In late 1992, a woman donating blood in New South Wales, Australia, was surprised to learn her blood tested HIV-positive. She contacted a doctor, Peter Collignon, in January 1993. Dr Collignon found she had no sex risk. However, she had experienced a short illness in December 1989, about a month after outpatient surgery to remove a cyst; Dr Collignon suspected the illness was from seroconversion, and that the women had gotten infected from unsterile procedures during cyst removal in November 1989.[1,2]
The doctor reported his suspicions to the New South Wales Health Department, which investigated by tracing and testing other outpatients treated at the same clinic on the same day. Four others tested HIV-positive. Three of these four were women with no sex risks (no partners, or HIV-negative partners). One of the four — likely the source of the outbreak — was a man who reported unprotected anal sex with men of unknown HIV-status.
The investigation did not determine the specific procedures that likely passed HIV from the suspected source patient to the four women. One possibility is that the doctor mismanaged and accidentally got HIV from the source patient into a multidose vial of local anaesthetic, and from there infected four women.
1. Collignon P. Patient-to-patient transmission of HIV [letter]. Lancet 1994; 343: 415.
2. Chant K, Lowe D, Rubin G, et al. Authors’ reply [letterl. Lancet 1994; 343: 415-416.
3. Patient-to-patient transmission of HIV in private surgical consulting rooms. Lancet 1993; 342: 1548-1549.
4. Schields JW. Patient-to-patient transmission of HIV [letter]. Lancet 1994; 343: 415