Acquired immunodeficiency syndrome (UPDATE 2000)
The Canadian Medical Association has developed the following general principles to serve as guidelines for various bodies, health care professionals and the general public. Specific aspects of infection with human immunodeficiency virus (HIV) and acquired immunodeficency syndrome (AIDS) that relate to physicians' ethical responsibilities as well as society's moral obligations are discussed. Such matters include: the need for education, research and treatment resources; the patient's right to investigation and treatment and to refuse either; the need to obtain the patient's informed consent; the right to privacy and confidentiality; the importance of infection control; and the right to financial compensation in the case of occupational exposure to HIV.
Physicians should keep their knowledge of AIDS and HIV infection up to date.
Physicians should educate patients and the general public in the prevention of AIDS by informing them of means available to protect against the risk of HIV infection and to avoid further transmission of the virus.
Health authorities should maintain an active public education program on AIDS that includes the school population and such initiatives as public service announcements by the media.
All levels of government should provide resources for adequate information and education of health care professionals and the public on HIV-related diseases; research into the prevention and treatment of HIV infection and AIDS; and the availability and accessibility of proper diagnosis and care for all patients with HIV infection.
HIV antibody testing
Physicians have an ethical responsibility to recommend appropriate testing for HIV antibody and to care for their patients with AIDS or refer them to where treatment is available.
Physicians should provide counselling to patients before and after HIV antibody testing.
Because of the potential psychologic, social and economic consequences attached to a positive HIV test result, informed consent must, with rare exceptions, be obtained from a patient before testing. However, the CMA endorses informed mandatory testing for HIV infection in cases involving the donation of blood, body fluids or organs.
The CMA recognizes that people who have doubts about their serologic status may avoid being tested for fear of indiscretion and therefore supports voluntary non-nominal testing of potential HIV carriers on request.
The CMA supports the Canadian Blood Service and Hema-Québec in their programs of testing and screening blood donations and blood products.
Confidentiality in reporting and contact tracing
The CMA supports the position that cases of HIV infection should be reported non-nominally with enough information to be epidemiologically useful. In addition, each confirmed case of AIDS should be reported non-nominally to a designated authority for epidemiologic purposes.
The CMA encourages attending physicians to assist public health authorities to trace and counsel confidentially all contacts of patients with HIV infection. Contact tracing should be carried out with the cooperation and participation of the patient to provide maximum flexibility and effectiveness in alerting and counselling as many potentially infected people as possible.
In some jurisdictions physicians may be compelled to provide detailed information to public health authorities. In such circumstances, the CMA urges those involved to maintain confidentiality to the greatest extent possible and to take all reasonable steps to inform the patient that their information is being disclosed.
The CMA Code of Ethics (article 22) advises physicians that disclosure of a patient’s HIV status to a spouse or current sexual partner may not be unethical and, indeed, may be indicated when physicians are confronted with an HIV-infected patient who is unwilling to inform the person at risk. Such disclosure may be justified when all of the following conditions are met: the partner is at risk of infection with HIV and has no other reasonable means of knowing of the risk; the patient has refused to inform his or her sexual partner; the patient has refused an offer of assistance by the physician to do so on the patient's behalf; and the physician has informed the patient of his or her intention to disclose the information to the partner.
The CMA stresses the need to respect the confidentiality of patients with HIV infection and consequently recommends that legal and regulatory safeguards to protect such confidentiality be established and maintained.
Health care institutions and professionals should ensure that adequate infection-control measures in the handling of blood and body fluids are in place and that the rights of professionals directly involved in patient care to be informed of and protected from the risks of HIV infection are safeguarded.
The CMA does not recommend routine testing of hospitalized patients.
The CMA urges appropriate funding agencies to assess the explicit and implicit costs of infection control measures and to ensure that additional funds are provided to cover these extraordinary costs.
Occupational exposure and the health care professional
Health care workers should receive adequate financial compensation in the case of HIV infection acquired as a result of accidental occupational exposure.
Physicians and other health care providers with HIV infection have the same rights as others to be protected from wrongful discrimination in the workplace and to be eligible for financial compensation for work-related infection.
Physicians with HIV infection should consult appropriate colleagues to determine the nature and extent of the risk related to their continued involvement in the care of patients.