Treat and Tell?

Paul, aged 28, is a long standing patient of yours, and has arrived for his usual three monthly appointment. You have known Paul since his family moved to your general practice’s area 11 years ago. Paul caught HIV 4 years ago, and he has been seeing you for his ongoing management over this time. You have witnessed Paul falling in love, and marrying Louise 14 months ago. Paul is not on any treatment for his HIVas he has maintained strong health. His CD4 count has remained above 500 and his viral load is very low, indicating that he does not currently need treatment for the infection itself or to prevent other opportunistic infections. There are no signs of deterioration of his immune system or of his health generally.

Paul asks you about going on treatment, not because his clinical situation requires it but because he wants to attempt to lower his viral load to reduce the chance of passing HIV onto his wife. “Treatment as prevention” has been in the media because of reports at the last World AIDS Conference, and Paul has read some of the information. He lets you know that he has found many articles on the internet that show that reduced viral load (due to treatment) greatly lessens the chance of transmission. Although Paul is also aware of the many complications that may arise from HIV antiretroviral therapy, he is willing to take the chance.

During your discussion with Paul, he tells you that he has not yet told Louise about his HIV status, and that until now they have been using condoms. Louise wants to stop using condoms but Paul is not yet ready to have the discussion about his status with her. Paul is afraid that she will no longer want to be with him. He says that he will need to have sex without condoms and this is the reason for the request to begin a treatment regimen.

Your practice is in an outer suburban area and it has a strong family focus. You are also the treating physician for Louise, and you know that she is keenly anticipating having a baby. You think how, once again, your clinical work involves intermingled ethical, legal and social issues, and how these will of necessity inform your duties and actions in relation to Paul and Louise.