Ethical aspects of HIV infection and reproduction

1. HIV infection is a transmissible disease with profound social and psychological implications for the woman, her partner and her family as well as for the health çare team and society. Its characteristics incinde a prolonged latent period, a very high morbidity and mortality and social stigma. in addition, there is as yet no vaccine or curative treatment. Vertical transmission from mother to fetus, or to infant via breast milk may occur. The incidence of this transmission may be reduced by drug therapy.
2. These facts bring shaıply into focus the ethical conflict between patient privacy and confidentiality and the need to protect the sexual partners, the health çare team and the public from a fatal communicable disease.
3. Because the disease has the potential of reaching epidemiç proportions, the overriding consideration of infection control for the whole population çomes into tension with the limits of individual rights. As well as aggressive educational programs, other measures that may be considered would be mandatory offering of antenatal screening and confidential disclosure of HIV status to sexual partners and to health çare workers at risk of exposure. Information regarding numbers of seropositive individuals should be made available to public health officials.
4. Individuals who are informed of positive serostatus suffer severe psychological sequelae including the sense that they have been given a death sentence. Furthermore discrimination based on seropositivity in regard to housing, jobs and insurance exists. Physicians have a duty, therefore, to provide nqt only individual counsel and çare for paitnets but also public advocacy to protect them from unfair ancl punitive actions.
5. While apprecıating the impoıtance of confidentiality and patient privacy, the ethical responsibility of individual patients to prevent harm to others stili exists. informed consent must be obtained prior to testing for HIV infection and communication of the resultant information. Eveıy effort should be made through counseling to convince individual patients of their responsibility to others including the importance of allowing such information to be used to protect sexual partners and health care workers. If in spite of eveıy effort, consent is not obtained and the risk of transmission is high in certain circumstances, with consultation, it may be justified to override patient confidentiality.
6. Assisted reproductive technology reqııires the elective donation of gametes, embryos or surrogate carriage of pregnancy. Because of the elective nature of this technology confidential counseling and testing can be done and inclusion of only those with negative HIV status is possible. To protect the interests ot those at risk of unvvantecl exposure to HIV inclucling the potential child only seronegative inclividuals should be allowed to participate.
7. Breastfeeding: in societies where safe. Affordable alternative methods of infant feeding are available, it may be ıınethical for an HJV infected mother to breastfeed her child. Where the risks of alternative infant feeding are high, the balance of risk to the infant.