Testing patients for HIV

Regarding Dr V Raman Kutty’s article on ethics in public health practice (1), I beg to differ with the author with respect to the following statement:

“Perhaps they forget that the patient has an equal right to know the HIV status of their health practitioner, since it is a well known route of spread.”

May I ask the author where he got this reference from? I believe that such reciprocal transmission is yet to be reported in case of HIV.

I have a few other points to raise. Why is there such secrecy about AIDS? Would you not like to know overall incidence and prevalence of HIV-infected patients in the region? If you don’t have the statistics, how do you understand the extent of the epidemic? How are you going to fight it on a war footing if you don’t even know (or want to know) statistics of infected individuals? If acute polio can be a notifiable disease, why not HIV? How ethical is it for an individual who has acquired HIV from other sources to knowingly infect his wife who is ignorant of his status? Is there any insurance policy or a job security for an individual who acquired the infection accidentally while serving humanity? There are no easy answers to these questions.

I feel there are many misperceptions and much hypocrisy when we talk about treating the HIV patient ethically. We need to change the overall attitude of society towards HIV patients. I fully agree with the concept that under no circumstance should there be discrimination against AIDS patients. However, I do not agree that HIV testing should not be made routine before any intervention. I can defend my statement for the reason that even the largest public hospitals in India will not be able to afford the expenses of medical and paramedical staff taking universal precautions for all patients routinely.

Let me quote the British Orthopaedic Association’s recommendations on what should be worn by the surgical team for the prevention of HIV and Hepatitis infection in operation theatres (these are only excerpts):

Protection of face and head: 1. Full eye protection goggles or visor, not spectacles; 2. Closely fitting hood of finely woven material, or disposable paper, covering the neck; 3. Ventilated hood or gown in high risk cases. (comment: these are currently not available in India).

Gowns: cotton gowns are not acceptable. Wrapover type of adequate length gown made up of high quality disposable paper, preferably laminated at the front and sleeves. They should be of a fabric with proven resistance to strike through.

Gloves: Double gloving with cotton outer gloves. Frequent changes of the outer gloves are recommended.

Foot protection: Wellington boots impervious to penetration, knee high, well overlapped by the gown.

In every case these precautions are obviously not practical. The question here is, are we well equipped and ready to treat HIV cases in epidemic proportions?

Doctors are like soldiers on the battlefield. Their dedication, commitment and sincerity should not be questioned. Are we going to ask our soldiers to lay their lives without arming them adequately for the fight against the very strong enemy? Denying the obvious fact that most public hospitals do not have these amenities is like pulling a hood over one’s eyes. Also, there is no quality control over the ‘HIV kit’ they provide the staff.

Ethical issues need to be re-examined in this perspective.