Part 2

Two years later, Mr Jones visits Dr Biggs for a routine appointment. Except for a knee injury, he is well, responding well to Highly Active Antiretroviral Therapy (HAART) and his HIV viral load is undetectable. Mr Jones mentions that his GP has referred him for orthopaedic surgery at a local private hospital. He has still not shared his HIV status with his GP, who he rarely sees, and he lets Dr Biggs know that he has not disclosed his status to the orthopaedic surgeon, either. In addition to his concerns about discrimination and privacy, Mr Jones is particularly concerned that information about his status might get back to his employer and that he could lose his job. His surgery is being paid for through a private health insurance scheme provided by his employer.

Dr Biggs says that surgeons sometimes take additional precautions with ‘high risk’ patients, e.g. double-gloving and possibly a space suit for the surgeon; and gloves, aprons and face visors for the theatre staff. He says he thinks that HIV+ patients are sometimes put at the end of surgical lists to minimise the risk of infecting other patients. He urges Mr Jones to tell the orthopaedic surgeon about his HIV status so that the surgeon and her team can take additional measures to protect themselves from the risk of infection. He also seeks to reassure Mr Jones of the surgeon’s duty of confidentiality and that systems are in place to prevent inappropriate disclosures.

Mr Jones refuses. He says he has been researching the issues on the internet and that the surgical team should be taking ‘universal precautions’ based on the assumption that all patients are potentially infected with blood-borne viruses. He becomes quite upset and says he will complain about Dr Biggs if he breaches his confidentiality by informing the surgeon or anyone else about his HIV status. Mr Jones adds that, in the event of a needlestick or similar injury to a healthcare worker, he would disclose his status.

Dr Biggs should certainly counsel Mr Jones to disclose his HIV status, but ultimately must respect his refusal unless he considers that failure to disclose will put the orthopaedic surgeon and her team at such a risk of infection that disclosure without consent could be justified. He might also explain that:

• Mr Jones should not interrupt taking his antiretroviral drugs during his hospital admission, which is a possibility if he wishes to conceal his medication from hospital staff; to do so would risk harming his health in the short term and developing resistance in his virus to the drugs he is currently taking, limiting his future therapeutic options and worsening his prognosis
• should he stop his treatment during his hospital admission, he risks rebound viraemia, with consequent risk to his own health as well as increasing the risk of passing on HIV to those caring for him
• the risk to his surgeon and the other staff caring for him during his operation is negligible while he is on treatment
• post exposure prophylaxis is most effective if given as quickly as possible after exposure to the virus; if a needlestick or similar injury occurred in theatre, Mr Jones would be unlikely to be made aware of it until some hours later, after he had recovered from his anaesthetic, if at all.

The Expert Advisory Group on AIDS (EAGA)⁵ advises that all teams of healthcare workers should work to identify and take precautions against exposure to blood-borne viruses. Doctors should help devise safe and reasonably practicable procedures and routines for performing tasks; make sure they are followed after appropriate training; and keep them under active review.

Standard infection control measures, determined according to the extent of possible exposure to blood or other body fluids, should be taken on the basis that all blood, tissues and some body fluids should be regarded as potentially infectious. Precautions should not be determined by knowledge or speculation about the infectious status of a (‘high risk’) patient. It would be inappropriate to take fewer precautions on the basis that the patient did not know or declare that they had, or was considered unlikely to have, a blood-borne virus, given the high level of undiagnosed HIV, hepatitis B and hepatitis C in the UK and the need therefore to treat all blood and body fluids as potentially dangerous.

There may be circumstances in which appropriate infection control procedures are not followed, for a variety of reasons (not all of them justifiable). If Dr Biggs is seriously considering disclosing Mr Jones’s status without his consent, he could enquire about the usual infection control procedures at the hospital where Mr Jones’s surgery is to take place, without disclosing Mr Jones’s identity. He might be reassured by this, or revert to Mr Jones if he still considers disclosure appropriate. Interference with Mr Jones’s privacy rights is, however, clearly less satisfactory than the implementation by others of appropriate infection control procedures. Dr Biggs should raise concerns if he encounters evidence of poor practice that leads him to breach his patient’s trust.⁶

In the event of a disclosure and a subsequent complaint, Dr Biggs might be able to justify his actions if he had good reason to believe that the surgical team were at risk, e.g. because they would not otherwise employ appropriate infection control procedures or if the nature of the procedure involved particular risks that are difficult to avoid (e.g. if Mr Jones’s surgery involved the use of power tools to cut through bone).

Contacting the surgeon to say a patient with a blood-borne virus is booked in on the day for which Mr Jones’s operation is planned would not necessarily be a breach of confidence, but it would not be a sensible course of action. It might lead to disclosure of Mr Jones’s status (if he was the only person booked in for surgery on that day, for example), confusion if he changed the date of his operation, or unhelpful speculation about who the patient is. It would also encourage and perpetuate poor practice: the use of universal precautions protects clinical staff from the risk of infection from all patients, including those who do not know their status. An estimated 83,000 people were living with HIV in the UK in 2008, with more than a quarter (27%) unaware of their infection,⁷  and many more with other blood-borne viruses of which they are unaware or might not disclose.

Key points:

Sharing information with other healthcare professionals is important for safe and effective patient care. Specialists should tell a patient’s GP the results of investigations, treatments provided and any other information necessary for the continuing care of the patient, unless the patient objects.

• There is a clear public good in having a confidential medical service. The fact that people are encouraged to seek advice and treatment, including for communicable diseases, benefits society as a whole as well as the individual.
• Confidential information can be shared when that is required by law, with the patient’s consent, or when there is an overriding public in disclosure.
• Making public interest judgements can be very difficult.  They require an appreciation of all the benefits and risks of disclosure and non-disclosure, as well as identification of the relevant legal and ethical considerations.
• If a patient with a serious communicable disease refuses to allow their status to be disclosed outside the healthcare team, doctors must respect their wishes, unless they consider that failure to disclose will put others at risk of infection. But such situations are likely to be very rare in the healthcare setting because most patients do not object, and because of the use of standard infection control measures.
• The risk of acquiring HIV infection following occupational exposure to HIV-infected blood is low.⁸  The UK Advisory Panel for healthcare workers infected with bloodborne viruses (UKAP) advises that there have been five documented cases of occupationally acquired HIV infections in healthcare workers in the UK. Four occurred before 1994, only one of whom received post-exposure prophylaxis (PEP). The most recent case was in 1999, when seroconversion occurred despite combination PEP. A further 14 probable cases of occupational acquisition of HIV in healthcare workers have been diagnosed in the UK. The majority of these healthcare workers had worked in countries of high HIV prevalence, and are presumed to have been infected outside the UK.

See Confidentiality: disclosing information about serious communicable diseases for further advice and links to other publications.