Disclosure has always been a major controversial issue amongst HIV clinicians and the public at large. Unfortunately discrimination is still a fact of life around here. Many HIV positive people are the victims of unfair dismissal by their employees. Many are shunned by their communities and even their families. But when it comes to sexual partners, I don't think there should even be any question about disclosure. Yes, everybody should have safe sexual practices, but if you know you have HIV, I think you have a responsibility to your partner to tell them what they are getting themselves into before you get involved with them.
I saw this patient: an older man who had quite advanced HIV disease. He was in a profession that implied that he was well educated. It was about his third visit and he was due to start ARVs. His wife and daughter were with him. He complained of urinary symptoms, so I asked my assistant to take him to have his urine tested. As soon as they had left, his wife turned to me and asked "doctor, has he been tested for HIV?" I was a bit puzzled for a moment. I tried to gauge what her understanding was of why her husband was seeking medical attention and that from an HIV clinic, but she did not understand what I was saying. She spoke a broken English whereas her husband was fluent in English. So fluent in fact that I did not use a translator to speak to him. The situation became clear to me: he had not disclosed his HIV status to his wife and because she was clearly not nearly as educated as he was and not able to speak English well, she had not been able to follow what was going on at his medical visits. He was not being forthcoming with her.
Her husband and my assistant then returned, I pulled my assistant aside and said to her "this patient's wife just asked me if we have tested him for HIV. I think he has been keeping her in the dark about his diagnosis. Can you please speak to them and figure out what's going on." My assistant asked the wife to leave the room and spoke to the husband in his first language. In the meanwhile, I finished my clinical notes and filled in his prescription. After a while she called his wife back in and spoke to her for quite some time. She then led them away and told me she would fill me in on what had happened when she got back.
This she did. The patient had been sick for quite some time. He had been married before and this was his second wife and he had in fact been sick when he had met her. I wondered who gets involved with a man who is so sick. But I digress. The wife was very young - she had just turned 21 - whereas her husband was in his fifties. He had not disclosed his HIV status to her, as I had suspected. But worse than that, he had known his HIV status when he first met her and did not tell her. My assistant had explained everything to her after speaking to her husband and had taken her HIV counselling and testing. She was positive. This woman was clearly not very intelligent and was very poorly informed about HIV, but her husband was clued up and had not only known he was HIV positive when he met her, but in all likelihood had transmitted it to her. My suspicion was reinforced by the fact that she was clinically very healthy, but not only that, she had a very healthy toddler with her. This implied that she had early stage HIV and probably did not have it when she was pregnant. Her husband, however, had very late stage HIV. I asked if the patient was the father of the child, who looked to be about 1 and a half years old, and my assistant said he was not. The woman had had the child before she met him. I breathed a sigh of relief. The child was most likely not HIV positive. I mentioned that the child should be tested anyway and my assistant said that the woman had decided to have the child tested at their next visit. The whole thing upset me so much, but at least the child would probably be ok I thought. But then it occurred to me that I had seen the woman breastfeeding the child - one of the ways HIV is transmitted from a mother to a child.