Ethical Dilemmas in HIV

Wendy Majewska

Senior Health Adviser

St George’s Hospital

London

Ethics

Hippocrates considered to be father of western medicine and contributed to establishing medicine as a profession

Hippocratic Oath seminal document on the ethics of medical practice rarely used in its original form today although serves

as foundation for other similar oaths and laws that define good medical practice

Four guiding principles

Pillars of ethicsNon-maleficence BeneficenceJustice Autonomy

Fertility treatment Organ donation End of life care HIV……

TerminalSexually transmitted

Ethical dilemmas?

Case 1

16 year old HIV positive female Sexually active Aware safer sex stated ‘uses condoms’ Brought male partner to clinic reporting ‘condom

broke’ Requested PEPSI Male 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 2

32yr old gay man diagnosed HIV+ PN

RMP 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 3

17 year old female Tested HIV positive through TOP service Came to UK aged 15 Foster care Pt felt likely to be infected vertically Did not want mother to know HIV status

Can we inform mother?

Can we withhold daughter’s HIV status?

Case 4

HIV+ newly diagnosed woman Unusual drug resistance assay Seen by consultant working at 2 sites

Recognised resistance pattern Clarified risk factors

Female 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 5

Pregnant woman Declined HIV testing in pregnancy Referred to HIV Midwife Referred to Health Adviser Issues re unborn baby

Is safeguarding of unborn child an issue?

Would the same apply across UK?

On-going ethical issues

Pregnant – refusing ART Contact of HIV+ refusing testing but in

other steady relationship Paediatric HIV - YP MTCT Confidentiality

Key points

Decision should not be taken alone Work as MDT Remember

Non-maleficence BeneficenceJustice Autonomy

Health Advisers are key in exploring ethical issues resolution of dilemmas

If not us, WHO?

HIV and the law

Offences Against the Person Act 1861 Sections of the OAPA 1861 ‘grievous bodily

harm’ Two 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&W 9 pleaded ‘guilty’ 5 pleaded ‘not guilty’

2 convicted longest sentence 10 years – 3 complainants other sentences range 2 - 4 and half years

2 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