Case 1: A 40 year old man presented in 1990 for a life insurance medical and routine blood tests including HIV antibodies. The HIV test was refused. Despite prompting, the reasons for this were not volunteered. Several days later, I received the patient’s results. This included an HIV antibody test identifying the patient. This was in contravention of our practice policy which is to code HIV results. The pathology request form was reviewed. This showed an HIV test had been added in different handwriting. Practice and pathology staff could not explain the source of this writing. The patient returned for his results. Fortunately, the patient raised the issue of the HIV test himself. He had changed his mind and had himself written on the request form before delivering the request form to the pathologist. The implications of his negative result were explained after discussing the patient’s risk factors for HIV with him.

Case 2: A 43 year old married clergyman presented in 2000 with a recurrent infection of his little toe. This developed into a pyodermic granuloma and was treated by curretage and diathermy. The preliminary pathology report queried Kaposi’s sarcoma and further staining was requested. The patient failed to call for his results. Based on my knowledge of this patient and his family, there were no risk factors for HIV infection. I considered whether to arrange an interview with this patient as soon as possible in order to take a detailed sexual history with a view to urgent HIV testing. I felt this course of action was likely to cause distress, that the risk of HIV in this patient was low, and that the delay in getting a final histological diagnosis was unlikely to alter the clinical course. The subsequent pathology report confirmed granulation tissue only.

DISCUSSION

General practitioners (GPs) owe duties to their patients to detect HIV infection and to offer pretest counselling before testing for serious communicable diseases.¹ Patients with mental illness, who are critically ill or unconscious may lack the capacity to give informed consent.¹ In these circumstances, researchers² and clinicians³ have justified HIV testing without consent. These arguments are rejected by others: some contend that failing to seek a patient’s consent before HIV testing is always wrong^4,5; while others suggest testing should only occur when it will alter the clinical care of the patient.⁶ The General Medial Council specifies rare circumstances when HIV testing may occur without consent.⁷ These guidelines emphasise the need to discuss actions with a colleague in order to ensure that one’s actions are reasonable and professional. Despite this literature, there is limited discussion concerning potential lapses in these procedures which can arise in general practice.

Patient autonomy and self determination underpin informed consent before HIV testing.¹ These cases illustrate times when informed consent may not be obtained in general practice: either because of systematic errors in the process of obtaining informed consent, coding, and receiving results, or because other pathology tests, such as skin biopsies, can act as surrogate markers of HIV.

In responding to these situations, GPs need to consider the organisational and legal dimensions of practice and their professional and ethical roles. These aspects of practice are central domains of general practice.⁸

Inadvertent HIV testing without consent raises two issues: firstly, the patient has the right to know what has happened and to be asked whether they wish to know their results; and secondly, the consult is more difficult to predict and plan, as the patient’s response to a positive or negative result has not been explored. In my opinion, more harm may be done to the doctor/patient relationship by deliberately concealing knowledge of the result, even if it is negative. The patient may find out at a later date of testing, if they receive treatment from a colleague or a locum of the practice and are asked about the reasons for the recent HIV test. This would be worse than discussing the error at the time it was discovered.

General practitioners have legislated guidelines concerning pretest counselling which can be considered as minimal standards of care.^1,7 The importance of documenting pretest counselling or a patient’s refusal to testing is illustrated by case 1 where HIV testing occurred because of a systems error. Documentation needs to cover what was discussed and the patient’s capacity to consent to, or decline, HIV testing.^1,7 I reflected on this incident, and have since changed my clinical practice: I now always take a coded HIV venous sample myself. Using this system, I can better ensure the confidentiality of my patients, and reduce the risks of patients organising an HIV test without pretest counselling. If a positive result had occurred in case 1, the GP’s professional and ethical role would have become more complex. The duty of care would expand to cover both the patient and their partner.⁹ Failure to notify the partner of the patient’s HIV status can represent a breach in duty of care.^1,7,9

Kaposi’s sarcoma can occur spontaneously in the elderly, however, in younger men it is usually a sign of AIDS.¹ General practitioners need to be very alert to the possibility of HIV infection. Acute HIV seroconversion and HIV infection can mimic conditions commonly seen in general practice including lymphadenopathy, fever, myalgia, cough, diarrhoea, candidiasis, and seborrhoeic dermatitis. Incorporating sexual and drug histories into routine clinical care can identify patients at increased risk of HIV. Case 2 demonstrates that the general practitioner needs to consider the possibility of HIV in association with the patient’s risk factors. Suggesting a possibility of HIV where it is unexpected and the risk is low, can in itself cause anxiety and distress. A valid argument to defer raising the possibility of an HIV diagnosis was made and supported by the subsequent histology in case 2.

This case series demonstrates bioethical dilemmas which can arise in HIV medicine in general practice. The GP plays an important role in assessing patient risks factors, facilitating early detection of HIV, and ensuring that testing occurs with informed consent. At times, these duties can compete with each other and GPS need to balance the rights of their patients and partners to optimise care.