HIV now reportable

BC comprises 13% of the Canadian population, but accounts for approximately 20% of newly reported HIV infections. After a decade of decline, overall HIV incidence is now showing a small but significant (6.5%) increase. The past decade also saw the emergence of separate HIV epidemics with both injection drug users and heterosexuals. Women comprised 22% of newly reported cases between 1996 and 2001. Estimates vary, but as many as 13000 British Columbians could be living with HIV. According to Health Canada, up to one-third of infected persons may be unaware of their status.

An emerging priority in HIV/AIDS prevention is to increase the awareness of individuals of their risk and to increase knowledge of HIV status. Public health involvement in active partner notification is essential to this strategy. Earlier this year, following a report by the provincial health officer, (www.healthplanning.gov.bc.ca/pho/other.html), cabinet approved a recommendation to add HIV to schedules A and B of the BC Communicable Disease Regulations.

Adding HIV to the list of reportable communicable disease results in an active partner notification process, with public health professionals providing skilled, trained assistance to physicians and their patients.

Partner notification means informing the partners of an “index patient” that they have been exposed to HIV. Partner notification is voluntary and, to the extent possible, anonymous.

A review of the evidence on the effectiveness of partner notification is found in this issue of the BCMJ. Active partner notification has been shown to be up to seven times more effective than passive partner notification in reaching contacts of an index patient.

To date, partner notification in BC has been passive, that is, left to individual physicians and patients, and there is no information on the extent to which partner follow-up is achieved.

Two other articles in this issue of the Journal set out in more detail the implications that reportability will have for patients, practising physicians, and public health practitioners ("The impact of HIV reporting on HIV pretest counseling" and "Public health follow-up of reported cases of HIV infection in BC"). Among these are the protection of confidentiality and informed consent. Lapses in both are reported by the HIV-affected community to be a problem for women and other marginalized groups, such as injection drug users and youth in BC.

While it is impossible to ensure that no breaches of informed consent or confidentiality will occur, including HIV under the communicable disease regulations reinforces the duty of confidentiality and allows for legal recourse in the event of such a breach. Under the Health Act, breaches of confidentiality are subject to penalties of up to $200000 in fines or 12 months in jail. In addition, the regulation allows patients to make an informed choice as to whether a positive test result is to be reported nominally or non-nominally. This provision is to ensure that persons at risk are not deterred from testing by concerns over privacy.

The College of Physicians and Surgeons raised concerns that these regulatory changes could prevent physicians from discharging their ethical duty to warn a third party at continuing risk of infection (e.g., the spouse of an HIV-infected patient who has refused to inform him or her or to change behaviors).

Accordingly the BC Communicable Disease Regulations have been further amended to enable a physician to make such concerns known to the medical health officer. Upon receiving this information the medical health officer may:

• Request further relevant information from the physician.

• Require the index patient to undergo further examination and to provide further relevant information.

• Disclose to any person who may be at risk of harm any relevant information the medical health officer feels necessary to address the harm or to prevent further harm.

A regulatory framework now exists that brings BC into line with other Canadian provinces and territories and allows physicians to discharge their ethical duty to warn a third party at risk. I urge all physicians to become informed about these changes and to work with the public health community in reducing HIV in BC.

—Perry Kendall, MB
Provincial Health Officer