1. Ethical Dilemmas in HIV Wendy Majewska Senior Health Adviser St George’s Hospital London

3. Ethics 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 practiceethics  rarely used in its original form today although serves as foundation for other similar oaths and laws that define good medical practice

4. Four guiding principles Pillars of ethics  Non-maleficence  Beneficence  Justice  Autonomy

5. Fertility treatment Organ donation End of life care HIV……  Terminal  Sexually transmitted Ethical dilemmas?

6. Case 1 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

7. Can PEPSE be given without disclosing HIV status? Should confidentiality be broken and HIV status disclosed?

8. Influencing factors  Risk of transmission 1:1000 -1:3000  VL  Length of exposure  Potential harm

9. Case 2 32yr old gay man diagnosed HIV+ PN  RMP 4 years  Tested HIV+ RMP – PN  Married 26 years - midwife  Reluctant to inform – reported no recent SI

10. Influencing factors  Sexual history  VL / CD4 count  On-going risk  Occupation  Co-habiting  Time frame  Collaborative working

11. 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

12. Can we inform mother? Can we withhold daughter’s HIV status?

13. Case 4 HIV+ newly diagnosed woman Unusual drug resistance assay Seen by consultant working at 2 sites  Recognised resistance pattern  Clarified risk factors Female pt at other clinic same resistance pattern – similar profile of sexual contact identified

14. Additional female patient identified – address noted as being the same as 1 st pt 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+

15. 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

16. HIV+ man knowingly exposed 4 women to HIV infection Can action be taken?  What action might be appropriate?

17. Case 5 Pregnant woman Declined HIV testing in pregnancy Referred to HIV Midwife Referred to Health Adviser Issues re unborn baby

18. Is safeguarding of unborn child an issue? Would the same apply across UK?

19. On-going ethical issues Pregnant – refusing ART Contact of HIV+ refusing testing but in other steady relationship Paediatric HIV - YP MTCT Confidentiality

20. Key points Decision should not be taken alone Work as MDT Remember  Non-maleficence  Beneficence  Justice  Autonomy

21. Health Advisers are key in  exploring ethical issues  resolution of dilemmas If not us, WHO?

22. HIV and the law 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

23. 14 prosecutions to date in E&W 9 pleaded ‘guilty’ 5 pleaded ‘not guilty’  2 convicted  longest sentence 10 years – 3 complainants  other sentences range 2 - 4 and half years 2 convictions were in women

24. Intentional Or Reckless Sexual Transmission Of Infection ‘….this area of the criminal law is exceptionally complex’ ‘….will be difficult to prove to the requisite high standard…’ 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