Officials at the Walter Reed National Military Medical Center are searching for an HIV positive patient, who was falsely diagnosed as being HIV negative.
The HIV positive blood sample was one of 150 that were sent from the Walter Reed medical center to the Navy Bloodborne Infection Management Center for routine tests.
After the sample tested positive , the patient connected to that sample was brought in for additional tests. However, further testing revealed the patient was HIV negative.
As a result, officials believe the HIV positive sample was mistaken for another person’s sample, from among the 150 samples originally sent. After retesting the original sample to confirm the HIV diagnosis, hospital officials have started to alert the other patients who may have had their samples switched. Someone among them may in fact be HIV positive without knowing it.
The Navy Bloodborne Infection Management Center is investigating the incident and it is unclear if the mix-up happened either at the hospital or at the center.
Although 150 samples were initially sent, medical staff narrowed down those affected to 79 by examining the blood type of the HIV positive blood sample. Currently four people have not contacted Walter Reed officials to be retested. The other 75 people are in the process of being tested.
According to Brigadier General Jeffery Clark, the director of the Walter Reed National Military Medical Center, hospital officials “have sent certified letters, phoned and emailed patients” to alert them to the mix-up.
“We strive for and practice transparency and strongly believe that our beneficiaries’ well-being is our highest priority,” medical center officials from Walter Reed said in a press release.
Clark said that no other similar incidents had happened at the medical center before and that the Navy Bloodborne Infection Management had been used by the hospital since 2010.
Dr. William Schaffner, an infectious disease expert at Vanderbilt Medical Center, said a switch-up of samples is incredibly rare and that hundreds of thousands of blood specimens are drawn and analyzed each day in the U.S. without incident.
Once a mix-up like this happens, Schaffner said the institution has to start “walking it back and trying to figure out where the glitch occurred and asking the related question if this is the only glitch that occurred."
“[If] in this group of 150 blood samples, no one was HIV positive then they might never have detected it. Now they have to find out exactly how this is happened,” said Schaffner.
Hana El Sahli, assistant professor of molecular virology and microbiology at Baylor College of Medicine in Houston, said it’s important to reach the infected patient since he or she can spend three to 10 years without showing any signs of HIV infection.
“This is an issue of importance to the person themselves and the community around them,” said El Sahli. “If you tell them they’re positive, they [are more likely to] use a condom. The altruistic gene kicks in.”