Ethical Dilemmas in HIV
Wendy Majewska
Senior Health Adviser
St George’s Hospital
London
Ethics
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Hippocrates considered to be father of western
medicine and contributed to establishing
medicine as a profession
Hippocratic Oath
 seminal
document on the ethics of medical practice
 rarely used in its original form today although serves
as foundation for other similar oaths and laws that
define good medical practice
Four guiding principles

Pillars of ethics
 Non-maleficence
 Beneficence
 Justice
 Autonomy
Ethical dilemmas?
Fertility treatment
 Organ donation
 End of life care
 HIV……

 Terminal
 Sexually
transmitted
Case 1
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16 year old HIV positive female
Sexually active
Aware safer sex stated ‘uses condoms’
Brought male partner to clinic reporting ‘condom
broke’
Requested PEPSI
Male partner unaware of HIV status
Patient did not want partner to know her HIV
status
Can PEPSE be given without disclosing HIV
status?
Should confidentiality be broken and HIV
status disclosed?

Influencing factors
 Risk
of transmission 1:1000 -1:3000
 VL
 Length
of exposure
 Potential harm
Case 2
32yr old gay man diagnosed HIV+
 PN
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 RMP
4 years
 Tested HIV+

RMP – PN
 Married
26 years - midwife
 Reluctant to inform – reported no recent SI

Influencing factors
 Sexual
history
 VL / CD4 count
 On-going risk
 Occupation
 Co-habiting
 Time frame
 Collaborative working
Case 3
17 year old female
 Tested HIV positive through TOP service
 Came to UK aged 15
 Foster care
 Pt felt likely to be infected vertically
 Did not want mother to know HIV status
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Can we inform mother?
Can we withhold daughter’s HIV status?
Case 4
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HIV+ newly diagnosed woman
Unusual drug resistance assay
Seen by consultant working at 2 sites
 Recognised
resistance pattern
 Clarified risk factors
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Female pt at other clinic same resistance pattern
– similar profile of sexual contact identified
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Additional female patient identified –
address noted as being the same as 1st pt
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PN – contact identified - attended
neighbouring hospital (KH) with TB
 HA
contacted KH clinic
 Man identified - HIV+ lost to follow up
 PN at KH identified 16 year old female HIV+

Index male patient diagnosed prior to
sexual contact with 4 female HIV patients
 History
from all 4 female pts indicated no
condom used
 None of the 4 females knew of each other

HIV+ man knowingly exposed 4 women to
HIV infection
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Can action be taken?
 What
action might be appropriate?
Case 5
Pregnant woman
 Declined HIV testing in pregnancy
 Referred to HIV Midwife
 Referred to Health Adviser
 Issues re unborn baby
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Is safeguarding of unborn child an issue?
Would the same apply across UK?
On-going ethical issues
Pregnant – refusing ART
 Contact of HIV+ refusing testing but in
other steady relationship
 Paediatric HIV - YP
 MTCT
 Confidentiality
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Key points
Decision should not be taken alone
 Work as MDT
 Remember
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 Non-maleficence
 Beneficence
 Justice
 Autonomy
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Health Advisers are key in
 exploring
ethical issues
 resolution of dilemmas
If not us, WHO?
HIV and the law
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Offences Against the Person Act 1861
Sections of the OAPA 1861 ‘grievous bodily
harm’
Two possible offences
 ‘reckless
transmission’ (section 20)
 ‘intentional transmission’ (section18)
•
To date not yet been a successful prosecution
for intentional transmission
14 prosecutions to date in E&W
 9 pleaded ‘guilty’
 5 pleaded ‘not guilty’
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2
convicted
 longest sentence 10 years – 3 complainants
 other sentences range 2 - 4 and half years
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2 convictions were in women
Intentional Or Reckless Sexual
Transmission Of Infection
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‘….this area of the criminal law is exceptionally complex’
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‘….will be difficult to prove to the requisite high standard…’
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There are other sensitivities: the relationship between the criminal
law and consensual sexual behaviour is delicate. The use of the
criminal law in the most intimate of physical exchanges is always
going to attract publicity and will invite strongly held and differing
views
Intentional Or Reckless Sexual Transmission Of Infection Guidance
Crown Prosecution Service