By PREM MISIR Ph. D

This paper was published: Misir, P., 1999. AIDS PATIENT CARE and STDs, 13(6), pp.327-334.

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 Toomey4 present two approaches being used in partner notification programmes: the duty of physicians to warn where they have 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. The authors 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 virtually all planning discussions of partner notification.

“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.”

Some of these issues are the duty to warn, the right to know, the responsibility to protect the
public health, the right of confidentiality and privacy, the need for protection against discrimination, and the duty to protect the family and social relationships. Confidentiality of the patient’s data must be protected as “the patient in analysis must learn to free 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.”5 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, Walters6 argues that there are valid grounds for violating the principle of confidentiality. First, the principle of confidentiality may conflict with the rights of the patient himself, as when the patient may be a threat to himself. Second, the principle may produce a conflict with the rights 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, even if the HIV-infected individual withholds consent. Third, the principle may generate a conflict between confidentiality and societal interests, as when physicians report communicable diseases. Violation of confidentiality therefore 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.

OTHER PARTNER NOTIFICATION
ISSUES
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 programs
• No curative treatment for AIDS
• Personal stigmatization and discrimination against AIDS

Potterat et al.7 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 gonorrhea8 (CDC, STD, 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 Sates is estimated to be $20 million annually. In Sweden, the cost factor is $460 U.S. per newly identified HIV-positive patient,9 quite comparable to the unit cost of $810 for a new HIV patient in the United States.10 The costs have to be 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.
Brandt2 makes the point that negative social meanings and inadequate public funding related to venereal disease (VD) can impede medical efforts. Even with the discovery of penicillin, VD researchers expressed indifference as they believed a cure for syphilis would promote sexual promiscuity. Thus, the cost factor in the treatment of AIDS is not only dependent upon its potential results, but also upon the negative social images associated with the disease.
Another argument against partner notification is its negligible value,7 as currently there is no cure for AIDS. Despite this fact, there is treatment. Early administration of zidovudine (AZT) extends the symptomless period of infection.11 Mortality among patients with advanced HIV infection declined from 29.7 per 100 person-years in 1995 to 8.8 per 100 person-years in the second quarter of 1997,12 a change attributable to the availability of HAART. Prophylaxis against P. carinii pneumonia and other opportunistic infections, reduces their frequency and severity.13 The incurability of AIDS at this time requires a new thrust toward developing a better quality of life for persons infected with HIV/AIDS and creating a priority for the development of effective partner notification programs, with the intent to eliminate the further spread of HIV.

References:
4. Bayer R, Toomey K. HIV prevention and the two faces of partner notification. Am J Public Health 1992;82: 1158-1164.
5. Ruben HL, Ruben DD. Confidentiality and privileged communications: the psychotherapeutic relationship revisited. Med Ann DC 1972;41:364-368.
6. Walters L. The principle of medical confidentiality. In: Mappes TA, Zembaty JS, eds. Biomédical Ethic. New York: McGraw-Hill, 1991:162-165.
7. Potterat J J, Spencer NE, Woodhouse DE. Partner notification in the control of the human immunodeficiency virus infection. Am J Public Health 1989;79:874-876.
8. Centers for Disease Control and Prevention. Syphilis and congenital syphilis—United States, 1985-1987. MMWR 1988;37:4876-4879.
9. Gieseck J, Ramstedt K, Granath F. Efficacy of partner notification for HIV infection. Lancet 1991;338:1096-1100.
10. Wykoff RF, Heath CW Jr, Hollis SL. Contact tracing to identify human immunodeficiency virus infection in a rural community. JAMA 1988;259:3563-3566.
11. Volbering PA, Lagakos SW, Koch MA. Zidovudine in asymptomatic human immune deficiency virus infection: controlled trial in persons with fewer than 500 CD4 cells-positive cells per cubic millimeter. N Engl J Med 1990;322:941-949.
12. Palella FJ Jr. Declining morbidity and mortality among patients with human immunodeficiency virus
infection. N Engl J Med 1998;338:853-860.
13. Leoung GS, Feigal DW, Montgomery A. Aerolized pentamidine for prophylaxis against Pneumocystis
carinii pneumonia: the San Francisco community prophylaxis trial. N Engl J Med 1990;323:769-775.