Ethical Dilemmas in HIVWendy MajewskaSenior Health AdviserSt Georges HospitalLondon
EthicsHippocrates considered to be father of western medicine and contributed to establishing medicine as a professionHippocratic Oath seminal document on the ethics of medical practicerarely used in its original form today although serves as foundation for other similar oaths and laws that define good medical practice
Four guiding principlesPillars of ethicsNon-maleficence BeneficenceJustice Autonomy
Fertility treatmentOrgan donationEnd of life careHIVTerminalSexually transmitted
Case 116 year old HIV positive female Sexually active Aware safer sex stated uses condomsBrought male partner to clinic reporting condom brokeRequested PEPSIMale partner unaware of HIV status Patient did not want partner to know her HIV status
Can PEPSE be given without disclosing HIV status?
Should confidentiality be broken and HIV status disclosed?
Influencing factorsRisk of transmission 1:1000 -1:3000VLLength of exposurePotential harm
Case 232yr old gay man diagnosed HIV+PNRMP 4 years Tested HIV+ RMP PN Married 26 years - midwifeReluctant to inform reported no recent SI
Influencing factorsSexual historyVL / CD4 count On-going riskOccupationCo-habiting Time frameCollaborative working
Case 317 year old female Tested HIV positive through TOP serviceCame to UK aged 15Foster carePt felt likely to be infected vertically Did not want mother to know HIV status
Can we inform mother?
Can we withhold daughters HIV status?
Case 4HIV+ newly diagnosed womanUnusual drug resistance assaySeen by consultant working at 2 sitesRecognised resistance patternClarified risk factorsFemale pt at other clinic same resistance pattern similar profile of sexual contact identified
Additional female patient identified address noted as being the same as 1st pt
PN contact identified - attended neighbouring hospital (KH) with TB HA contacted KH clinic Man identified - HIV+ lost to follow upPN at KH identified 16 year old female HIV+
Index male patient diagnosed prior to sexual contact with 4 female HIV patients History from all 4 female pts indicated no condom used None of the 4 females knew of each other
HIV+ man knowingly exposed 4 women to HIV infection
Can action be taken?What action might be appropriate?
Case 5Pregnant womanDeclined HIV testing in pregnancyReferred to HIV MidwifeReferred to Health AdviserIssues re unborn baby
Is safeguarding of unborn child an issue?
Would the same apply across UK?
On-going ethical issues Pregnant refusing ARTContact of HIV+ refusing testing but in other steady relationshipPaediatric HIV - YPMTCTConfidentiality
Key pointsDecision should not be taken aloneWork as MDTRemember Non-maleficence BeneficenceJustice Autonomy
Health Advisers are key in exploring ethical issues resolution of dilemmas
If not us, WHO?
HIV and the lawOffences Against the Person Act 1861Sections of the OAPA 1861 grievous bodily harmTwo possible offences reckless transmission (section 20)intentional transmission (section18)To date not yet been a successful prosecution for intentional transmission
14 prosecutions to date in E&W9 pleaded guilty5 pleaded not guilty2 convictedlongest sentence 10 years 3 complainants other sentences range 2 - 4 and half years2 convictions were in women
Intentional Or Reckless Sexual Transmission Of Infection
.this area of the criminal law is exceptionally complex
.will be difficult to prove to the requisite high standard
There are other sensitivities: the relationship between the criminal law and consensual sexual behaviour is delicate. The use of the criminal law in the most intimate of physical exchanges is always going to attract publicity and will invite strongly held and differing views
Intentional Or Reckless Sexual Transmission Of Infection GuidanceCrown Prosecution Service