Reporting HIV..?

[MedPR]

Is it the physician's responsibility to notify the public health department and the spouse of an HIV positive patient? Or is it the public health department's responsibility to notify the spouse and any other individuals at risk?

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[BlackSwan]

Notify the pool?

 

[syoung]

I'd say former. And latter.

 

[LizzyM]

This is spelled out in State law. Years ago when I looked into this, the rule in one state was that a physician could (but was not obligated to) notify a spouse if the patient refused to do so.

If HIV is a reportable disease (I would be surprised if it were not reportable in all 50 states) then it must be reported to the health department.

 

[smq123]

Is it the physician's responsibility to notify the public health department and the spouse of an HIV positive patient? Or is it the public health department's responsibility to notify the spouse and any other individuals at risk?

Frequently, the lab that runs the test notifies the health department.

 

[MedPR]

This is spelled out in State law. Years ago when I looked into this, the rule in one state was that a physician could (but was not obligated to) notify a spouse if the patient refused to do so.

If HIV is a reportable disease (I would be surprised if it were not reportable in all 50 states) then it must be reported to the health department.

I know that it must be reported to the health department, I just wasn't sure what the deal was with notifying partners/others at risk.

For example, there's nothing that the patient can do/say that prevents you from telling the health department. However, if the patient tells you not to tell his/her spouse, are you then bound by confidentiality and simply rely on the health department to notify the appropriate people? Or does the law supercede confidentiality?

But yea you answered that it varies by state.

Frequently, the lab that runs the test notifies the health department.

As a physician are you obligated to follow up and make sure the lab notified them? Meaning, can you be sued if you didn't notify the health department because you assumed the lab would?

 

[loveoforganic2]

At least in LA, your responsibility is to send the information to the department of health. That said, patients don't need to give their names to get an HIV test - they can choose to do so anonymously (thus, you'd have no way to notify a spouse; the results of the test still go to the department of health though)

 

[plumhill]

Is it the physician's responsibility to notify the public health department and the spouse of an HIV positive patient? Or is it the public health department's responsibility to notify the spouse and any other individuals at risk?

This situation came up in a bioethics website and the discussion specifically stated that the physician had a duty to the spouse to disclose the HIV positive status, since the spouse would be at a very high risk of becoming HIV positive.

http://depts.washington.edu/bioethx/topics/confidc1.html

 

[MedPR]

This situation came up in a bioethics website and the discussion specifically stated that the physician had a duty to the spouse to disclose the HIV positive status, since the spouse would be at a very high risk of becoming HIV positive.

http://depts.washington.edu/bioethx/topics/confidc1.html

Yea, but duty doesn't always mean legally obligated. The answer even says it is "generally advisable" to encourage the patient to inform his wife on his own. Why would you encourage your patient to do something that you yourself are legally obligated to make sure happens? If the law tells me I am responsible for something, I am not going to delegate that responsibility to someone else unless they are going to also assume all legal/ethical consequences if they do not perform that duty per the law.

 

[plumhill]

Yea, but duty doesn't always mean legally obligated. The answer even says it is "generally advisable" to encourage the patient to inform his wife on his own. Why would you encourage your patient to do something that you yourself are legally obligated to make sure happens? If the law tells me I am responsible for something, I am not going to delegate that responsibility to someone else unless they are going to also assume all legal/ethical consequences if they do not perform that duty per the law.

Well yes, it's always better for the patient to tell his/her spouse from an ethical standpoint. After all, it is their disease/news to share, they are married, and the patient should try and feel comfortable disclosing this piece of information. However, in situations where the patient DOESN'T want to tell his/her spouse, then the physician does have a responsibility to the spouse to disclose the risk of exposure to HIV, and the physician is legally obligated to alert health officials. Whether or not the physician is legally obligated to tell the spouse is going to be a state issue, but ethically speaking, "duty" plays a pretty strong role in what a physician should or should not do.

 

[wpierce118]

Is there something in healthcare privacy laws allowing disclosure to spouses? Because I'd imagine that if the patient didn't want to tell their spouse, they'd be angry and possibly litigious if you did.

 

[MedPR]

Well yes, it's always better for the patient to tell his/her spouse from an ethical standpoint. After all, it is their disease/news to share, they are married, and the patient should try and feel comfortable disclosing this piece of information. However, in situations where the patient DOESN'T want to tell his/her spouse, then the physician does have a responsibility to the spouse to disclose the risk of exposure to HIV, and the physician is legally obligated to alert health officials. Whether or not the physician is legally obligated to tell the spouse is going to be a state issue, but ethically speaking, "duty" plays a pretty strong role in what a physician should or should not do.

That's what I was unsure of and originally asking about.

 

[plumhill]

Is there something in healthcare privacy laws allowing disclosure to spouses? Because I'd imagine that if the patient didn't want to tell their spouse, they'd be angry and possibly litigious if you did.

In many situations, yes; but in this case, the risk of a person being at such a high risk of contracting HIV would outweigh confidentiality.

 

[wpierce118]

In many situations, yes; but in this case, the risk of a person being at such a high risk of contracting HIV would outweigh confidentiality.

I guess what I'm asking is whether it would outweigh confidentiality in both legal and ethical contexts, or just in an ethical context?

 

[plumhill]

Definitely ethical context, and from my knowledge, many legal contexts. But I'm not familiar with these sorts of laws outside of my home state, so it would depend.

 

[giants25]

From a medical ethics course I'm taking, your required to report it to the health department and should tell the patient to tell their spouse/significant other. If they refuse, you do have a right to notify them yourself, as it is a public health hazard that affects them personally. But I think it's different state by state.

http://aids.gov/hiv-aids-basics/just-diagnosed-with-hiv-aids/your-legal-rights/legal-disclosure/

 

[sector9]

Here's what the Texas Medical Association says about it on their ethics page

The applicable law of the State of Texas requires the physician to report to the Texas Department of Health cases of Human Immunodeficiency Virus (HIV) infection as well as cases of Acquired Immune Deficiency Syndrome (AIDS). Although the law does not require a physician to notify a spouse of a positive test result for AIDS or HIV infection, a physician under Texas law may inform a spouse of a positive test. In addition, the physician should counsel and attempt to persuade the infected patient not to endanger other parties.

http://www.texmed.org/template.aspx?id=392

Here's what the New York Department of Health has to say

How are CD4s and viral loads supposed to be reported? The regulations specifically require laboratories to report positive viral load tests or CD4<500 results (in addition to confirmed HIV positive antibody test results). These two types of test results define "HIV-related illness" for the purpose of reporting. To alleviate the burden of reporting such tests by providers, the Department will rely on reporting from laboratories for HIV-related illness.

To what extent will patients be interrogated regarding partners and especially spouses? Patients will be asked to name partners voluntarily. This will not be done in a coercive manner.

Is spousal notification mandatory? The only mandatory component is for physicians to report known contacts; a spouse is defined as a contact. Domestic violence screening is required. The patient and physician should consider options for how notification of the spouse proceeds once it is determined there is no risk of domestic violence.

http://www.health.ny.gov/diseases/aids/regulations/reporting_and_notification/question_answer.htm

 

[Pattycake25]

In many situations, yes; but in this case, the risk of a person being at such a high risk of contracting HIV would outweigh confidentiality.

Seems logical to me, but unfortunately, logic and the law do not often mix. It's definitely a good idea to be well-versed in the law for your area for these special cases though.

 

[Cambino]

Uh let's maybe face the facts a little bit and exchange 'spouse' with 'partner' if we're to speak about the general population. It should be the main concern anyway... you would think HIV is transmitted much more frequently through non-married couples. Is there still a moral imperative to notify the partner?

 

[MedPR]

From a medical ethics course I'm taking, your required to report it to the health department and should tell the patient to tell their spouse/significant other. If they refuse, you do have a right to notify them yourself, as it is a public health hazard that affects them personally. But I think it's different state by state.

http://aids.gov/hiv-aids-basics/just-diagnosed-with-hiv-aids/your-legal-rights/legal-disclosure/

Thanks for the input, but that doesn't help at all.

The question is/are "Are physicians legally obligated to notify an HIV-positive patient's spouse? If so, does that legal obligation supercede patient confidentiality?"

There's no question about physicians being obligated to notify the health department. There's no question that ethically a physician should inform the spouse. And a physician having the right to notify them doesn't make the physician legally obligated.

 

[Cambino]

From a medical ethics course I'm taking, your required to report it to the health department and should tell the patient to tell their spouse/significant other. If they refuse, you do have a right to notify them yourself, as it is a public health hazard that affects them personally. But I think it's different state by state.

http://aids.gov/hiv-aids-basics/just-diagnosed-with-hiv-aids/your-legal-rights/legal-disclosure/

Any good philosopher should know that you don't attain objective knowledge from a philosophy course/philosophical inquiry; rather, you critically assess and exchange ideas, etc. So the fact that you think you are required to report it to the health department and tell pt and S.O. of HIV statuses based on ideas shared in your philosophy class (and I've taken it) makes your argument inherently mistaken. Subjective discussion produces opinion, but this is still an irrelevant post to the topic yet I continue to add volume to the irrelevant post...
This is coming from a philosophy major.

 

[pietachok]

Thanks for the input, but that doesn't help at all.

The question is/are "Are physicians legally obligated to notify an HIV-positive patient's spouse? If so, does that legal obligation supercede patient confidentiality?.

In the state of CA they are not obligated to tell the spouse because you cannot tell the spouse against the wishes of the infected patient due to confidentiality laws. this will vary somewhat state to state.
The department of public health theoretically will end up doing the notification. As the physician, aside from encouraging the patient to tell the spouse you are allowed, if the spouse is your patient, to encourage standard of care for that patient...i.e. Move her check up earlier in the schedule & take a thorough sex hx, & find something in the hx that merits an sts test i.e."because we recommend this for all monogamous women if they don't use protection"

 

[LizzyM]

Uh let's maybe face the facts a little bit and exchange 'spouse' with 'partner' if we're to speak about the general population. It should be the main concern anyway... you would think HIV is transmitted much more frequently through non-married couples. Is there still a moral imperative to notify the partner?

You would have less protection under the law to disclose to a "partner" who is not a spouse. The law presumes that married couples have sex with each other and that is the justification of breeching the confidentiality of the patient's medical record. If the couple were in a registered domestic partnership in a state that doesn't allow marriage for same sex couples, then you might invoke the same law but being a "partner" doesn't have any standing under the law.

 

[alisvolatpropri]

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[NickNaylor]

As a certified HIV counselor, you must respect patient confidentiality in this case. Physicians are under HIPAA regulation and must respect patient confidentiality. If a patient is tested positive, the results do go to the US government for record keeping, but those records are under the highest security. You are under no obligation to inform anyone outside of the patient's direct clinical care of any ailment. You can highly suggest that the patient tell their spouse or any sexual partners they have, but it is out of your hands from that point on. Once the patient is placed on ARVs and has low viral titers, the risk is greatly minimized, but it is up to the physician to further educate about preventative sexual measures.

I think you don't know what you're talking about. Rarely is a physician OBLIGATED to contact spouses and known sexual contacts, but in almost all cases it would not breach ethical guidelines. If the physician is the only one who knows about a positive HIV test and the spouse/sexual partner refuses to tell those who he/she had sex with about it, you mean to tell me that I "must respect patient confidentiality," even if so doing likely means causing great bodily harm to those affected?

No thanks.

 

[SilverCat]

So what would you do if the patient refuses to tell their partner about their HIV status, and refuses to tell you the name of their partner?

You can't really do much at that point, right, except encourage them to tell their partner about their status?

One last question- what are the guidelines about physicians who are hepatitis B, hepatitis C, or HIV positive? Are there restrictions on their practice?

 

[theseeker4]

I think you don't know what you're talking about. Rarely is a physician OBLIGATED to contact spouses and known sexual contacts, but in almost all cases it would not breach ethical guidelines. If the physician is the only one who knows about a positive HIV test and the spouse/sexual partner refuses to tell those who he/she had sex with about it, you mean to tell me that I "must respect patient confidentiality," even if so doing likely means causing great bodily harm to those affected?

No thanks.

+1. Definitely ethically and morally proper to report the risk to anyone put at risk by the patient. Defer to law of course, which depends on where you are practicing, but saying a patient's confidentiality trumps the safety of someone they are putting at risk, knowingly and willingly, is a BS argument.

 

[theseeker4]

So what would you do if the patient refuses to tell their partner about their HIV status, and refuses to tell you the name of their partner?

You can't really do much at that point, right, except encourage them to tell their partner about their status?

One last question- what are the guidelines about physicians who are hepatitis B, hepatitis C, or HIV positive? Are there restrictions on their practice?

For the first part, obviously you can't do anything outside the law to track down their family, and if you simply don't know, you probably can't do anything else after reporting it to the health department. For the second, universal precautions protect both the patient and the health care professional, and I have never heard of any legal restrictions on their ability to practice. This may vary by locality, but I believe there are no restrictions nor duty to report to anyone.

 

[NickNaylor]

So what would you do if the patient refuses to tell their partner about their HIV status, and refuses to tell you the name of their partner?

You can't really do much at that point, right, except encourage them to tell their partner about their status?

One last question- what are the guidelines about physicians who are hepatitis B, hepatitis C, or HIV positive? Are there restrictions on their practice?

As theseeker4 said, obviously you can't do anything if you don't have the information. However, I would certainly do my best to acquire it and notify those involved if at all possible. But yes, you really can't do much besides encourage them to tell their partners.

In the past, those physicians were actually excluded from "high risk" procedures. Are you a surgeon and contracted a chronic, infectious disease? Too bad - find another line of work. Now, though, I don't think those physicians have any limitations on their practice. Obviously you would want to be especially careful and perhaps take more stringent precautions (e.g., PPE in cases when other physicians may not use it), but beyond that I don't think it'll hamper you at all. TheProwler (a surgical resident) might be able to shine some insight on the subject, though.

 

[alisvolatpropri]

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[NickNaylor]

I never said that a physician has to inform anyone outside of the wishes of the patient. Actually, as a future physician, you should know the importance of patient-doctor confidentiality as stated by HIPAA and that you probably take a refresher every year for. Breeching that trust injures the medical field. It does seem morally wrong to not disclose to the spouse, but it is up to the physician to properly educate, guide, and provide resources (tons of help groups available) to help the patient prepare to tell their significant other, it is NOT their responsibility to do it themselves, and can be legally punished (at least in the state of MA). I'm unsure of legal recourse in other states, but HIV has not been clearly defined as imminent danger in medicine and so physicians cannot be held liable unless they have been told and documented that: the parties engage in unsafe behavior on a regular basis; such behavior is actually unsafe/unprotected; the patient intends to continue such behavior even after being counseled to desist by the therapist; HIV transmission will likely occur in the future. Exposure to HIV in any other context would not be an imminent danger invoking the practitioner s duty to warn. As a clinician, it is a moral duty to followup with the patient to check if they have confided to their partner yet and continue to consel them until it happens. So before you accuse people of lacking information, why don't you ask ID attendings what they do in the clinics...

I thought the understanding was that you would obviously only inform people that the patient has had unprotected sex with? 😕😕 Of course you're not going to tell random people that your patient has HIV, even if those people MAY have had unprotected sex with him/her. That's idiotic and obviously violates the patient's privacy. As others have mentioned, though, especially in the case of a spouse it is largely presumed that they are a sexual partner. Unless you know for a fact otherwise, it would not be inappropriate to notify the spouse. Again, you may not be OBLIGATED to do so, but just because you aren't obligated in this case doesn't mean you suddenly are in the ethical wrong because you decide to notify them.

In this case, if I know my patient has unprotected sex with someone and I know the identity of that someone (i.e., the patient has given the identity of the person), I see it as my moral duty to notify them, ESPECIALLY if the exposure is recent. ART can be incredibly effective if started extremely early. Not doing so and simply hoping that the patient tells them is unacceptable in my view. I would notify them even if it puts me in professional hot water (notice how I leave out "ethical" there?) - again, though, only if the patient has given me the identity of the person and acknowledges that they had unprotected sex with him/her.

 

[pietachok]

Those seeking answers on this thread needs to look up the law in the state where they are located or intend to train/practice. People rightfully have strong opinions on this, but some of what has been presented as "obvious" or "moral obligation" is merely an opinion & in conflict with the laws of some states, which of course vary greatly (e.g. MA can criminialize not telling a spouse, IL allows contact of a married partner by the physician, CA allows none of the above).

 

[LizzyM]

I never said that a physician has to inform anyone outside of the wishes of the patient. Actually, as a future physician, you should know the importance of patient-doctor confidentiality as stated by HIPAA and that you probably take a refresher every year for. Breeching that trust injures the medical field. It does seem morally wrong to not disclose to the spouse, but it is up to the physician to properly educate, guide, and provide resources (tons of help groups available) to help the patient prepare to tell their significant other, it is NOT their responsibility to do it themselves, and can be legally punished (at least in the state of MA).

It varies by state. In some states it is permissible, and not a violation, to inform a spouse if the patient refuses to do so. The state determines that the spouse's right to know over-rides the patient's right to keep that information private.

Note that I said permissible. This means that one is allowed to do so but it does not mean that the physician MUST do so or that the physician has a legal obligation to do so.

Long story short: know your state laws if you are practicing medicine in that state. If you are an HIV counselor, do as you are told by your supervisors but don't assume that what you are told to do in one place is the law throughout the entire US.

 

[wholeheartedly]

I think I remember in one state the physician notifies the health department of sexual contacts and the health dept. sends out some kind of notice that doesn't name the patient that states that the contact was named as someone possibly exposed to HIV and explains how to go about getting tested.

That way patient privacy is not technically violated, although if it is a spouse or the only one you're sleeping with you're probably going to figure it out.

 

[MeGoodManIThink]

Physican can break confidentiality if immediate danger to specific persons or if it is a danger to the public


the answer is yes, he can tell the spouse and yes he should report it to health department

 

[alisvolatpropri]

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[Praefectus]

Notify the pool?

👍 I don't know how people missed this gem.

 

[SpecterGT260]

Is it the physician's responsibility to notify the public health department and the spouse of an HIV positive patient? Or is it the public health department's responsibility to notify the spouse and any other individuals at risk?

This is a matter that is out of the physicians hands. You are obligated to report and to contact past sexual partners for testing. It is a public health thing and supersedes confidentiality.

I saw some people mentioning things like "only in matters of abuse" and the like. Not true. You will take some ethics components in medical school and they will let you know about these things before you hit clinics. As a general rule confidentiality is premier, but this is one of the FEW health laws that is both intuitive and useful and positively impacts public health. You don't report minor STDs or pregnancy in minors because it deters minors from seeking health = bad for public health. You report HIV because spreading it is worse than hurting the feelings of the patient in this case. This is one of those "Don't give a damn if you agree or not, this is the policy" type of things so any further discussion really only can reflect opinions on what is "right" and not what is actually called for

 

[SpecterGT260]

It varies by state. In some states it is permissible, and not a violation, to inform a spouse if the patient refuses to do so. The state determines that the spouse's right to know over-rides the patient's right to keep that information private.

Note that I said permissible. This means that one is allowed to do so but it does not mean that the physician MUST do so or that the physician has a legal obligation to do so.

Long story short: know your state laws if you are practicing medicine in that state. If you are an HIV counselor, do as you are told by your supervisors but don't assume that what you are told to do in one place is the law throughout the entire US.

I must be in a more strict state than many... or it is possible that I am confusing hospital policy with law.

I just am aware of talk where people are looking at it from vague patient's rights standpoint and in many hospitals the tough calls are already made for you 👍 So these ethical dilemmas are more like fun thought exercises than real clinical problems.