What is a physician's duty when a patient with Human Immunodeficiency Virus (HIV) refuses to disclose their status to their spouse despite counseling?

Physician's Duty When HIV-Positive Patient Refuses Spousal Disclosure

If an HIV-positive patient refuses to notify their spouse despite counseling and continues to place them at risk, you have an ethical and legal responsibility to inform the spouse that they are at risk of HIV infection. 1

Stepwise Approach to This Ethical Dilemma

Step 1: Intensive Counseling and Patient Education

• Provide empathic, client-centered counseling to help the patient understand the serious health consequences to their spouse 1
• Conduct a personalized risk assessment and help develop a realistic HIV-prevention plan 1
• Emphasize that the spouse needs immediate evaluation for potential HIV exposure and may benefit from post-exposure prophylaxis if exposure was recent 1
• Explain that the spouse is at risk of mortality from untreated HIV infection if they remain unaware of their exposure

Step 2: Offer Health Department Assistance

• Inform the patient that confidential partner notification services are available through local or state health departments 1
• Explain that health department professionals can notify partners without revealing the patient's identity, which many patients prefer due to the confidentiality advantage 1
• This provider referral approach allows trained professionals to handle the notification while protecting patient privacy 1

Step 3: Document Your Efforts

• Document all counseling attempts and the patient's continued refusal to disclose 1
• Record that the spouse remains at ongoing risk of HIV transmission 1

Step 4: Invoke Duty to Warn as Last Resort

The decision to breach confidentiality should be a last resort, applicable only when all efforts to persuade the patient to disclose have failed. 1

• This duty-to-warn is most applicable to primary care physicians who have knowledge about a patient's social and familial relationships 1
• Disclose only the information necessary to prevent harm (HIV exposure risk) and only to the person who needs to know (the spouse) 2
• When possible, discuss the breach with the patient beforehand, though this is not required if it would compromise the warning 2

Critical Considerations

Balancing Confidentiality with Public Health

• While confidentiality should be protected to the greatest extent possible, it must be balanced with the duty to protect others and public health 1
• In cases where a person's life or safety is at stake, the duty to protect life outweighs the duty to maintain confidentiality 3
• HIV/AIDS remains a stigmatized disease with severe consequences from disclosure, making this decision particularly weighty 1

Legal Framework

• Familiarize yourself with your state's specific legislation governing HIV disclosure, as requirements vary by jurisdiction 1, 2
• Confidential reporting of newly diagnosed HIV infections to health departments should occur as dictated by local law 1
• Many jurisdictions protect physicians who breach confidentiality when necessary to prevent serious harm 2, 4

Common Pitfalls to Avoid

• Don't breach confidentiality prematurely: Exhaust all counseling and health department referral options first 1
• Don't disclose more than necessary: Only reveal that the spouse is at risk of HIV infection; avoid unnecessary details about the patient's behavior or other medical information 2
• Don't assume the patient will eventually disclose: If the patient continues risky sexual behavior with the spouse while refusing disclosure, intervention is necessary to prevent transmission 1
• Don't forget about post-exposure prophylaxis timing: The spouse may benefit from nPEP if notified within 72 hours of exposure 1