Partners' notification rights

There is increasing pressure for partner notification to be employed as an HIV prevention tool in the United States, in the same way as for other sexually transmitted infection such as syphilis. It is argued by critics of current public health responses that the rights of the uninfected have been sacrificed by the failure to pursue partner notification, and that the process of policy making has been `captured' by political interest groups. But advocates for the primacy of privacy and consent have argued that past public health measures have been authoritarian in character and are unsuitable for dealing with a disease which carries so much social stigma. Two often conflicting medical practices provide the basis for ethical debates about whether partners of people with HIV should be informed that they may have been at risk. One is strongly biased towards the protection of confidentiality (contact tracing); the other towards the identification of partners (the ethical duty of doctors to warn their patients of risks).

The pros and cons of contact tracing

Contact tracing was developed as a means of informing partners with the cooperation of the person diagnosed with a sexually transmitted disease. This practice developed with the emergence of a cure for syphilis, and usually preserved the anonymity of the informant. In the case of HIV, those who saw contact tracing as a prevention tool argued that it should be extended to cover HIV infection. Others questioned whether, in the absence of a cure, contact tracing was a justifiable procedure. Far better, they argued, to rely on voluntary testing and on general education. Contact tracing might provide a false sense of security to those at risk who remain uncontacted.

Possible benefits:

• Alerts people to a possible risk they might otherwise have been unaware of. For instance, as many women are unaware that they are at significant risk of HIV infection (e.g. if their male sexual partner is engaging in risky sexual behaviour which is not discussed within the relationship), contact tracing could alert them to a risk which they would not easily have been able to assess.
• A more economical use of resources than the broad spectrum public education campaigns in low prevalence populations.
• Epidemiologically useful to monitor the spread of HIV infection and to gather data on modes of transmission.
• Medically advantageous: it brings people under medical surveillance far earlier than might otherwise have been the case.

Possible drawbacks:

• It dilutes the confidentiality of counselling around HIV testing and shifts the focus of counselling from the needs of the individual who has tested positive to the partners of that person.
• Likely to be seen as a substitute for a more aggressive public education campaign in the same way as HIV testing was.
• Only effective in sexual networks where low rates of partner change are apparent, and ineffective amongst sex workers or `promiscuous' gay men.
• Affects the individual's right not to know that they have HIV infection.
• Likely to induce complacency amongst those sections of the population which already consider themselves to be at low risk, whether heterosexuals or monogamous gay men.
• Likely to be effective only in areas of low social mobility and low clinic workload i.e. outside London.

The duty to warn

Some argue that in certain circumstances, the ethical duty of the doctor is to the partners of the patient, and that notification of partners should take place.

The British Medical Association has made it clear that doctors should only warn the partners of HIV-positive patients where there is a serious and identifiable risk. This situation is only likely to arise for GPs, since GUM clinic records are confidential by law. BMA advice states:

• It is unethical for a registered medical practitioner to refuse treatment, or investigation for which there are appropriate facilities, on the ground that the patient suffers, or may suffer, a condition which could expose the doctor to personal risk.
• It is ethically acceptable for a surgeon to request a patient to be tested for HIV prior to an operation, providing that the criteria used to select those asked to be tested are reasonable, and explicit consent is obtained without pressurising the patient. In seeking consent, the patient should be told that the test is intended mainly for the benefit of the surgeon and that refusal to be tested will not affect the treatment given.

The assumption that routine testing of all patients for HIV antibodies protects health care workers from HIV infection is false. Only proper infection control procedures can fully protect health care workers from HIV infection.