HIV-Related lssues

CONFIDENTIATITY
As with all medical information there is a presumption of confidentiality on the part ofthe phvsician. Because of the social stigma of HIV there is an additional layer of confidentiality and consent required. When a patient enters the hospital or other health-care facility there is general consent given that allows the routine testing of blood for chernistry and hematology and so on. There is an additional HIV-related consent required to test for HIV. \hen a patient signs a release to distribute or transmit medical information there is an additional consent required for HIV or AIDS-related information. You cannot mandate automatic HIV testing of patients without their specific informed consent that you will be testing for HIV
For example, a woman com€s at 10 weeks of pregnancy for prenatal care. She has a historv of sexually transmitted diseases such as gonorrhea. You offer HIV testing, which the patient refuses, as a routine part of prenatal care. She returns at 14 and l8 weeks of pregnancy but is still refusing because of anxiety that she may be positive. You inform the patient that there are medications that can reduce transmission from mother to child to less than 2 percent. She persists in her refusal. \4rat should you do now?
Although there are medications to prevent transmission of HIV to the fetus during pregnancl, you cannot compel mandatory testing of pregnant women. The woman has the right to refuse testing as well as to refuse antiretrovirals. Therefore, you should offer HIV testing universally to all pregnant women-but there is no mandatory testing of the pregnant woman without her express consent to do so. If the woman is found to be HIVpositive you cannot mandate the use of antiretrovirals even though they are safe and
effective in preventing transmission of the virus from mother to ch d. Althoueh from time to time, there is aberrancy in the Jegal systen.r that tries to prosecute a drug_u.ing or alcohol-using pregnant woman, the autonomy of the mother lcgalry outweighs thc safety of the fetus.
For example, an HlV-positive tvoman comes to labor and clelit ery at 40 weeks of pregnancy. She has a very low CD4 coult (less than 50) and a high viral load (more than 500,000). You offer her a Caesarian section and intravenous zidovu_ dine, which can cut the transmission rate in half even on the day of delivery. The woman is anxious, but clearly has the capacity to understand the implications of this decision on both her health and the health ofher child. She is stirr refusins the C section and medications. What should you do next?
Fortunately this circumstance is rare and the HIV perinatar transmission rate in the united States is well undcr 5 percent. However, a rvoman’s right to choose her own forms ofhealth care are considered superior to virtually all other treatment concerns. The wrong answer in a question like this would be to give the medications an1.way, to gct a court order to compel the patient to take the zidovudine, to ask the father for consent for either the zidovudine or the C section, or to sedate the patient and pcrforn the C sectior.r.
The autonomy of the mother is regarlv superior to beneficence for the fetus. Althoush a 40- lveek fetus is a viable child, the fetus is still inside the woman’s body and doesn t become a person until it is delivered. A noman has the right to refuse HIV testing in pregnancl, to refuse antiretroviral medicati.ns in pregnancy, anci to refuse a c-section even if it will markedly benefit the child.
PARTNER NOTIFICATION Thc high level of confidentiality concerning HIV can only be breached under very specific cucumstances such as when the health of a third party is at risk. A crrcumstance such as this would be rvhen an HIV-positive person has a sexual or needle-sharing partner that is at risk. The method of notification follows the steps of first counsering a patient to notiry his partners voluntarily’ This wourd be ideal and follows the general theme of uSMLE, rvhich is to first answer “encourage discussions, when listed as one of the choices. If the patient is either emotionally unable or unwilling to notj$ their partners the next step is to notiry the Department of Health to start the process of contact tracing. The health department interviews the patient and attempts to construct a list of partners in order to notify them.
This is a voruntary process and therc is neither a penalty nor criminal threat of prosecu-tlon if the patient chooses not to co’rply. 'fhe hih d"p".t;;r’,t.,.n ,.rr.t, notice to the partner that there is a bealth_relatr or their potentiar ".;’; il:iiil.:.jlHffj,I#Hii:,i:jift:;:.T
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reveared to the partner and the conndentiaritv or lf the patiert is stilJ unwilling to disclose the names ofhis contacts you cannot compel him to do so. There is no incarceration paticnt rvill not notiff his partncrs rrmtnal penalty for not disclosing these names. If a rou have resar r–,'i, ,., .,.f ;::X.r.T.,
’.::,“j#j#5ffi:i i::,T…HJjyou do notify the partner, but it is r **{:t_#;1tiliilL’t;:#J:::i"i"ffi#;:,TJff :'iffi:i,::
For example, you have a patient in your cJinic who is accompaned by her boy ui"il tn: is ciearly having unpru-recred sex because ,t " l, pi.grru.rt. When youask if her boyfriend knows her HIV staru…, ,Jr" ,"ys, ;;:.;; not_he mightleave me if I told him.’, you haye a protracted discussion about the critical inrportance of not putting her partner at risk. you strongly enco"r"r" i., a ,., nr n
HIV status. On a subscquent visit, when yuu urk h””. ifrh" t or"noiln.a 1", po.,n.,she says, “Not yet.,you krow the boyfriend b…”",. h. ;…;;;a’i., he, to th.office visits. \4rat shoulcl you do? — -!!v’ir(
I"^:…Ll. 0",n," duty to the patient in rerms of her health care an<t her confidentiality.,ton’eyer, ),ou also have a duty to protect the partncr. you f,"". f.g"f i_.’'r",ty ifyou notii/the partnly. At this point cither you can ask the heaith a.pur,rn…* a ,ro,ify the partner or ::: lr:i Ir I yo^urself. If the partner were to seroconvert for HIV and you did not makesure he lvas notified you rvould be legally liable because you aJ ,.rJ, tolto* your duty toivarn. This is similar to having a psychiatric patient who told rou rr"lvu, gorng to harm ill.ili:-1tjn:rln you have a duty to maintain the confia"",.ii,i"i ,n" p"tient, you also]la\e a duty to iDfofln the person at rrsk.
H IV-POSITIVE HEATTH-CARE WORKERS
There is no duty on the part of an Hlv-positive health care worker to inforn.r his patientl of his HIV status. Universal precautions are supposed to be maintained. These should protect the patients. An HIV-positive physician who practices high-risk surgical and obstetric procedures is expected to maintain precautions to protccl tlre patients fiom transnission,
REFUSAI- TO TREAT HIV-POSITIVE PATIENTS
It is ethically unacceptable to refuse to treat Hlv or take care of HlV,positive patients simply because they are HIV-positive. lf you have a physician to whom you refer patients for various treatments, it would not be ethical for that person to discriminate only on the basis of the patient being HIV-positive. On the other hand, you cannot con.rpel a physician to take over the management of any patient if the physician doesn,t u.ant to do so. If your question brings up the subject of rcfusal, the best answcr is to refcr the paticnt to someone else who will perfnrm the care.