The weather in Fort Pierce, on Florida's east coast, was sunny and unseasonably warm on a recent September afternoon. But inside her parents' three-bedroom house, 22-year-old Kimberly Bergalis lay shivering on the family-room sofa, worn out from a trip to the beach just a block away. Her skin had a chalky cast, and her body appeared frail beneath the blanket that covered her loosely. In a matter-of-fact voice, she spoke of the days she has spent fighting off debilitating nausea and vomiting—and of her struggle to maintain her weight at a fragile 101 lbs. after a loss of 32 lbs. over the past 10 months.
Kimberly's symptoms would be familiar to any AIDS victim. Her story, however, is tragically unique. She believes—and a Centers for Disease Control report strongly suggests—that she contracted the deadly disease during a 1987 tooth extraction performed by the late Dr. David J. Acer, one of the nation's 5,000 health-care providers now known to have AIDS. Of the 146,746 documented cases of AIDS reported in the U.S. since 1981, three are health-care workers who were infected by their patients. Twenty-one others infected by patients have tested HIV-positive but do not yet have AIDS. Kimberly's could be the first case in which the disease was given to a patient by a health-care professional.
Some medical experts, including Dr. Sanford Kuvin, vice-chairman of the National Foundation for Infectious Diseases, believe it was bound to happen. "In my opinion," he says, "the sad story of Kimberly Bergalis is just the tip of the iceberg. There is blood spilt between the patient and the provider during invasive medical procedures. Common sense dictates that that blood can be exchanged both ways."
If Kuvin is correct, the ramifications could be enormous: America's commitment to respecting the privacy of every AIDS victim could be seriously compromised, and the relationship between health-care providers and their patients could be altered forever. Not surprisingly, the case has created a storm of controversy, with the American Dental Association and the American Medical Association pitted against the CDC. At the center of the debate is Kimberly Bergalis.
All who know her agree that Kimberly is the last person they would have thought might get AIDS. Kimberly was born in 1968 in Tamaqua, a small town in eastern Pennsylvania, the eldest of three daughters of George and Anna Bergalis. In 1978 the family moved to Florida. George, 46, now works as finance director for the city of Fort Pierce; Anna, 46, is a public health nurse in a Vero Beach clinic specializing in sexually transmitted diseases. After a year of public school, Kimberly was enrolled in Catholic school, where she remained through 12th grade.
"I had a strict upbringing," she says. "Everything was books, books, books. I was in the Math League, Spanish Club, the National Honor Society. But I wasn't allowed to date or be involved in after-school activities. I had to come straight home to baby-sit and study."
In 1985 Kimberly enrolled at the University of Florida in Gainesville. "I really came out of my shell there," she says. A business major with dreams of joining a big-city actuarial firm, Kimberly belonged to a business fraternity and during her free time gave her friends haircuts at $5 a head. And while she enjoyed a social life, dating was not a priority. "I wasn't much into it, one-on-one," says Kimberly. "I like being with lots of people." She did have two boyfriends during college, but was not sexually active and, she says, she remains a virgin. "I wanted it to be special," she says of her decision to wait.
In December 1987, Kimberly had to have two molars extracted. Like many public employees in their area, the Bergalises were covered by the CIGNA Dental Health plan, which referred Kimberly to Dr. Acer. A native of Cleveland, Acer graduated from Ohio State University's dental college in 1974. After serving two years as a dentist at Hahn Air Base in West Germany, he returned to the U.S. and in 1981 set up a practice in the resort community of Jensen Beach, 35 miles up the coast from Palm Beach.
In the fall of 1987, Acer, a bachelor, had been diagnosed with AIDS. It has not been made public how he contracted the disease, but according to CDC spokesman Kent Taylor, the dentist "had one of the common risk factors." Last month, four days after his death at age 40, a poignant open letter he had written to his patients was published in several Florida newspapers. In it he said that early in the course of his disease, he had consulted with medical experts about whether to continue his practice. "The experts advised me that as long as I followed the guidelines promulgated by the Centers for Disease Control for health-care providers who were infected with HIV (AIDS), that I could safely continue to practice as a dentist," he wrote. The guidelines, which call for the use of rubber gloves and a mask, and which Acer said he followed "religiously," did not include telling his patients of his illness.
According to a former colleague, Miami periodontist Leonard Ostroff, Acer was a "humanistic, therapeutic and benevolent individual. He was a fine dentist." Kimberly recalls that Acer wore gloves and a mask and that nothing happened during the course of the extractions to indicate that he might have cut himself or stuck himself with a needle.
Fifteen months later, in March 1989, Kimberly developed the first in a series of ailments that eventually included sore throats, ulcerated tonsils and oral thrush, the last a fungal infection common among infants—and AIDS patients. But because she had no risk factors for AIDS, doctors tested her for leukemia and hepatitis instead. When Kimberly went home for Thanksgiving, her mother was shocked. "I thought, 'My God, she looks just like a patient at the clinic where I work,' " says Anna. "She had the symptoms of AIDS."
The results of Kimberly's first HIV blood test about three weeks later were inconclusive, so a second test was administered. On Jan. 24, 1990, she received the unbelievable news: She had AIDS.
At first, Kimberly recalls, "I kept waiting for them to say there's something else." Her family too was devastated. "She had her whole life in front of her," says Anna. For George, it is the absence of hope that weighs most heavily. "You have to face the fact that a cure won't make it in time for her," he says. Both admit that at work, away from Kimberly, they often break down and cry.
After the initial shock, Kimberly and her parents began to focus on where she might have contracted the virus. "I told her, 'You've got to tell the doctors if you were doing something that put you at risk,' " says Anna. "But she insisted she was telling the truth." Adds George: "Her sickness would have been easier to accept if she'd been a slut or a drug user. But she had everything right."
As with all new cases of AIDS, the CDC was alerted, and because her case was so unusual, Kimberly was questioned in February by two CDC investigators and a state health department worker. It was a difficult process. "A lot of things they wanted to know were very private and hard to talk about," she says. "In a way I feel I've been victimized twice." George recalls that when Kim insisted she was a virgin, investigators visited her at home alone and told her she had nothing to fear by telling them otherwise. She gave them the phone numbers of her friends, many of whom were asked about her sexual activity and whether she was an IV drug user. Investigators even wanted to know if Kimberly had ever been molested, perhaps by her father. George was infuriated by the suggestion, says Kim.
He and the rest of the family, as well as Kimberly's two college boyfriends, agreed to be tested. The results were all negative. In the end it was Anna who suggested Dr. Acer as the possible source. Through his office she had learned he was suffering from pneumonia. "He was barely 40," she says. "Then he closed his practice. It was the only place she could have gotten it."
In July, the CDC released its report. Without identifying the people involved, it concluded that "the case...is consistent with transmission of HIV to a patient during an invasive dental procedure, although the possibility of another source of infection cannot be entirely excluded.' " The CDC's most persuasive evidence was a test, called DNA sequencing, analyzed at the Los Alamos National Laboratory in New Mexico, on viral samples taken from Dr. Acer and Kimberly Bergalis. According to Dr. Harold Jaffe of the CDC's division of HIV/AIDS, "The viruses of the dentist and patient were much more like those that occur in cases where it is known that one person infected another than in unrelated cases."
Kimberly was relieved to hear about the report. But she didn't anticipate the skepticism that followed. Some experts pointed out that if Dr. Acer did infect Kimberly, the incubation period had been unusually brief—just two years compared with the national average of seven to 10 years. Others noted that DNA sequencing is a new technique and not necessarily definitive. Still others argued that a patient's account of high-risk behavior is often not reliable.
"I don't by any stretch of the imagination think that this link is proven," says Dr. M. Roy Schwarz, chairman of the American Medical Association's AIDS Task Force. Dr. Robert T. Ferris, past chairman of the Florida Board of Dentistry, put it more strongly. The CDC's conclusion "is not only difficult to believe, but it flies in the face of everything the CDC and other governmental authorities have told us." he wrote in the Palm Beach Post.
According to the CDC's Kent Taylor, an incubation period as brief as two years would be "unusual but not unheard of." Still, he acknowledges that a link between Dr. Acer and Kimberly has been indicated rather than proved. "We can only say." he reports, "that there was possible transmission based on all the information we have."
Despite the controversy, the Bergalises decided to go public with their plans to file a lawsuit charging Dr. Acer with malpractice for not informing Kimberly of all the risks of the procedure, and CIGNA with corporate negligence for not adequately monitoring the health of their doctors. Kimberly's lawyers hope the suit will provide damages in the millions and that future patients will be protected from health-care providers with AIDS.
Kimberly feels little bitterness toward the man she believes is responsible for her impending death. "I don't think he ever meant for this to happen," she says. Nor does she dwell on a potential cash award. "It doesn't matter to me," she says, "because unless there's a cure, I'm not going to benefit from it."
Her hope, she says, is to protect others who might suffer her fate. Bob Montgomery, one of Kimberly's attorneys, believes she has already accomplished that. On Sept. 21 it was revealed that two more of Dr. Acer's patients have turned up HIV-positive. (Since Dr. Acer's letter, nearly 500 have been tested.) It remains to be seen if, through DNA testing, a likely connection can be established between their viruses and Dr. Acer's and, if so, whether the CDC will revise its guidelines.
It is a worrisome prospect. If those like Dr. Kuvin of the National Foundation for Infectious Diseases, who is now a consultant to Kimberly's lawyers, have their way, the CDC would call for "testing of all health-care workers and patients involved in invasive procedures," which are defined as those in which body tissues are penetrated by an instrument. But others, such as the AMA's Dr. Schwarz, believe such a step is unwarranted. "Until science proves it unequivocally," he says, "we think...that it would not be wise to change the guidelines—unless CDC has evidence we don't know about."
For now, the CDC only acknowledges looking into the possibility of making revisions. "This case concerns us greatly," says spokesman Taylor. "But even if confirmed it will be only one documented transmission from heath-care worker to patient of 146,746 total transmissions."
Understandably, Kimberly feels differently. After all, she is that one case. "And," she says, "I don't want to let it happen to somebody else."
—Bonnie Johnson, Meg Grant in Florida, with additional reporting from Don Sider
- Meg Grant,
- Don Sider.