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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

Please also click here for a response from BHIVA: Every missed HIV diagnosis is a failure of care

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Readers' comments (6)

  • I understand the need for considering the above ethical issues, but doesn't over-egging the importance of the ethics behind the test deter clinicians from offering it? This all just seems a bit outdated. Certainly in secondary care, we're essentially told that an HIV test should be normalised, and not become the lofty, weighty decision that makes people question whether it should be offered. After all, in what is essentially now a long term chronic disease, shouldn't we be treating the test with the same regard as, say, a fasting glucose for detection of diabetes? Diabetes will affect a) employment (eg. if HGV driver) b) insurance premiums, and can carry social stigma - but we don't have articles about the ethical considerations of offering testing.

    I would think an overly sensitive approach simply exacerbates the stigma - if GPs have to talk about HIV status in hushed tones, and consider keeping it out of secondary care referrals, it just makes the whole thing more secretive and enhances the perceived shame. There are very few referrals where HIV status doesn't impact - be it through associated conditions or just a broader understanding of the patient as a whole - omission can hinder secondary care considerably, by missing associations and could also cause communication issues if they are seen to be ignorant of the patient's broader health.

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  • @11:49 well said.

    When I was in training 15 years ago, I was told that even having a a negative test recorded in the GP records could have an impact on a patient's ability to get life insurance. Therefore pre-test counselling was particularly important.

    But now, the ethical issues are no different to those arising for any other screening we do.

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  • what a load of rubbish. Agree with above comments. Why are we singling HIV out over anything else? Why such a stigma? Lots of things have stigma and we still test for them.
    I do sti testing for lots of people and I simply tell them what we are testing for and give them the requisition to go to the lab.

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  • I had to check the date on this article as its sentiments belong in the early noughties surely? We've moved on from all of this as others have said, we are actively encouraged in secondary care to normalise HIV testing and to try and think of testing for it in as many situations as possible. There are no special ethical considerations over and above those that are applied to all investigations. How on earth did this article get printed??

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  • **sorry, in Primary Care, not secondary care!

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  • Please see the response from British HIV Association supporting GPs to test for HIV:

    London, UK - 21 December 2016 Professor Chloe Orkin, Chair of the British HIV Association said: "Every HIV diagnosis that is overlooked or missed by any doctor is a failure of clinical care. People whose HIV is diagnosed late have frequently been seen by a doctor prior to their diagnosis without an HIV test being offered. Nobody dies from being offended, but by overstating the 'ethical issue' of offending patients when offering HIV testing, this article risks HIV infections being missed or diagnosed too late. This oversight means that people fail to receive the treatment and care they need which in turn leading to unnecessary illness and in some cases death. HIV testing is important in preventing onward transmission as people who are diagnosed and treated are no longer infectious to other people. NHS Trusts are reporting missed HIV diagnoses as serious untoward incidents and performing root cause analysis on each one. Surely missing a diagnosis of HIV is a greater medico-legal risk to the medical profession than offending someone by offering a test. This article risks re-inforcing the HIV associated stigma that we have spent 30 years fighting.

    "The recent recommendations (1 Dec) by NICE and Public Health England to expand GPs remit in offering HIV testing are based on robust evidence that shows an urgent need to increase the awareness and uptake of HIV testing in England. The advice will also help make HIV testing a routine investigation and – we hope – help reduce the stigma that allows HIV to flourish.

    "HIV currently infects 17 more people each day in England, many of whom will remain unaware of their infection precisely due to the stigma which still clings to this undiscriminating and life-threatening condition. We don't have a vaccine or a magic bullet, but we could potentially stop nearly all transmission of HIV, nearly all new infections, purely by diagnosing people earlier and putting them on treatment (and by using PrEP), but we are signally failing to do this. More extensive testing, without wasting too much time on risk assessments (which are too often wrong) is the key part of this. This testing cannot be done just in GUM clinics, where there is very little extra capacity, so MUST be done in other settings – particularly in primary care. Without this increased testing, we will never change the epidemiology of HIV in the UK, and every year there will be another 6000 new diagnoses.

    "We believe that GPs are perfectly capable of negotiating complexity in all areas of their practice as well as understanding the critical importance of HIV testing. Let’s not exacerbate this by adding our own preconceptions about who needs testing. It’s time to implement the evidence-based NICE guidance that all doctors are expected to follow to deliver best outcomes within safe, competent practice."

    http://www.bhiva.org/BHIVA-response-to-Pulse-article-12-Dec-2016.aspx

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