march 2007 THE OUTHERN AFRICAN JOURNAL OF HIV MEDICINE 44 The Southern African HIV Clinicians Society initiated an online discussion forum on ‘HIV Ethics and Policy’ in 2007. The first case study concerned the ethical question of whether a surgeon with HIV/AIDS on antiretroviral therapy should have disclosed her HIV status to her patient when she discovered blood on the inside of the first of her double gloves after surgery. The case study, and some responses submitted to the forum, follow below. ETHICS CASE STUDY Disclosure of doctors with HIV/AIDS on antiretroviral therapy Marlise Richter, BA Hons, MA, LLM School of Public Health, University of the Witwatersrand, Johannesburg David Spencer, MB ChB, MMed, DTM&H Kimera Consultants, Edenvale, Johannesburg CASE STUDY 1 AA is a medical doctor and practises in South Africa. While still in training some years ago, she had a needle-stick injury followed some weeks later by a seroconversion illness. At the time antiretrovirals (ARVs) were unavailable, and indeed the diagnosis was missed: it was the late 1980s and she was working in a mine hospital. Some years later AA discovered her HIV status while trying to obtain insurance cover. She was referred to Dr T a few years later when her CD4 cell count had fallen. Since the mid-1990s AA has been on ARVs – almost all available ARVs have been used over this 10-year period. In 2006, her CD4 count was above 500/μl and her viral load has been undetectable for many years. In the middle of 2002, AA called Dr T to report that after doing a surgical procedure earlier in the day, she had noticed some blood on the internal glove during de-gloving. She had double-gloved and the blood was seen after the first glove was removed. When she took off the next glove, however, she could not find any laceration on her own finger (below the site of the blood on the glove), and she therefore assumed that the blood was the patient’s and not her own. (The procedure had involved the insertion of a needle into a large vein in the neck of the patient, and had been uneventful apart from quite a bit of bleeding from the operative site. A nurse had had to compress the area for several minutes at the end of the procedure to arrest the haemorrhage.) AA asked Dr T’s advice on the following ■ whether he thought she should inform the patient of the incident; ■ was there any likelihood that the blood in the glove was actually hers, and ■ might there be a possibility that the patient had been exposed to her blood and possibly to the HIV virus? At the time, AA viral load was undetectable and she was on round-the-clock ARVs. Dr T expressed the opinion that that it seemed unlikely that the patient had been exposed to the doctor’s blood and that post-exposure prophylaxis (PEP) was not indicated for the patient. Disclosure to the patient would mean the possibility that the doctor’s HIV status would become known beyond her immediate family and Dr T, and that her medical practice and livelihood might be jeopardised. It seemed that the risk to the patient was not significant or measurable. Dr T counselled against informing the patient of any risk and against initiating PEP. Three months later Dr T was asked to see a patient who had recently been diagnosed as HIV positive. He was the man on whom the surgical procedure had been carried out by AA. Blood tests revealed recent exposure to the virus: initially negative HIV antibody tests (HIV Elisa) but with an extremely high viral load. The HIV Elisa subsequently became positive. The patient started on ARV therapy and has remained well. He noted that he had had a range of sexual partners, and believed that one of these might have infected him. Some time later the patient returned to Dr T. He was perplexed. He had seen all of his sex partners, and each had tested HIV-negative. ‘Doctor, where did I get this infection?’ he asked Dr T. ‘Do you think that it might have been at the time of the medical procedure some months earlier?’ He recalled that there had been a lot of bleeding from his neck following the operation, and that a nurse had ‘stuck her finger in the hole to stop the bleeding’. He asked whether he could have got the infection from the nurse. Dr T has been unable to DNA-fingerprint AA’s virus owing to its being undetectable. Dr T wanted to confirm resistance mutations that might identify whether the patient’s and AA’s virus are the same. The patient’s viral genotype revealed a fully sensitive HIV-1 virus, and he has achieved viral suppression on first-line ARV therapy. AA had viral genotyping several years ago when she showed evidence of resistance. Her virus has multiple resistant mutants, and for some years now she has been maintained on ‘salvage