Sharing information about a patient’s HIV status 

Background

Jonathan visits a GUM clinic to be treated for anogenital warts. As a new patient he’s offered some standard tests for chlamydia, gonorrhoea, syphilis and HIV. His HIV test comes back positive.

Dr Biggs reassures Jonathan and arranges a follow-up appointment to discuss confirmatory testing, treatment, partner notification and the risks and medico-legal issues around onward transmission.

Scenario

Jonathan immediately expresses anxiety about his privacy. He explains to Dr Biggs that a friend suffered discrimination after accidental disclosure of their HIV status. 

Jonathan also doesn’t get on well with his GP is afraid the GP will discriminate against him and disclose his HIV status to others in the practice. Whilst he’s open to partner notification, he says he does not want his GP informed of his diagnosis.

What should the doctor do?

1. Accept Jonathan’s decision?
2. Try to convince Jonathan to change his mind by reassuring him of why the GP needs to know about the diagnosis but ultimately respect Jonathan’s decision?
3. Inform Jonathan that he’s duty-bound to inform the GP because the GP needs to know to provide safe, effective care and to keep themselves and their clinical colleagues safe? 

What the doctor did

Dr Biggs strongly encourages Jonathan to agree to informing his GP. He explains the benefits and reassures him about his GP’s duty of confidentiality. He also suggests that Jonathan consider registering with a new practice if he doesn’t get on well with his current GP. 

However, Jonathan remains adamant that he does not want his GP to be told about his diagnosis.  Dr Biggs respects Jonathan’s decision. 

What the doctor had to consider

• There is a clear public good in having a confidential medical service. Otherwise patients might avoid seeking medical assistance which could leave them at risk of harm. 

• Sharing information with other healthcare professionals is important for safe and effective patient care.  Unless the patient objects, 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.  

• If a patient with a serious communicable disease refuses to consent to disclosure, a doctor must respect their wishes, unless failure to disclose will put others at risk of infection. Although such situations are likely to be very rare because of the use of standard infection control precautions.

• If a patient objects to the disclosure of their diagnosis, the doctor should explore the patient’s reasons; explain the benefits of sharing the information and the risks of not sharing it

Background

Two years on from his HIV diagnosis, Jonathan visits Dr Briggs again.  He is responding well to treatment and his HIV viral load is undetectable.  He mentions that he is having knee surgery but he still hasn’t shared his diagnosis with his GP, so the surgeon has not been told. 

Scenario

Jonathan tells Dr Briggs that the operation is being paid for by his work’s private health insurance and he doesn’t want his diagnosis  getting back to them

Dr Biggs knows that surgeons sometimes take additional precautions with ‘high risk’ patients like double-gloving or putting them at the end of surgical lists. But he also knows the surgical team should be taking ‘universal precautions’, as any patient could have a blood-borne virus. 

Jonathan notices Dr Biggs hesitation and says he’ll complain if his confidentiality is breached. He says that if there’s a needlestick injury, he promises to disclose his HIV status.

What should the doctor do?

1. Accept Jonathan’s decision not to disclose his HIV status to the surgeon?
2. Explain that he must inform the surgeon with or without Jonathan’s consent, to protect them and their team from the risk of infection?
3. Contact the surgeon and say that a patient with a blood-borne virus is booked in on that  date but not say who it is?

What the doctor did

Dr Biggs decides against disclosing the information without Jonathan’s consent. Jonathan’s viral load is undetectable which lowers the likelihood of transmission, and he knows that the surgical team at this hospital have appropriate infection control procedures. 

However, he explains that Jonathan wouldn’t be made aware of a needlestick injury until hours later, if at all. This surprises Jonathan. He changes his mind and asks for the surgical team to be given his HIV status. 

What the doctor had to consider

• Confidential information can be shared when required by law, when the patient consents, or when there is an overriding public interest in disclosure.
  
• Disclosure might be justified if a doctor has good reason to believe that the surgical team are at risk e.g. they wouldn’t usually employ ‘universal precautions’ or the procedure involves hard-to-avoid risks such as using power tools to cut through bone

• UK Department of Health guidance on blood borne disease advises that standard infection control measures should be taken because all blood, tissues and some body fluids should be considered potentially infectious. Around 13% of patients don’t know they have HIV, hepatitis B or hepatitis C (Public Health England). 

• He should raise his concerns if  knows there is poor practice at the hospital, which could lead to a doctor to feel that he/she has to breach his patient’s confidentiality.