Four ethical issues to consider before offering HIV tests to your patients
Dr Pallavi Bradshaw advises
Few could criticise the intention behind NICE and Public Health England’s proposal to offer HIV testing to 3.7m people living in high prevalence areas. The plan to put this into practice – through HIV testing offered by a GP during a routine appointment – does however raise some ethical and medicolegal issues which doctors will want to consider in advance.
1. Broaching the issue of a test will need to be done swiftly, but sensitively
Any GP will be acutely aware of the constraints of a 10 minute consultation, in which time the patient will naturally want to discuss the problem they have come to seek advice on. Broaching and explaining the sensitive topic of an HIV test on top could be challenging and will require some thought. While GPs have expertise in discussing intimate and personal issues, raising the possibility of HIV could be met with distress or even offence. Cultural sensitivities and beliefs would also need to be considered.
2. You must obtain informed consent, which can take time
Informed consent must be obtained during this time, and while lengthy pre-test counselling is no longer a requirement, a discussion would at the very least need to make the benefits of testing clear to the individual, provide details of how the results will be given and answer a range of questions.
For some patients, such as those who are vulnerable, have impaired capacity or language problems when English is not their first language, this discussion may take longer and additional support may be required. Particular consideration will also need to be given to young adults who may have the capacity to consent to a test but may not fully comprehend the implications. Furthermore, the implications of HIV reach far beyond health. Employment, for example, can be impacted and doctors should be aware that this makes obtaining valid consent for a HIV test more complicated.
GPs will need to ensure they impart sufficient information and can also provide the necessary support and counselling for the patient should the HIV test result return positive.
3. You need to balance your duty of confidentiality to patients with possible risks to others
A positive result will of course have major implications for the patient’s family, current and past sexual partners. GPs are bound by a duty of confidentiality to their patients; this trust sits at the very heart of the doctor-patient relationship. But it is not absolute – a GP can justify breaching confidentiality if failure to disclose information may expose others to risk of death or serious harm. These judgements can be complex and require specialist input – and they become even more complex when other members of the patient’s family are patients at the GP practice too. The GMC’s guidance on confidentiality provides further information and case studies on disclosure of HIV status.
GPs may also face conflict about whether to disclose HIV status when referring patients to secondary care for unrelated medical problems, or when the patient may be undergoing surgery. The situation becomes legally more challenging if a patient under 18 has a positive test result and does not wish their parents to be notified. These are dilemmas GPs can face already, but they could become more prevalent with a possible increase in positive results, due to the higher numbers of patients being tested.
4. Patients may request their status is hidden from other practice staff
Finally, experience shows that some HIV positive patients do not want the GP practice knowing of their status because they live within the same community as the staff. In some instances they may ask the GP to keep HIV related notes in a secure area of the computerised record which can only be accessed by the GP. This can be done, but doctors should ensure this does not lead to incomplete information being passed to future practices or in referrals. Further advice can be found within the GMC’s guidance on confidentiality and consent, and your MDO is also there to offer medicolegal advice whenever it is needed.
Dr Pallavi Bradshaw is a senior medicolegal adviser at Medical Protection Society