeficiency virus by masking the identity of the persons from whom genetic material is obtained.

Agency Affected: Department of Health and Human Services: Public Health Service: Centers for Disease Control

Status: Closed - Not Implemented

Comments: The agency has indicated its intent to follow recommendation but does not expect to conduct other investigations of this type except in very rare instances.