Regulating doctors, ensuring good medical practice

Confidentiality case study: serious communicable diseases

Should a doctor override a patient’s objection to disclosure of their HIV status?

Part 1

Jonathan Jones visits a Genitourinary Medicine clinic with what he suspects are anogenital warts. He is examined and provided with podophyllotoxin for his warts, and offered advice on how it should be applied and what to do in the event of complications. The clinic’s policy is to offer chlamydia, gonorrhoea, syphilis and HIV tests to all new patients, in line with national guidance, and Mr Jones is offered these along with information about the benefits of testing and how the result will be given.1  He consents, and the HIV test comes back positive.

Mr Jones is seen by Dr Brian Biggs, who tells Mr Jones about confirmatory testing, the likely stage of the disease and how it is treated. He reassures Mr Jones that HIV is a treatable medical condition and the majority of those living with the virus remain well on treatment. He asks if he has any other immediate concerns and provides him with written information about HIV and about the services that are available to patients in the area. He arranges a follow-up appointment for the following week to discuss the results of confirmatory testing and Mr Jones’s future treatment, partner notification and the risks of onward transmission of HIV and the medico-legal issues associated with this.

Mr Jones immediately expresses anxiety about his privacy, having witnessed a friend suffer discrimination following accidental disclosure of his HIV status. He is open to partner notification, although he has not been sexually active for a few months; but he says that he does not want his GP informed of his diagnosis. He has not got on well with his GP in the past and he fears discrimination in the practice as well as further, inappropriate disclosure of his status.

Should the doctor…

  1. 1. Simply accept Mr Jones’s decision not to inform his GP?
  2. 2. Explain the legal and ethical duties of non-discrimination and confidentiality in an effort to reassure Mr Jones about his GP, as well as the GP’s need for information to provide safe, effective care; but ultimately respect Mr Jones’s decision?
  3. 3. Tell Mr Jones that he’s duty-bound to inform the GP, both because his GP wouldn’t be able to provide safe or effective care without this knowledge and for the safety of the GP and her clinical colleagues?

Sharing information with other healthcare professionals is important for safe and effective patient care. That is why, when patients haven’t been referred by a GP, specialists are advised to ask for patients’ consent to inform their GPs before starting treatment. Specialists should also tell the 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 (Good medical practice paragraphs 50 to 53).

That may be particularly important for a patient like Mr Jones, who will be under medical care for the rest of his life and is likely to need antiretroviral medication at some stage. Antiretroviral drugs have many potential serious interactions with other commonly prescribed medications and it is important that his GP is aware of this if she is to provide safe and effective care. In addition, HIV-infected patients are at a higher risk of several chronic morbidities including hyperlipidaemia, impaired glucose tolerance and renal disease.  GPs play a crucial role in the management of patients’ long-term medical conditions, such as cardiovascular disease, in whose treatment knowledge of HIV status may be important. ‘HIV services should strongly advise patients to register with a GP and to inform their GP of their HIV diagnosis. Unless patients refuse consent, HIV services should keep GPs updated regarding their patients’ clinical status and medication’.2

In this case, Mr Jones does object. Confidentiality is important to all patients, but some patients who have or might have serious communicable diseases may have particular concerns (Confidentiality: disclosing information about serious communicable diseases, paragraph 2). 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. Patients might avoid seeking medical assistance altogether if they do not believe the information they share with their doctors is secure. That could be dangerous both for the individual patient and for the wider community (Confidentiality paragraphs 6 and 36).

Dr Biggs should strongly encourage Mr Jones to consent, explaining the clear benefits of informing his GP of his status, and seek to reassure him about his GP’s legal and ethical duty of confidentiality. All patients are entitled to good standards of care, regardless of what disease they might have, or how they acquired it. If he cannot be reassured, Dr Biggs might suggest that Mr Jones registers with a new GP practice

Ultimately, Mr Jones’s decision must be respected unless there is an overriding public interest in disclosing the information without his consent. Doctors and nurses at his practice will not be at risk of infection if standard infection control procedures are followed. It is much less likely for exposure-prone procedures to be undertaken in primary care than in hospitals. It is important that all blood and body fluids and tissues are regarded as potentially infectious, and healthcare workers should follow precautions scrupulously in all circumstances to avoid contact with them.4

Footnotes:

1UK National Guidelines for HIV Testing 2008 (British HIV Association, Association for Sexual Health and HIV and British Infection Society); Standards for the management of sexually transmitted infections (BASSH & Medical Foundation for AIDS and Sexual Health, 2010); Consent: patients and doctors making decisions together (GMC, 2008).

2Standards for HIV Clinical Care (British HIV Association, Royal College of Physicians, British Association for Sexual Health and HIV and British Infection Society, 2007)

3See Health clearance for tuberculosis, hepatitis B, hepatitis C and HIV: New healthcare workers  (Department of Health, 2007), Health Clearance for Tuberculosis, Hepatitis B, Hepatitis C and HIV for new Healthcare Workers with direct clinical contact with patients (Scottish Government, 2008), HIV-infected health care workers: Guidance on management and patient notification (Department of Health, 2005) and HIV Infected Health Care Workers: Guidance on Management and Patient Notification (Scottish Government, 2005) for examples of advice on exposure-prone practices in different settings from the UK Advisory Panel for Health Care Workers Infected with Blood-borne Viruses.

4Guidance for clinical health care workers: protection against infection with blood-borne viruses (Expert Advisory Group on AIDS and the Advisory Group on Hepatitis, 1998).