-A social system perspective
Ethical issues
THE TRANSMISSION of AIDS constitutes a harm done to others, and therefore needs to be addressed strategically to modify high-risk behaviour, paying particular attention to privacy and confidentiality.  Bayer and Toomey (1158-1164, 1992) present two approaches being used in partner notification programmes: the duty of physicians to warn where the physician has knowledge of the identity of the person at risk, and contact tracing where the physician may be unaware of the identity of the person(s) at risk.  They contend that partner notification programmes have been embroiled in controversy where processes that are essentially voluntary are perceived as mandatory, and those that observe confidentiality are seen as an invasion of privacy.
Ethical issues predominate in any planning discussion of partner notification, and quite rightly so.  Some of these issues are the duty to warn, the right to know, the duty to protect the public health, the right of confidentiality and privacy, protection against discrimination, and the duty to protect the family and social relationships.  Confidentiality of the patient’s data must be protected, for “the patient in analysis must learn to freely associate and to break down resistance to deal with unconscious threatening thoughts and feelings.  To revoke secrecy after encouraging such risk-taking is to threaten all future interactions” (Ruben & Ruben, 1972).  Confidentiality, if perceived by the patient to be secured, may enable the patient to provide full disclosure of symptoms, causes, and persons exposed. Confidentiality also is necessary to safeguard the rights of privacy.
However, Walters (162-165, 1991) argues that there are grounds for violating the principle of confidentiality.  Firstly, this principle may ensue in conflict with the rights of the patient himself, as when the patient may be a threat to himself.  Secondly, the principle may produce conflict with the right of an innocent third party, as in the case of a bride-to-be who may not know the bridegroom-to-be has a viral infection, but her physician knows.  Should the physician provide full disclosure?  In such a case, the physician can invoke a ‘privilege to disclose’ and effect the warning. Although the HIV-infected individual withholds consent.  Thirdly, the principle may generate a conflict between confidentiality and societal interests, as when physicians report communicable diseases.  Violation of confidentiality has to be assessed on an individual basis and carefully balanced against any adverse impact on society.  This violation cannot be applied as a general rule in the physician-patient relationship, especially in the case of AIDS as a viral infection.

Issues associated with partner notification
Partner notification must be voluntary to satisfy the needs, will, and perceptions of different constituencies, and to eliminate objections presented against its usage. Some criticisms of partner notification are as follows:
– Too expensive to effect partner notification programmes
– No curative treatment for AIDS
– Personal stigmatization and discrimination against AIDS

Potterat and others (874-876, 1989)  argued against these objections.  Voluntary partner notification of HIV status is cost effective when we consider that all of the 35,000 cases of syphilis (CDC, MMWR, 1988), 40% of gonorrhea  (CDC, STD, MMWR, 4876-4879, 1988), and a number of chlamydia cases, are methodically checked for sexual partner data.  For 100,000 AIDS cases, the cost of a partner notification program in the United States (U.S.) is estimated at $20 million annually.  In Sweden, the cost factor is US$460 per newly identified HIV-positive patient (Gieseck , Ramstedt, Granath, 1096-1100, 1991) quite comparable to the unit cost of $810 for a new HIV patient in the U.S. (Wykoff, Heath, Hollis, 3563-3566, 1988).  The costs have to weighed against the benefits of halting the spread of HIV.  However, the issue of cost for easily treatable STDs, in which transmission is blocked by readily available treatment, is very different from that of HIV, where there is no cure, or drug to block transmission.  The issue of curability is distinct from one of treatment with the intention to eliminating the spread of HIV, as is virtually possible for all other STDs.  Nevertheless, the partner notification approach could be a preventive measure if it is effective in identifying new cases.

(This paper was published in AIDS PATIENT CARE AND STDs, Vol. 13, No. 6, June 1999 (USA)