psy 699 week 4 disscussion1
Steven911
ContentServer14.pdf
2011; 33: e50–e56
WEB PAPER
The ethics of HIV testing and disclosure for healthcare professionals: What do our future doctors think?
JULIE M. AULTMAN1 & NICOLE J. BORGES2
1Northeastern Ohio Universities College of Medicine, USA, 2Wright State University Boonshoft School of Medicine, USA
Abstract
Aim: This study examined future medical professionals’ attitudes and beliefs regarding mandatory human immunodeficiency virus
(HIV) testing and disclosure.
Method: A total of 54 US medical students were interviewed regarding mandatory testing and disclosure of HIV status for both
patient and health care professional populations. Interviews were qualitatively analyzed using thematic analysis by the first author
and verified by the second author.
Results: Medical students considered a variety of perspectives, even placing themselves in the shoes of their patients or imagining
themselves as a healthcare professional with HIV. Mixed opinions were presented regarding the importance of HIV testing for
students coupled with a fear about school administration regarding HIV positive test results and the outcome of a student’s career.
Third- and fourth-year medical students felt that there should be no obligation to disclose one’s HIV status to patients, colleagues,
or employers. However, most of these students did feel that patients had an obligation to disclose their HIV status to healthcare
professionals.
Conclusion: This study gives medical educators a glimpse into what our future doctors think about HIV testing and disclosure, and
how difficult it is for them to recognize that they can be patients too, as they are conflicted by professional and personal values.
Introduction
The overall aim of this qualitative study is to gain a deeper
understanding of future doctors’ attitudes and beliefs regarding
mandatory human immunodeficiency virus (HIV) testing and
disclosure, and to explore current medical students’ personal
biases and stigmas surrounding HIV testing and disclosure.
Present and future doctors may face the challenges of having
to not only request that patients disclose their HIV status, but
also to decide whether to report one’s own HIV status to
patients, colleagues, and/or employing healthcare institutions.
By examining and identifying some of the beliefs and attitudes
surrounding such dilemmas, we believe this information can
be of help to medical educators as they work with medical
students and their clinical preceptors to resolve many of the
social and ethical problems associated with the stigma of HIV
disclosure, while improving the overall health of individuals
and communities. In addition to the presentation and analysis
of our data, we provide curriculum recommendations for
ethics education for HIV testing and disclosure for medical
students. First, we will provide descriptive background infor-
mation on HIV testing and disclosure.
HIV testing
In the United States, there are several private and public HIV
testing sites including free-standing clinics, hospitals, state
Practice points
. Present and future healthcare professionals may face the challenges of having to not only request that patients
disclose their HIV status, but also to decide whether to
report one’s own HIV status to patients, colleagues, and/
or employing healthcare institutions.
. Given the lack of knowledge about HIV testing, and the problems with anonymity, patients and HCWs alike,
even when knowledgeable in HIV treatment and pre-
vention, are often reluctant to get tested for HIV out of
fear that positive test results will affect reputations,
employment status and insurance benefits.
. Differences were noted among pre-clinical students (first- and second-year students) and clinical students
(third- and fourth-year students who have been fully
exposed to patient care) with respect to the duty to
patient care versus duty to oneself.
. By examining and identifying some of the beliefs and attitudes surrounding such dilemmas, this information
can be of help to medical educators as they work with
medical students and their clinical preceptors to resolve
many of the social and ethical problems associated with
the stigma of HIV disclosure, while improving the
overall health of individuals and communities.
Correspondence: J. M. Aultman, Department of Behavioral and Community Health Sciences, Northeastern Ohio Universities College of Medicine
and Pharmacy, 4209 State Route 44, PO Box 95, Rootstown, OH 44272-0095, USA. Tel: 330-325-6113; fax: 330-325-5911; email:
e50 ISSN 0142–159X print/ISSN 1466–187X online/11/010050–7 � 2011 Informa UK Ltd. DOI: 10.3109/0142159X.2011.530311
health departments, and clinician offices. Every state, along
with Guam, Puerto Rico, and the US Virgin Islands offers
confidential testing, where a person’s name is recorded with
test results, and 45 states including Guam and Puerto Rico,
offer anonymous testing, where no name is used or connected
to test results (Center for Disease Control 2005). In reporting
cases of HIV, almost every state uses names. Five states use
name-to-code reporting and eight states only use codes. While
it is important to test and report individuals with HIV to better
understand the spread of the disease, to develop better safety
and preventative measures, and to deliver needed healthcare
to those who are afflicted, there are several ethical concerns
about the procedures for testing and reporting. Globally, many
efforts have been made to develop surveillance and reporting
programs. For example, in 1999, a European HIV reporting
system including 39 countries of the World Health
Organization (WHO) European Region was developed for
AIDS reporting. Persons who test positive are identified in
various ways (e.g., names, codes/identification numbers) and
reported by clinicians and/or laboratory personnel depending
on the regulations of individual countries. D’Amelio et al.
revealed that 27% of the 121 countries evaluated have
legislative measures in place mandating HIV testing for
vulnerable populations (e.g., commercial sex workers, men
who have sex with men, injecting drug users; D’Amelio et al.
2001; Li et al. 2007). Worldwide, many individuals do not
know the differences between anonymous and confidential
testing,1 or if they are aware of mandatory testing and
reporting programs, they may refuse to get tested, realizing
with a positive result their names or identifying information
may be reported. For those individuals who are living in states
that do not give them the option for anonymity, they too are
less likely to get tested. Recently, recommendations by the
Center for Disease Control (CDC 2006) suggest that all adults
and adolescents (ages 13–64) should be given voluntary,
automatic, and routine HIV tests upon entering a healthcare
facility so as to normalize HIV screening as a routine part of
medical care. Marcia Angell argues there is a need for HIV
testing to become more routine (Angell 1991). Using an ‘‘opt-
out’’ approach, individuals may have the opportunity to
decline testing, but healthcare workers (HCWs) are obligated
to provide basic information about HIV, including what
positive and negative test results mean. Although these
recommendations may help to normalize the HIV screening
process, there may be no options for anonymity, which may
persuade individuals to opt-out, or even forgo medical
attention altogether out of fear of being tested without prior
consent.
Given the lack of knowledge about HIV testing, and the
problems with anonymity, patients and HCWs alike, even
when knowledgeable in HIV treatment and prevention, are
often reluctant to get tested for HIV out of fear that positive test
results will affect reputations, employment status and insur-
ance benefits. Although previous studies have critically eval-
uated both patients’ and HCWs’ perspectives regarding HIV
testing and disclosure (see, for example, Dixon-Mueller 2007;
Galletly et al. 2008; Kagan et al. 2008; Tesoriero et al. 2008),
there are few recent studies examining medical students’
perspectives (see e.g., Evans et al. 1993).
HIV disclosure
When tackling the issue of HIV disclosure, most studies focus
on whether patients have a duty to disclose their HIV status to
their partners and to healthcare professionals so as to acquire
needed therapies and treatments, as well as to protect
healthcare professionals from even the slightest possible
exposure. Many critics conclude that patients do have a duty
to disclose their HIV status to their partners, to anyone who
may be susceptible to HIV transmission, or to those profes-
sionals who are obligated to provide care and treatment.
Under this popular line of reasoning, supported by the CDC,
the American Medical Association, among other health orga-
nizations, a public health ethic appears to take precedent over
individual freedoms and the right to privacy. However, when
tackling the issue as to whether HCWs also have a duty to
disclose their HIV status to their patients (Perry et al. 2006),
there is little consensus as to whether disclosure is valuable,
especially given the low probability of transmission. In 1991,
CDC recommended that infected HCWs with HIV or Hepatitis
B should not perform exposure prone procedures unless they
have ‘‘sought council from an expert review panel and [have]
been advised under what circumstances, if any, they may
continue to perform these procedures.’’ The CDC defined an
exposure-prone procedure to include ‘‘digital palpitation of a
needle tip in a body cavity or the simultaneous presence of the
health care worker’s fingers and a needle or other sharp
instrument or object in a poorly visualized anatomic site.’’ And,
even if the panels permit them to practice, it is recommended
that HCWs must still inform patients of their serologic status
(Gostin 2000). The American Medical Association’s policy on
HIV disclosure reads, ‘‘HIV infected physicians should disclose
their HIV seropositivity to a public health officer or a local
review committee, and should refrain from doing procedures
that pose a significant risk of HIV transmission, or perform
those procedures only with the consent of the patient and the
permission of the local review committee.’’ Furthermore, ‘‘A
physician who has HIV disease or who is seropositive should
consult colleagues as to which activities the physician can
pursue without creating a risk to patients’’ (Blumenreich 1993).
Marcia Angell in ‘‘A Dual Approach to the AIDS Epidemic,’’
wrote that patients have a right to know whether a doctor or
nurse who performs invasive procedures is infected with HIV.
Infected HCWs should refrain from invasive procedures, or
should expect to have reasonable alternative work
(Blumenreich 1993). Nevertheless, the 1995 Clinton adminis-
tration instructed CDC to review its guidelines that arbitrarily
restrict HIV infected HCWs, which possibly lead to
discrimination.
Critics, such as American Law Professor, Gostin, have
proposed new national policies, emphasizing patient safety by
ensuring that infection control procedures are systematically
implemented in healthcare settings, which would focus on
‘‘safer systems of practice rather than excluding and stigma-
tizing infected healthcare workers’’ (Gostin 2000).
Furthermore, Gostin argues that while a physician may
choose to put the patient first by disclosing his or her status,
the law should not require HCWs to disclose their HIV status,
since it is an invasion of the privacy of the HCW, and a
The ethics of HIV testing and disclosure
e51
possible professional detriment to the therapeutic relationship
following such an emotional and unsettling conversation with
patients. That is, since the HIV infected HCW is also a patient,
disclosure may be embarrassing and damaging to one’s
professional reputation. Besides the fear of discrimination
and the view that disclosure is an invasion of privacy, Gostin
and others believe that since the risk of HIV transmission from
HCW to patient is too low to meet the legal standard for
disclosure, informed consent guidelines and laws should not
require HIV infected HCWs to disclose their status to patients.
But if disclosure may be embarrassing and damaging to a
HCWs medical career or transmission is too low to meet the
legal standard for disclosure, it would seem as though patients,
just as HCWs, should not be required to disclose their HIV
status when seeking non-invasive care, which may not be
relevant to the treatment and monitoring of HIV. Nonetheless,
healthcare professionals purport, simply for preventing harm
to self and other, the HIV status of patients should be known
regardless of the level of harm in diagnosing, monitoring, or
treating patients for related and non-related conditions and
preventative care.
In the following study, these ethical issues are tackled by
our medical student-participants – our future doctors, whose
perspectives regarding HIV testing and disclosure for both
patients and HCWs give us insight into their critical thoughts
and ethical decision-making regarding personal and patient
care, and whether guidelines such as those created by the CDC
will be followed, or ignored, by our future physicians whether
they practice nationally or internationally with different
guidelines and laws.
Methods
During 2006–2007, a total of nine focus groups, containing 54
volunteer student-participants (34 females and 20 males),
ranging in ages 18–26, from two, four-year medical schools in
the United States, were interviewed by the investigators of this
qualitative study. Both medical institutions have an equal ratio
of males and females enrolled (50 : 50); however, there is an
unexplainable disproportionate number of female students
who volunteered at each level of their medical education
(years 1–4). All medical students were invited to participate via
email invitations and in-person classroom announcements,
both of which included an informational sheet describing the
study and role of voluntary participants (e.g., students may
freely accept or decline participating in the study, any student
who participates may leave the study at any point). Full
institutional review board (IRB) approval was obtained prior to
the start of the study. Six focus groups, containing 30 first- and
second-year students (19 females and 11 males) were inter-
viewed during their non-clinical training at their respective
medical schools. Three focus groups, containing 24 third- and
fourth-year medical students (15 females and 9 males), were
interviewed during their clinical training at their respective
medical schools, with the exception of three, third-year
medical students (3 males) who were interviewed during a
psychiatry clinical rotation at a local hospital. All IRB guide-
lines and ethical procedures were followed (i.e., informed
consent). All student-participants were asked a pre-established
set of general, open-ended questions regarding mandatory
testing and disclosure of HIV status for both patient and health
care professional populations. The open-endedness of these
questions, commonly used in qualitative research, prompted
students to verbalize their interpretations of concepts (e.g.,
‘‘compulsory’’ or ‘‘mandatory’’) and freely give their opinions
on difficult, ethical and professional issues, which enabled the
investigators to gain data with a range of attitudes and beliefs.
The pre-established, general questions used in the recorded
interviews are as follows:
(1) Do you think medical students should be tested for
HIV? How about physicians? Other healthcare
professionals?
(2) Should HIV testing be voluntary or mandatory? Why or
why not?
(3) Do you think that patients should disclose their HIV
status to their physician?
(4) Are there any circumstances under which a patient
should not disclose this information about their health
status?
(5) If a physician has HIV, do you think he/she should
disclose this to his/her patients? Please explain why or
why not.
These pre-established questions comprise the first part of this
study; a separate set of questions focusing on current medical
students’ perspective on and use of universal precautions
comprise the second part of the study and findings are
reported in a separate paper titled ‘‘The ethical and pedagog-
ical effects of modeling ‘not-so-universal’ precautions’’.
Interviews for the first part of this study were conducted for
30–45 minutes, while focus group interviews for the entire
project lasted 60–75 minutes. Investigators used a hand-held,
digital audio recorder to record all interviews. Project inves-
tigators took hand-written notes during each focus group,
alerting them to significant points and patterns of experiences,
beliefs, and attitudes. All recorded interviews were transcribed.
Names and other identifiers that were verbalized by students
during the focus group sessions were not transcribed.
Transcripts were qualitatively evaluated by the project inves-
tigators individually and then collectively to ensure that
emerging themes in the data were objectively identified and
analyzed using thematic data analysis, whereby repetitive
themes emerged from students’ responses and meaning units
were recorded and coded. The project investigators included
the authors of this article, both of whom also conducted the
focus groups at their respective institutions; the first author
analyzed the data, and the second author verified the analysis.
Data from students’ answers (from the above questions and
discussion that followed) were divided into two significant
categories: HIV testing and HIV disclosure.
Results
In general, there were no identifiable differences in the reports
given by medical student-participants from the two medical
schools. In addition, there were no identifiable differences in
responses among males and females. However, there were
significant differences among pre-clinical students (first- and
J. M. Aultman & N. J. Borges
e52
second-year students) and clinical students (third- and fourth-
year students who have been fully exposed to patient care)
with respect to the duty to patient care versus duty to oneself.
Although most students expressed their personal opinions,
many students provided insightful, constructive, well-sup-
ported arguments surrounding HIV testing and disclosure,
often placing themselves in the shoes of their patients or
reflectively thinking on what it would be like to be a physician
with HIV. The focus groups conducted were useful not only
for the purposes of this study, but also for students’ medical
education by giving them an opportunity to discuss and reflect
upon a controversial topic in medicine and public health.
Specific results from this study are divided into two primary
sections, ‘‘HIV testing’’ and ‘‘HIV disclosure,’’ along with
relevant sub-sections.
HIV testing
Do you think medical students should be tested for HIV? How
about physicians? Other healthcare professionals?
In response to the first focus group question, first- and second-
year students at both medical schools reported that testing can
reduce the social stigma associated with HIV; by having every
student experience the testing procedures from ‘‘a patient’s
perspective’’, along with a formal education about HIV from
clinical, psychological, and social perspectives, the stigma
could be reduced and students would be better informed to
help their patients and themselves in the prevention and
treatment of HIV. The majority of students who supported HIV
testing in medical school (or when they became licensed
physicians) felt that testing for HIV is an important step toward
physically and emotionally caring for themselves and their
patients. They also recognized that attitudes and beliefs may
positively change in ways that alleviate current stigma as HIV
screening increases or becomes a normalized practice.
However, not all students supported HIV testing for medical
students and/or healthcare professionals.
A total of nine first- and second-year students at both
medical schools feared the consequences of the HIV tests.
Their greatest fear was that of the medical school or
administration finding out about any risk factors (drug use0
or positive test results, which, they believe, would ruin
students’ future medical careers. They expressed they would
not be valued or accepted as an HIV professional, which
interestingly, provoked students to think about what patients
may feel and think with respect to their own professional lives.
Students from both medical schools feared their privacy would
not be protected and that positive results would show up on
their permanent records. One male first-year student explained
that he would not want to get tested for incurable STDs
‘‘because of the possibility of the school finding out.’’ Other
students reported that because the transmission rate was so
small, and universal precautions were in place, there would be
no need to get tested. Twelve students at each stage in the
four-year medical school curriculum explicitly argued that only
those who are at risk for HIV should be tested, but that testing
should be voluntary regardless of the risks to patients and
colleagues. Students from both medical schools (approxi-
mately 75%, or 40 out of 54 clinical and non-clinical) reported
that if healthcare professionals were tested positive for HIV,
negative consequences, such as lawsuits, loss of medical
licenses, and limited patient interaction, could occur. Rather
than directly answering the focus group question, third-year
students at both medical schools were inquisitive and asked
about the benefits of knowing the results of an HIV test as it
relates to the safety and protection of others. After re-directing
their questions and answers (when dialogue got ‘‘off-track’’) by
asking how they felt about being tested as medical students,
these third-year students felt that tests should be given to
healthcare professionals only if there is a significant transmis-
sion rate from physician to patient. Two fourth-year students at
one medical school added that ‘‘testing is expensive’’ and
some people, especially medical students, may not be able to
pay for the tests. The availability and accessibility of medical
resources needed to test medical students and healthcare
professionals alike was a general concern among the fourth-
year students, as well as how information gained from the tests
is going to be used (e.g., will information hurt your potential to
get insurance). Overall, there was little concern regarding the
possibilities of transmission of HIV from physician to patient.
Mandatory testing
Should HIV testing be voluntary or mandatory? Why or
why not?
It was duly noted among first through third-year medical
students at both institutions that the stigma becomes reduced
when testing is mandatory. First-year students at one medical
school indicated that mandatory testing may help more people
get treatment. A first-year student at the second medical school
indicated that ‘‘if we are not disclosing information about
ourselves then I don’t think we can ask our patients to provide
the information – no double standard.’’ Another student
reported, ‘‘I think I would lean towards HIV testing be
voluntary instead of mandatory. I really value having individ-
ual rights.’’ However, another first-year student stated, ‘‘I
would say mandatory. It’s just like. . .like our pap smears and
we test for that annually, and it’s not stigmatized. I don’t see
why we couldn’t do the same thing with HIV. Encourage
women and men to get their annual HIV test if they, or you
know, at least every few years. . .’’
Second-year students generally thought that so long as laws
(or guidelines) were in place to protect discrimination,
healthcare professionals and students should be mandatorily
tested. A female second-year student, echoing the same
sentiment, suggested that testing be anonymous and confi-
dential if it were to be mandatory. Another second-year
student felt that one would be more likely to pay attention [to
universal precautions] if a person’s HIV status were known.
While first- and second-year students from both medical
schools indicated the stigma would be greatly reduced with
mandatory testing, third- and fourth-year students felt that
discrimination would occur and the stigma would continue to
exist, even though ‘‘HIV is no longer a death sentence.’’
More than half of students (63%, or 34 out of 54 clinical and
non-clinical) interviewed at both medical schools explicitly
argued that individual rights are critical. If tests were manda-
tory, the right to privacy should be upheld to protect the
The ethics of HIV testing and disclosure
e53
student or healthcare professional from negative conse-
quences, such as employment and insurance discrimination.
These students also indicated that mandatory testing would be
a waste of resources, since it is a common belief among
students and healthcare professionals that ‘‘we do not typically
engage in risky behaviors, such as unprotected sex, or fail to
use universal precautions’’.
Patient disclosure
Do you think that patients should disclose their HIV status to
their physician? Are there any circumstances under which a
patient should not disclose this information about their health
status?
We found that first- and second-year students (approximately
73%, or 22 out of 30 non-clinical students) expressed that
patients should disclose their HIV status to their physicians in
order to educate oneself and to prevent the possibility of a
misdiagnosis or wrong treatment regimen. A first-year student
at one medical school indicated that HIV testing is a mandatory
practice within the US military, so he has to get tested each
year that he is enrolled with the military. However, many first-
and second-year students indicated that because of the
potential for discrimination, patients should not have to
disclose their HIV status. One first-year student believed that
it is the physician’s responsibility to prevent the disease. First-
year students from both medical schools suggested that if a
physician or healthcare professional does not have to disclose
their HIV status to the patient, then the patient should not have
to disclose his or her status.
The general consensus among third- and fourth-year
students at both medical schools is for patients to disclose
their HIV status in order for healthcare professionals to
properly treat their patients and for properly protecting
themselves when working with HIV infected patients. Both
groups of students recognized that the stigma associated with
HIV would still exist regardless of patient disclosure. Most
third- and fourth-year students (79%, or 19 out of 24 clinical
students) articulated how transparency about one’s disease
and disease-related behaviors, or disclosure specifically, is an
important patient duty; it is the patient’s duty to protect the
healthcare professional and to seek and adhere to treatment.
Physician disclosure
If a physician has HIV, do you think he/she should disclose this
to his/her patients? Please explain why or why not.
First-year students at one medical school felt that if there is a
risk, then the physician should disclose his or her HIV status.
First- and second-year students at both medical schools
believed that it is up to the physician to disclose. One first-
year student at another medical school exclaimed that I am
‘‘too shocked even to imagine’’ this could happen to a
physician. Another first-year student believed that so long a
physician can practice medicine, disclosing such personal
information to a patient is acceptable. A third student believed
that disclosure should depend on the specialty of the
profession. A male second-year student at one medical
school ‘‘would feel guilty’’ if he did not disclose his HIV
status to patients.
Those first- and second-year students who believe that
physicians should not disclose their HIV status to patients
explained that ‘‘the patient is not caring for the doctor,’’ or that
it is ‘‘not professional to disclose personal things.’’ Some first-
and second-year students indicated that due to the potential
loss of clients, a physician should not disclose his or her HIV
status. A second-year student stated ‘‘if you are an HIV surgeon
you wouldn’t be making the money because you would be
limited to only surgeries that involve only HIV patients.’’
One third-year student suggested that physicians disclose
their status in order to send the message to patients that they
too need to take precautions. Another third-year student
reported ‘‘We need to learn personal responsibility not just
with universal precautions but with whatever status we have.’’
A fourth-year student at one medical school placed himself in
the shoes of his patients and reported, ‘‘If I was a patient, I
would want to know no matter what kind of doctor [was
treating me].’’ Six students questioned why even discuss HIV
as a threat, since the threat is so slim and prophylaxis is
available. Knowing hepatitis was a greater threat, these
students could not understand why HIV is still an issue.
Three out of 10 fourth-year medical students believe the
patient has a right to know. The majority of third- and fourth-
year students believe that disclosure will not help the
healthcare professional or his or her patients, since the risk
of transmission is very slim.
Discussion
In this study, we explored how medical students feel about
HIV testing and disclosure, and sought to understand some of
the dilemmas they may face as future healthcare professionals.
Due to the qualitative nature of this study (i.e., using open-
ended questions in a focus group format), our medical student-
participants considered a variety of perspectives, even placing
themselves in the shoes of their patients or imagining
themselves as a healthcare professional with HIV. Regarding
duty to patients versus duty to oneself, when placed in the
physician’s shoes, third- and fourth-year medical students
consider the consequences (to themselves) more than patient
care, but emphasized patient obligations and responsibilities in
being transparent about their disease and disease-related
lifestyles and behaviors. First- and second-year students
emphasized the importance of testing to provide better care
to patients; they placed themselves in their patient’s shoes, and
were more empathetic to the emotional and social needs of
patients compared to the third- and fourth-year students. The
investigators attribute this difference to the lack of clinical
training among first- and second-year students, who are
idealistic in providing good care to patients and have not
(yet) developed jaded or cynical attitudes, which we witness in
more clinically-oriented students, interns, and residents. Also,
third- and fourth-year students generally have more exposure
to the business and legal practices related to medicine, and
confront justice issues such as resource allocation and avail-
ability (one reason why these students may have considered
the cost of compulsory testing).
J. M. Aultman & N. J. Borges
e54
Some students describe their unresolved conflicts between
their personal freedoms and professional obligations. For
example, medical student-participants, in identifying one of
the core ethical dilemmas of HIV testing and disclosure, report
that anonymity is important in the preservation of privacy and
personal freedom, but question how these values should be
balanced against the greater good of society. These ethical
issues are tackled by our medical student-participants – our
future doctors, whose perspectives regarding HIV testing and
disclosure for both patients and HCWs give us insight into their
critical thoughts and ethical decision-making regarding per-
sonal and patient care, and whether guidelines such as those
created by the CDC will be followed, or ignored, by our future
physicians. Mixed opinions were presented regarding the
importance of HIV testing for students coupled with a fear
about school administration regarding HIV positive test results
and the outcome of a student’s career.
Regarding HIV disclosure, some of our medical student-
participants recalled the case of Dr. David J. Acer, an American
dentist who was believed to have infected his patients with
HIV in the late 1980s, but immediately dismissed this case,
since accidental transmission of HIV from doctor to patient
was never proven (Tuboku-Metzger et al. 2005). Given the
lack of evidence showing a risk of transmission from a HCW to
a patient, our third- and fourth-year medical students felt that
because the risk was so slim, there should be no obligation to
disclose one’s HIV status to patients, colleagues, or employers.
However, most of these students did feel that patients had an
obligation to disclose their HIV status to healthcare profes-
sionals due to a greater risk of transmission.
Many physicians, in general, feel the most essential thing in
life is to continue practicing medicine and that disclosing their
HIV status would have negative outcomes, including perma-
nent loss of employment (Gerberding 1996; Fost 2000; Gostin
2000, 2002; LeBlanc 2002; Weiss et al. 2005). Based on our
collected data, many of the medical students interviewed were
also afraid of the possible negative outcomes for disclosing
such a highly stigmatized disease. However, some students,
especially those in the early stages of their medical training,
thought that some of these negative outcomes could be
prevented if medical students are tested before making career
decisions that could affect themselves and their future patients
(e.g., choosing to practice psychiatry instead of surgery). A few
medical student-participants thought that HIV disclosure could
benefit the therapeutic relationship, others thought patients
should not be privy to HCWs personal information, but that
employers should be made aware so as to monitor safety
practices. Some physicians, who have disclosed their HIV
status to their department chairs or others in authoritative
positions, felt a sense of relief and were able to practice
medicine without stigmatization and discrimination, and with-
out affecting patient care. For example, one Chicago psychi-
atrist explained, ‘‘I felt that though completely asymptomatic,
informing my department heads that I was HIV sero-positive
was the only way to keep work related stress at more
manageable levels . . . I only share the information about my
being HIVþ during the course of treatment when a patient
clearly needs the example of a role model and slow progressor
living productively with HIV to provide a contrast to their
hopelessness regarding their own diagnosis.’’ (Shernoff 1996).
In closing, this study helps medical educators understand
students’ mindset, opinions, and beliefs about HIV testing and
disclosure. For those medical schools who already have this
topic integrated into their ethics curriculum, their faculty may
want to compare and contrast the goals and objectives for their
lectures and courses with the depth and breadth of perspec-
tives shared by students in this study. For schools where this is
not currently an ethics topic, we encourage their faculty to
derive innovative methods for exploring students thinking
about and discussing these issues, especially the effects of HIV
on the healthcare professional as patient. Learning opportu-
nities should be provided to medical students across the
curriculum to address the dilemmas regarding HIV testing and
disclosure as it is important to self-care of physicians, patient
care, and to the practice of medicine. It is important that
medical educators create safe forums for students to discuss
their perspectives, feelings, and attitudes surrounding HIV
testing and disclosure, and to provide up-to-date information
regarding HIV transmission and rules governing when and
how to report possible transmission (e.g., needle sticks).
Furthermore, medical education should recognize the need to
teach students about caring for themselves in addition to
caring for patients. Most of our students participating in this
study had not thought about how their own health, or absence
of health, could affect patient care and their career choices as
physicians. By educating students about their own personal
health and well-being, we as medical educators have the
power to change the clinical environment, guiding our
students to become more professionally and personally
responsible for themselves and their patients, to seek help
and guidance without fear (e.g., to report a needle stick
without fear of being reprimanded by superiors), and to
recognize that disclosure in some instances is a moral
obligation to both patient and self. Although the sample size
was small, and the context of pre-clinical and clinical training
provided needed support in understanding the possible
differences among these student groups, this study gives
medical education a glimpse into what our future doctors think
about HIV testing and disclosure, and how difficult it is for
them to recognize that they can be patients too, conflicted by
professional and personal values and fearful of the conse-
quences in their professional lives. Medical education needs to
acknowledge that our future doctors may be or become
patients with a highly stigmatized disease, to create an
environment that neither discriminates patient nor profes-
sional, and to guide students in recognizing and resolving
conflicting personal and professional values and interests.
Declaration of interest: The authors report no conflicts of
interest. The authors alone are responsible for the content and
writing of this article.
Note
1. Anonymous testing uses code numbers to identify your test.
Your name is never used. You use the code to get your results.
The ethics of HIV testing and disclosure
e55
You are the only person who knows your results. With
anonymous testing, you have complete control in deciding
who to tell and when. With confidential testing, your name is
recorded and linked to your test results. Even though this
information is kept private, others may have access to this
information, including health care providers, your insurance
company, and the health department.
Notes on contributors
JULIE M. AULTMAN, PhD, is a Bioethicist and an Associate Professor of
Behavioral Sciences at Northeastern Ohio Universities College of Medicine
and Pharmacy.
NICOLE J. BORGES, PhD, is an Associate Professor in the Department of
Community Health and Assistant Dean, Medical Education Research and
Evaluation in the Office of Academic Affairs at the Boonshoft School of
Medicine at Wright State University.
References
Angell M. 1991. A dual approach to the AIDS epidemic. New Engl J Med
324:1498–1500.
Blumenreich GA. 1993 [Internet]. The law and the AIDS-infected healthcare
worker. American Medical Association Legal Briefs. Available from:
http://www.aana.com/Resources.aspx?ucNavMenu_TSMenuTargetID=54
&ucNavMenu_TSMenuTargetType=4&ucNavMenu_TSMenuID=6&id=
2411&
Center for Disease Control 2005 [Internet]. Current Status of HIV Infection
Surveillance, January 2005. [Accessed 2008 November 11]. Available
from: http://www.hhs.gov/asl/testify/t050623a.html
Center for Disease Control 2006 [Internet]. MMWR Reports. 55(RR14):1–17.
[Accessed 2008 November 11]. Available from: http://www.cdc.gov/
mmwr/preview/mmwrhtml/rr5514a1.htm?s_cid=
D’Amelio R, Tuerlings E, Perito O, Biselli R, Natalicchio S, Kingma S. 2001.
A global review of legislation on HIV/AIDS: The issue of HIV testing.
JAIDS 28:173–179.
Dixon-Mueller R. 2007. The sexual ethics of HIV testing and the rights and
responsibilities of partners. Stud Fam Plann 38:284–296.
Evans JK, Bingham JS, Prat K, Carne CA. 1993. Attitudes of medical students
to HIV and AIDS. Genitourin Med 69(5):377–380.
Fost N. 2000. Patient access to information on clinicians infected with
blood-borne pathogens. J Am Med Assoc 284:1696–1698.
Galletly CL, Pinkerton SD, Petroll AE. 2008. CDC recommendations for opt-
out testing and reactions to unanticipated HIV diagnoses. AIDS Patient
Care STDS 22:189–193.
Gerberding JL. 1996. The infected healthcare provider. New Engl J Med
334:594–595.
Gostin LA. 2000. Proposed national policy on health care workers living
with HIV/AIDS and other blood-borne pathogens. J Am Med Assoc
284:1965–1970.
Gostin LA. 2002. Rights and duties of HIV infected health care profes-
sionals. Health Care Anal 10:67–85.
Kagan I, Ovadia KL, Kaneti T. 2008. Physicians’ and nurses’ views on
infected health care workers. Nurs Ethics 15:573–585.
LeBlanc B. 2002 [Internet]. Does the duty to disclose include personal
disclosure by professionals? Professional practice and liability on the
net, 4(1). [Accessed 2008 November 11]. Available from: http://
www.sml-law.com/publications/newsletters-detail.asp?DocID=2326
Li L, Wu Z, Wu S, Lee SJ, Rotheram-Borus MJ, Detels R, Jia M, Sun S. 2007.
Mandatory HIV testing in China: The perception of health-care
providers. Int J STD AIDS 18(7):476–481.
Perry JL, Pearson RD, Jagger J. 2006. Infected health care workers and
patient safety: A double standard. Am J Infect Control 34:313–319.
Shernoff M. 1996. Physicians living with HIV/AIDS. J Int Assoc Physicians
AIDS Care 2(11). [Accessed 2008 November 13]. Available from: http://
www.thebody.com/content/art2467.html
Tesoriero JM, Battles HB, Heavner K, Leung SY, Nemeth C, Pulver W,
Birkhead GS. 2008. The effect of name-reporting and partner notifica-
tion on HIV testing in New York state. Am J Public Health 98:728–735.
Tuboku-Metzger J, Chiarello L, Sinkowitz-Cochran RL, Casano-Dickerson A,
Cardo D. 2005. Public attitudes and opinions toward physicians and
dentists infected with bloodborne viruses: Results of a national survey.
Am J Infect Control 33:299–303.
Weiss ES, Makary MA, Wang T, Syin D, Pronovost PJ, Chang D, Cornwell
EE. 2005. Prevalence of blood-borne pathogens in an urban, university-
based general surgical practice. Ann Surg 241:803–319.
J. M. Aultman & N. J. Borges
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