An ongoing dialogue on HIV/AIDS, infectious diseases,
June 24th, 2008
HIV Occupational Post-exposure Prophylaxis: Do the Right Thing
From one of our local HIV providers:
There were two occasions recently when our local infectious disease doctor was consulted by the emergency room to decide what type of post exposure prophylaxis regimen to recommend for individuals who had sustained an occupational exposure (needlesticks) to two of our HIV positive patients. It had been known to the emergency room physicians that the patients had been HIV-infected and that they were receiving their care here. The ID physician contacted our clinic for information about the patients to come up with the most appropriate preventive regimen.
Some here have felt that we could not give information out to the physician to preserve patient confidentiality.
But others (including myself) felt strongly that given the CDC recommendations that information should be obtained regarding the source patient’s antiretroviral therapy, the resistance pattern, and the viral load in order to recommend the best regimen for PEP to avoid HIV transmission, it was completely appropriate for the ID physician to try to get more information.
I would be curious to know your thoughts on this issue ….
One of the (many) things that has always bugged me about “HIV exceptionalism” — where HIV is treated differently from other infectious diseases — is the way it burdens healthcare providers who sustain occupational exposures to blood-borne pathogens.
From a medical perspective, the answer to the above case is simple: reveal the source patients’ HIV viral load, resistance profile, and current treatment to the ID doctor trying to manage the exposed healthcare worker — and go ahead and disclose hepatitis B and C status while you’re at it. This is the best thing for the unfortunate nurse (or doctor or medical student or phlebotomist or maintenance worker) who is likely now trembling with anxiety over the exposure. Bad enough that they have had the injury; even worse that they would need to be managed in an information vacuum.
From an ethical perspective, it seems fairly straightforward too. We should do whatever we can, within reason, to protect the healthcare worker and prevent HIV transmission. That’s the benefit of revealing source patient information to the clinician trying to craft the best preventive strategy. This outweighs the risk to that patient (the source) for the disclosure, which should be minimal — after all, the information is being released to a clinician, who presumably understands the importance of patient confidentiality.
And that’s what I emailed back to the doctor who’d contacted me.
Ah, but what about the legal issue? She also emailed a respected local lawyer, who wrote:
As the lawyer I have to point out that any time a person’s private medical information is disclosed without authorization from the person (the source patient) and for the benefit of another person one is potentially running the risk of violating several federal and/or state privacy and confidentiality laws.
Uh-oh. Could someone possibly argue not to give out the information? What if the person exposed contracted HIV due to the wrong preventive therapy being prescribed?
Fear not, there’s more:
With all that said, these are clearly difficult medical/ethical/legal issues. At times, where the risk of harm caused by the disclosure/breach of privacy or confidentiality of the source patient is extremely low and the potential benefit to another patient is great, potential liability may be trumped by medical/ethical decision making. And, hopefully even the most strident protector of patient privacy/confidentiality would agree that it was the right thing to do.
Great, so we’re in agreement after all.
Do the right thing.
4 Responses to “HIV Occupational Post-exposure Prophylaxis: Do the Right Thing”
Paul E. Sax, MD
Contributing Editor
NEJM Journal Watch
Infectious Diseases
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Thank you for writing about this topic. It seems that not much time goes by without someone bringing up the issue of confidentiality as a barrier to sending and receiving medical information between medical offices.
Obviously frivolous sharing of medical information is wrong and against the law. Confidentiality rules however are not there to stop the appropriate sharing of information between medical professionals.
In the specific case of HIV because of history of discrimination, and stigma, etc. Mass law still states that the HIV status (HIV viral load, resistant testing could be proxy HIV tests) can not be shared with anyone without the patient’s consent.
How could the “anyone” include medical providers directly involved in the care of that HIV positive patient or the patient who has been exposed to that patient?
Information needs be shared for appropriate care of both HIV positive patients and patients who have had exposure to HIV.
Perhaps it is time for the Massachusetts law to have an addendum to put the mind of medical providers at is when they are engaged in appropriate sharing of information.
I agree that in this case, the information should be shared, but only because the recipients are clinicians who understand the need to maintain as much confidentiality as possible. Unfortunately, despite all of our efforts, the average layperson still does not understand how HIV is transmitted and how to protect themselves.
Take the recent case in Texas where an HIV-positive man was sentenced to 35 years in prison for spitting in the mouth of a corrections officer. He was sentenced for assault with a deadly weapon. There is no evidence that HIV is spread this way, yet a jury of his so-called peers found him guilty despite this. Then there was a story on the news last year about the owner of a trailer park barring an HIV positive child from using the showers.
Because of this ignorance, I’d be very uneasy about getting rid of the HIV exceptionalism. Obviously some changes need to be made, but the public cannot be expected to behave rationally when it comes to HIV.
Providers, especially in the mental health area, are so frightened of “the Privacy Laws” that often decisions are made in an attempt to avoid litigation rather than practice “best practice”. Privacy laws are very poorly understood possibly because we rely on others to interpret them for us. Actually take a look at the privacy laws yourselves, especially the sections on exceptions – you will be pleasantly surprised at how sensible they are and how they do let you make the decisions that are “the right thing”.
I would strongly agree with Dr.Paul Sax. The information on the patient’s viral load, resistance pattern, treatment schedule, Hep.B & C status is of vital importance for protecting the health care worker. There cannot be any objection to providing this information in the context of a controlled clinical setting. The law should not be left ambiguous. It should be amended to state this explicitly.
The HIV patient deserves our respect and support to lead a useful and dignified life. However our attitude should not be taken to unnecessary extremes to become harmful to the society.
Twenty five years ago I suggested two control measures at a meeting.
(1) Compulsory sterilisation of HIV patients with a child bearing potential .
(2) Indelible, painless branding of the patient at a normally invisible region
e.g. over the pubis so that anyone having intimate relations is aware of the risk and take the necessary precautions.
The audience were horrified!