Practice dilemma - A patient's HIV status

The dilemma: You are running late in a morning surgery. A newly registered patient comes to see you and tells you that he has been diagnosed as being HIV positive. He has started treatment and is under close review at a nearby hospital. His wife is also a patient at your practice and he asks you to make sure that under no circumstances is his wife told about his illness. He is concerned that if she finds out, his marriage would be over. What should you do?

The patient may be emotionally vulnerable after this difficult diagnosis (Photograph: SPL)
The patient may be emotionally vulnerable after this difficult diagnosis (Photograph: SPL)

A GP's View
Dr Judy Duckworth is a salaried GP in Cornwall
At this first consultation, it is vital to establish a good rapport and an empathic, supportive relationship as the basis for his future care. I would firstly establish his agenda; is he seeking a guarantee of confidentiality, which I cannot give? His wife is also my patient, and I have a duty of care to each individual. If she is at risk of contracting HIV, failure to disclose this could delay diagnosis and place her at risk of serious harm.

He is coming to terms with the diagnosis, and will have fears about his relationship and his health, so it is important to allow him to express his feelings and expectations. This may require a longer consultation time but I would not reschedule the appointment to a more convenient time, as he may be emotionally vulnerable and might not return.

I would discuss the importance of early diagnosis and the effectiveness of treatment in improving life expectancy, and the potential risk to his wife's health should she be denied screening and treatment.

I would ask whether they practise safe sex and if she may have already contracted HIV.

I would emphasise the importance of telling his wife and offer my support in doing so, either on his behalf, or in a joint consultation. Should he refuse to consent to disclosure, I would explain that I may be obliged to inform her anyway. I would offer a further appointment the following day, to allow time for reflection, and I would offer a referral for counselling.

I would seek advice from the GMC, my partners and his hospital consultant before making a decision to disclose without consent.

A medico-legal opinion
Dr Sonya McCullough is a medico-legal adviser for the Medical Protection Society

Doctors are bound by a duty of confidentiality to their patients but this is not absolute. Confidentiality is at the centre of maintaining trust and ensuring a healthy doctor-patient relationship.

In this case the patient is coming to terms with a difficult diagnosis but he should be encouraged to tell his wife about his HIV status.

The doctor should refer the patient to hospital for a sexual health screen and contact previous sexual partners. Where there has been a 'casual encounter' the hospital clinic can use the 'provider referral' system, thus maintaining the patient's anonymity.

The situation with his wife is more complex. The doctor could offer to help break the bad news to her with the patient present or in a one-to-one consultation. The doctor should discuss how the patient can prevent transmission of HIV to his partner, for example, safe sex including consistent use of condoms and use of post-exposure prophylaxis.

If the doctor has concerns that the patient is practising unsafe sex with his wife and has not disclosed his status to her, then the doctor can justify breaching confidentiality and disclosure in the public interest (if failure to disclose may expose others to risk of death or serious harm).

In recent legal cases, the judgment indicated that anyone infected must disclose this to any sexual partner and must use protection in sexual intercourse.

A patient's view
Elizabeth Brain is an expert patient

Even though you are running late, this situation is so critical you must immediately and fully engage with the patient.

As he wishes to keep the matter secret from his wife, it may be that he is still in a state of shock and has not yet thought through the consequences of his decision. While his position may be very understandable, there are matters of both marriage and health to address.

It is unlikely that the patient would be able to keep his HIV status a secret indefinitely. How would he explain a potentially serious deterioration of his health in future? Not telling his wife will cause him to suffer further anxiety, possibly making it more difficult to tell his wife. The impact on their marriage will be much greater if the wife finds out after years of deceit.

The patient is hoping to maintain his marriage, but he could risk placing his wife's health, and perhaps life, in serious danger. His duty to her both as a human being and as a partner is to explain the situation so she can make informed decisions about her own health.

The sooner he makes a disclosure to her, the sooner she can be protected and the more likely their marriage is to survive.

This should be the GP's approach when speaking to him. You could invite both the patient and his wife to come to the surgery for a discussion.

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