HIV Testing: Anonymous versus confidential

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JohnMadden

JohnMadden

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On one of my interviews, I received an ethical question related to HIV/AIDS. Here's a synopsis: One of your patients receives a positive result for an HIV test. However, you learn that the patient is engaged to one of your close friend's children. After talking with your patient, they make it clear that they will not inform their fiancee of their HIV status. What would you do?

After attempting to address the question, I also learned that certain states do NOT offer anonymous HIV testing (which surprised me). I wanted to get opinions on whether or not you believe states should deny access to anonymous HIV testing.

Background:
Currently, the majority of states (80%) offer anonymous and confidential testing, which gives patients the right to not have their names reported to the health department for a positive test result. The states that do not provide anonymous testing are:

Alabama
Idaho
Iowa
Mississippi
Nevada
North Carolina
North Dakota
South Carolina
South Dakota
Tennessee
 
JohnMadden said:
On one of my interviews, I received an ethical question related to HIV/AIDS. Here's a synopsis: One of your patients receives a positive result for an HIV test. However, you learn that the patient is engaged to one of your close friend's children. After talking with your patient, they make it clear that they will not inform their fiancee of their HIV status. What would you do?

After attempting to address the question, I also learned that certain states do NOT offer anonymous HIV testing (which surprised me). I wanted to get opinions on whether or not you believe states should deny access to anonymous HIV testing.

Background:
Currently, the majority of states (80%) offer anonymous and confidential testing, which gives patients the right to not have their names reported to the health department for a positive test result. The states that do not provide anonymous testing are:

Alabama
Idaho
Iowa
Mississippi
Nevada
North Carolina
North Dakota
South Carolina
South Dakota
Tennessee
Click to expand...

No anonymous testing IMO. In fact, I think anyone that tests positive for any STD needs to be registered in some national database. That way, anyone can log on and check the status of whoever they are about to do.
 
JohnMadden said:
On one of my interviews, I received an ethical question related to HIV/AIDS. Here's a synopsis: One of your patients receives a positive result for an HIV test. However, you learn that the patient is engaged to one of your close friend's children. After talking with your patient, they make it clear that they will not inform their fiancee of their HIV status. What would you do?

After attempting to address the question, I also learned that certain states do NOT offer anonymous HIV testing (which surprised me). I wanted to get opinions on whether or not you believe states should deny access to anonymous HIV testing.

Background:
Currently, the majority of states (80%) offer anonymous and confidential testing, which gives patients the right to not have their names reported to the health department for a positive test result. The states that do not provide anonymous testing are:

Alabama
Idaho
Iowa
Mississippi
Nevada
North Carolina
North Dakota
South Carolina
South Dakota
Tennessee
Click to expand...

I think the way it works is that a person might get a letter saying, "One of your past or present sexual contacts has tested positive for an STI. Please come to X to get tested." I don't think it says, "Joe Blow, your old boyfriend, has AIDS."
 
sirus_virus said:
No anonymous testing IMO. In fact, I think anyone that tests positive for any STD needs to be registered in some national database. That way, anyone can log on and check the status of whoever they are about to do.
Click to expand...

That's exactly why people don't want to get tested or go in for things like psychiatric help. There is a stigma attached to HIV or "mental health issues", so people choose to avoid them rather than incur the wrath of their insurance company or lose their job.
 
Dookter said:
I think the way it works is that a person might get a letter saying, "One of your past or present sexual contacts has tested positive for an STI. Please come to X to get tested." I don't think it says, "Joe Blow, your old boyfriend, has AIDS."
Click to expand...

Just for clarification:
The reporting of the positive test and name is reported to the STATE. Prior sexual contacts have nothing to do with the reporting...
 
I would tell the girl, regardless of the consequences. If she contracted the disease later, I would never be able to forgive myself. This actually came up in my life real recently. My roommate told me he had HPV during a real serious conversation. He and my girlfriend's sister started to crush on each other and I flat out told her. I know he wouldn't have said anything because he sleeps with girls all the time and doesn't mention it (in fact, he said that he didn't have it just a short time later when I told him to stay away from her). Maybe I betrayed our friendship, but if he gave her the disease and I knew about it I wouldn't be able to stand myself.
 
I think people need to file their HIV status(and other infectious STDs) with their tax returns yearly. Sounds drastic, but we need to know these things for the "greater good of society".
 
Is it true that you can break doctor-patient confidentiality when you become aware that someone will commit a crime, such as a psychiatric patient who is about to kill an ex-girlfriend? If so, I think that legally and ethically it is right to inform the friend's daughter of the HIV status. It is illegal to knowingly spread HIV, and since the patient has made it clear that he is going to do so I think you have some obligation to stop it. Even if it turns out that doctor-patient confidentiality rules in this situation, I might still have to tell her-- it is hard to justify letting someone knowingly contract an incurable and lethal virus.
 
Bartelby said:
Is it true that you can break doctor-patient confidentiality when you become aware that someone will commit a crime, such as a psychiatric patient who is about to kill an ex-girlfriend? If so, I think that legally and ethically it is right to inform the friend's daughter of the HIV status. It is illegal to knowingly spread HIV, and since the patient has made it clear that he is going to do so I think you have some obligation to stop it. Even if it turns out that doctor-patient confidentiality rules in this situation, I might still have to tell her-- it is hard to justify letting someone knowingly contract an incurable and lethal virus.
Click to expand...

An interesting point. When I read JohnMadden's scenario, I assumed that a doctor could *not* tell. However, I do believe you're right that, in most or all states, knowingly transmitting the virus to someone else can be prosecuted as assault. And, since you have advance knowledge of a crime, maybe it is reportable.

I don't think you could tell her directly, but it does seem possible that you'd be allowed to report it to local authorities. Hmmmm. Interesting.

Law2Doc? Are you out there?
 
I guess I made the mistake of asking two questions in one thread.🙄

1. The ethical scenario in the original post:
Thus far, it seems that people would find a way to inform a family friend of a partner's HIV status.

2. Should states deny anonymous testing:
Any thoughts here?
 
Wanna_B_Scutty said:
An interesting point. When I read JohnMadden's scenario, I assumed that a doctor could *not* tell. However, I do believe you're right that, in most or all states, knowingly transmitting the virus to someone else can be prosecuted as assault. And, since you have advance knowledge of a crime, maybe it is reportable.

I don't think you could tell her directly, but it does seem possible that you'd be allowed to report it to local authorities. Hmmmm. Interesting.

Law2Doc? Are you out there?
Click to expand...

Yeah, my first response to the question was that it's unlawful to knowingly spread HIV/AIDS, thus there is some avenue to let her know - probably through the local authorities.

As to your second question, I feel like I need to know more, because obviously there's a reason the other 40 states do allow anonymous testing. Pros and cons anyone?
 
couldnt the fiancee later charge the guy for attempted manslaughter anyway? i would tell her because engaging in sexual activing and knowingly transmitting the disease seems damn criminal to me. even if they had already had sex, there may be a chance she hadnt gotten it.
 
variablistic said:
obviously there's a reason the other 40 states do allow anonymous testing. Pros and cons anyone?
Click to expand...

I am not sure on this one, but I am guessing that if you have an HIV positive diagnosis on your record it could be hard to get health insurance. Since HIV disproportionately affects poor people who may not have health insurance, maybe they would like to test anonymously first so that if they are HIV positive they can have the time to find a way to buy an appropriate policy and figure out if they have any affordable treatment options (obviously they would keep the diagnosis to themselves). Also, HIV is highly stigmatized so maybe states are worried that patients might avoid testing altogether if the testing was not anonymous. I guess legislators may believe it is better for the individual to know their status even if no one else does, so at least in that year-long symptom free window they would be more likely to avoid spreading it.

As for whether it is better to offer anonymous testing or not, that is a tough call. I support anonymous testing, because someone who would test and then knowingly spread the virus anonymously would probably be inclined to just not test and ultimately spread the virus without anonymous testing as well. Honest people, however, would likely avoid high risk activities if they received a diagnosis, even an anonymous one.
 
JohnMadden said:
Just for clarification:
The reporting of the positive test and name is reported to the STATE. Prior sexual contacts have nothing to do with the reporting...
Click to expand...

That's not true. Prior sexual contacts are notified if the patient provides that information. They get a letter saying they need to be tested. Obviously, the catch is getting the patient to gives you the names of these other people...
 
This is interesting. I believe the doctor should tell the fiance, probably because of those legal reasons that some others have stated.

As far as anonymous testing, I think that it is probably good. On the other hand, since I know someone that is HIV positive and still sleeps around without telling the potential partners, I wish there was more that could be done from a public health point of view.
 
I think the doctor should tell the fiance. Also, isn't it a crime to engage in high risk sexual relations with someone KNOWING that you have HIV/AIDS, without telling them about it?
 
Kfire326 said:
I think the doctor should tell the fiance. Also, isn't it a crime to engage in high risk sexual relations with someone KNOWING that you have HIV/AIDS, without telling them about it?
Click to expand...

It is in NC. I am pretty sure it is illegal to have unprotected sex if you have HIV here, even if you are married.
 
Patients have the presumption of confidentiality in their interaction with the physician. This is the basis for the trust relationship and is enshrined in the Hippocratic Oath.

Because of the specific nature of HIV, State laws have been enacted regarding testing and confidentiality. In my State, a physician may reveal it to the patient's spouse, if the spouse does not do so. The information can also be shared with those who have been the victims of assault by the patient. (If a rapist is caught and tests positive, the person who was raped can be informed). It might be against the law to inform a woman or her parents that her fiance is positive for HIV.

States that require the reporting of names to the State authorities are placing surveillence and (I presume) contact tracing (informing people that they may have been exposed to an infectious disease and should be tested) above individual privacy rights. The list of reportable diseases is long and the tradition of reporting communicable diseases to the State Health Department is a long-standing one (smallpox, measles, anthrax are among the reportable diseases, see http://www.health.state.ny.us/nysdoh/cdc/cdcrept.pdf for an example). HIV was the exception to the rule because of the stigma attached to the disease early in the epidemic and the feeling that it was better to let people be tested and do their own "contact tracing" than to have people refuse testing altogether because they mistrusted the State to keep their sensitive information confidential.
 
sirus_virus said:
No anonymous testing IMO. In fact, I think anyone that tests positive for any STD needs to be registered in some national database. That way, anyone can log on and check the status of whoever they are about to do.
Click to expand...
Or hire for a job...(not)🙄 This is personal health info and should not be made available to the public. If you are about "to do" someone and are concerned about their HIV status, go and get tested with them.
 
MChitty said:
As far as anonymous testing, I think that it is probably good. On the other hand, since I know someone that is HIV positive and still sleeps around without telling the potential partners, I wish there was more that could be done from a public health point of view.
Click to expand...
Well, that just reminds you that you should never assume that your new partner is "clean."
 
Interesting article about the topic of doctor-patient confidentiality here.

As for the anonymous testing debate, I think the key issue has to do with stigma, as LifetimeDoc mentioned. A major tack of HIV/AIDS groups working in southern Africa (and elsewhere, I presume, but I can really only speak about that region as it's what I'm familiar with) is to lower the level of stigma surrounding HIV so that more people will be comfortable with testing and treatment. In some parts of Africa, the stigma of being HIV+ comes with significant repercussions, much greater than (I think) those suffered by patients in the US. In Africa, I believe offering anonymous testing is essential as a preliminary step in getting the virus under control until the stigma is more manageable.

In the U.S., though, the situation is very different. In addition to the repercussions of the HIV+ label being less drastic, we have greater access to treatment. From a public health standpoint, then, we have to wonder: will we do better controlling the spread of HIV+ by offering anonymous testing, thus providing a safe environment for people to learn their status and individually take (or not take) steps to prevent spread to their partner(s)? Does anonymous testing provide a necessary incentive? Or will we have more luck with a database and notification, which could potentially deter some people from getting tested at all?

It's a really interesting problem. I think the stakes change as the disease and its treatment options change. Twenty years ago, I imagine anonymity was a much bigger priority for HIV+ patients in the U.S. than it is now.

I wonder if there's a historical example of another disease that could provide some comparative insight. TB maybe? I don't know much about how stigma surrounding TB may have changed, but I believe the CDC keeps tabs on all PPD-positive TB patients (or maybe just sputum-positive?). Hmm...
 
jochi1543 said:
Well, that just reminds you that you should never assume that your new partner is "clean."
Click to expand...

I completely agree. It's just angers me how irresponsible people can be. But yes, when you are sleeping with someone whose past you don't know, it's a risk you take.
 
Anonymous testing exists so that patients can avoid the stigma of having a request for an HIV test in their file. It doesn't matter whether it came back positive or negative, some insurance companies may balk that a test was ever performed. If confidential HIV testing was a standard part of patient care, maybe as a society we could get to a point where anonymous testing is unnecessary.
 
i agree with the database.... definately everyone should have mandatory STD checks and be reported and put online...

kinda like the sex offenders... ur picture gets put online with date of offence...
 
A public database with people's STD status is a horrible idea because it's a huge and unnecessary breach in confidentiality. What about someone who contracts chlamydia and then gets treatment. Do they stay in the database even though they're no longer a threat to spread the disease? And sure, it would be nice to know for certain your sexual partner's health status, but can you imagine your co-workers/parents/neighbors/strangers being able to look at your health history?? There would be no way to control who could look at it, which would make it available to a huge group of people who have no business knowing it at all. The truth is that most people don't contract STDs because they are lied to. They get them because they assume that someone looks "clean", or they just don't ask. If you don't ask someone their HIV status, then they might not feel any huge obligation to tell you (especially if you're using protection). So ASK!!!

Reading this board it's clear that there is definitely still a lot of stigma related to HIV, even among us "altruistic" pre-meds. The focus immediately went to those people living with HIV who "sleep around" or who "knowingly infect people". While I in NO WAY condone knowingly and maliciously infecting someone with a chronic illness, this is the exception rather than the rule.

Also, try to look at the OP's interview situation with some empathy. Imagine being diagnosed HIV-positive, and all the fear, rejection, and sadness that accompanies this diagnosis. It is narrow-minded to immediately force that person into sharing that diagnosis with their fiance. Consider that his statement that he has no plans to tell her might be a knee-jerk reaction to simply being terrified. I'm not saying that he shouldn't share his status. If they are in a sexual relationship, he absolutely should. But there should be counseling services that can help him to figure out a way to disclose that information in a way that makes him comfortable. For many, the HIV-positive diagnosis is some of the worst news of their life, and it's understandable that yelling it from the rooftops isn't at the top of their list of things to do.
 
Oh and for some people, it's anonymous testing or no testing. In my opinion, anonymous testing is ALWAYS better than no testing.
 
HailMary said:
Oh and for some people, it's anonymous testing or no testing. In my opinion, anonymous testing is ALWAYS better than no testing.
Click to expand...
Agreed, people simply wont get tested, and that's far worse. What if someone contracts AIDS through birth, is it fair for that child's name to be plastered in some database, only to be teased and harassed during their childhood? 🙁
 
Kingfish said:
I would tell the girl, regardless of the consequences. If she contracted the disease later, I would never be able to forgive myself. This actually came up in my life real recently. My roommate told me he had HPV during a real serious conversation. He and my girlfriend's sister started to crush on each other and I flat out told her. I know he wouldn't have said anything because he sleeps with girls all the time and doesn't mention it (in fact, he said that he didn't have it just a short time later when I told him to stay away from her). Maybe I betrayed our friendship, but if he gave her the disease and I knew about it I wouldn't be able to stand myself.
Click to expand...
Err...but the problem with that is that so many people have HPV that you almost definitely stepped over the line. In fact, ~70% of sexually active people have been exposed to HPV just because it's that common.

It's just that most people with HPV don't know about it and it goes away after a while anyway.
 
SIREN said:
Agreed, people simply wont get tested, and that's far worse. What if someone contracts AIDS through birth, is it fair for that child's name to be plastered in some database, only to be teased and harassed during their childhood? 🙁
Click to expand...

Is it fair for the person they have sex with on prom night for them to not be in such a database?
 
Good ethics question!


1- My first course of action would be to strenuously try to convince the HIV+ person to tell their partner/fiance/whatever. However, if that didn't work, I think I would tell them.

When I thought that through, my conclusion was different from my instinct of "get out of my business" and "medical confidentiality." I had to imagine my sister marrying a guy who just wasn't going to tell her.



2- As for the anonymous testing, I think that I think that state-funded testing should do what it wants with the info. However, private anonymous testing shouldn't be banned (was that part of this issue?). I have to agree that anonymous is better than none, but if you are given the choice- more people will choose to be tested anonymously than would choose NOT to be tested if anonymous testing wasn't available. <-- My opinion


Like I said, this was a goody but a toughy. I reserve the right to change me mind.🙂
 
RogueNine said:
Is it fair for the person they have sex with on prom night for them to not be in such a database?
Click to expand...


If you're going to be having sex, there is going to be some risks. Kind of like playing guns, but a lot more fun.

Educate, educate, educate.
 
BTW, back on topic about HIV, there definitely should be anonymous testing, although I think there should be some kind of post-test counseling requirement in case someone actually tests positive, to help them deal with the news and so they'll be less likely to just hide it from other people.

Truth is that if you made it seem like having HIV means you'd be treated like a 2nd class citizen nobody would ever bother getting tested, which would make things overall pretty useless.

Anyways, while ethically we do care about them spreading the disease to other people, if you go about ruining people's lives just because they have HIV that's not entirely ethical either. So yeah it's kind of an issue.

As for the patient in the example I'd basically try to convince them to tell their fiancee themselves (pointing out that it's possible to get a conviction for manslaughter, etc if you don't). But failing that I'd do my best to make sure that they'd be super careful when "having relations". Although even if someone tested anonymously there might be some sort of partner notification system you could use anyway.

Ratting out the patient wouldn't really do any good though. Maybe you'd save his fiancee from getting HIV, but after she dumps him are you going to be able to follow him around finding out who he's sleeping with for the rest of his life? And now he just won't trust doctors or healthcare providers because the last time he did trust a doctor they ruined his marriage. So all those people he later has sex with are going to be put at risk by your action of ruining his current relationship.

That said, from a friend point of view you also perhaps have an obligation to your friend. But from a general person point of ethics it doesn't make any sense to tell on your patient since you'd just expose someone else to the risks (or many someone elses). And if anything your patient will be less likely to reveal to future partners that they're HIV+ because of how their previous relationship went.

I guess it comes down to whether you're a better friend or a better doctor.

Solution is probably just to not see family friends as patients, lol.
 
RogueNine said:
Is it fair for the person they have sex with on prom night for them to not be in such a database?
Click to expand...
Great blanket statement in the form of a question. *bleh* Is it fair to assume they will have sex on their prom night? Is it fair to assume whether or not they will even live long enough to see their prom? Why should these children be denied their integrity? Why must we assume that they would try to pass this horrific disease to someone else, having dealt with it, for a lifetime? Why can't these people be looked upon as caring individuals, who are sincerely concerned about the health and welfare of others? Many children who are fortunate enough to survive this disease, use their own lives as an example to further educate, give insight and dissipate some of the myths regarding this disease. 🙂
 
RogueNine said:
Is it fair for the person they have sex with on prom night for them to not be in such a database?
Click to expand...

The person they have sex with on prom night should be taught to use protection and ASK about their partner's HIV status, so that there are no unfortunate surprises. That person is responsible for protecting him/herself and making a good decision. However, if they grew up in this country they probably only know that they're supposed to be abstinent and nothing else... :barf:

This statement perpetuates the stigma that there are HIV predators and HIV victims, that we can't trust HIV+ people to be honest about their status. Also, a lot of people these days don't know the last name of the people they're having sex with... How do you propose to look up these people in a national database?? I'm guessing you'd need at the very least a full name and DOB, but how do you know that the John Smith with syphilis is the same John Smith that you're about to get down with?

Maybe we should make them get HIV+ tattoos on their junk so that we know for sure...
 
HailMary said:
Maybe we should make them get HIV+ tattoos on their junk so that we know for sure...
Click to expand...

Do you even know what you are saying? People would never get tested if they thought there was a chance of that. You are nutz. Why don't you start thinking of patients as human beings before you start treating them like criminals or research animals before you become a physician. Please.
 
hmm. I thought this thread was about "I had sex for the firstime, and I am worried about getting HIV. "

Well, use a condom! better yet, stick to abstinence 👍
 
LifetimeDoc said:
Do you even know what you are saying? People would never get tested if they thought there was a chance of that. You are nutz. Why don't you start thinking of patients as human beings before you start treating them like criminals or research animals before you become a physician. Please.
Click to expand...

Sheesh! Can't you detect sarcasm !?!
 
LifetimeDoc said:
Do you even know what you are saying? People would never get tested if they thought there was a chance of that. You are nutz. Why don't you start thinking of patients as human beings before you start treating them like criminals or research animals before you become a physician. Please.
Click to expand...

If you read any of my previous posts you'd know that that was a completely sarcastic (if not the most tasteful) statement. I've done clinical HIV research full time for the last year and a half, I see HIV+ people every day, and they are very much human beings to me. That's why I do what I do. I was using that statement to point out how ridiculous I think using a public registry would be. Chill out.
 
ryandote said:
Sheesh! Can't you detect sarcasm !?!
Click to expand...

Sorry, it broke last Tuesday! 😀
aabf18_sarcasm_detector.jpg
 
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