This document summarizes a clinical case involving a 29-year-old homeless man presenting with shortness of breath, coughing up blood, and weight loss. Examination and tests revealed cavitating lesions in his lungs suggestive of tuberculosis, and a positive HIV test. He was started on anti-tuberculosis treatment and referred to sexual health clinic given his HIV diagnosis. The document then discusses legal issues around confidentiality, disclosure obligations for healthcare professionals, and cases establishing higher disclosure standards for those with infectious diseases like HIV.

1. Year 4 Law SSS: Matt Redmond 3547108

2. Contents
Section 1 – Clinical Case
Section 2 – Discussion of the legal issues
Brief recap of confidentiality
Some interesting cases
What this means for us as clinicians

3. First, a little background information...
Age: 29 Sex: Male Occupation: Homeless
PMH: IVDU
FH: Unremarkable
SH: MSM with multiple sexual partners. Oral and anal
intercourse, both active and passive, condoms
“usually”. No foreign travel.
Drinks “infrequently”, smoking history 16py
DH: No medications, NKDA

4. “So, what seems to be the problem?”
Presenting Complaint
 Gradual onset shortness of breath at rest
 Not worsened by posture
 Worsened by exercise
Associated with:
 Right sided pleuritic chest pain
 Denied radiation
 Productive cough (>3/52) with small amounts of blood
 Weight loss
 Night sweats

5. “Nice deep breaths in and out please.”
Examination
 General: Seemed uncomfortable at rest, and unwell.
 CVS: Unremarkable – although recent IVDA noted
 Resp: SOBAR. Some bronchial breathing bilaterally in the
upper lobes, which were also dull to percussion.
 GI: Unremarkable
 Neuro: Unremarkable
 GU: Unremarkable

6. Radiology
Report:
This is a
good quality
PA chest
radiograph
which
demonstrates
bilateral
upper-lobe
cavitating
lesions,
suggestive
of
tuberculosis
infection.
Dr M Redmond
MBBS MD MRCP
FRCR
Consultant
Radiologist
Image sourced from MDCH TB Programme

7. The plot thickens...
 The patient was referred from casualty to the care of the
respiratory physicians
 On admission the chest ward, the history and
examination was repeated. It was noted that he had a
generalised lymphadenopathy and strange rash on his
trunk...

8. Norfolk and Norwich
University Hospital
DERMATOLOGY DEPARTMENT
This photograph
demonstrates a diffuse
erythematous
maculopapular rash on the
trunk of a 29 year old
IVDU.
The lesions are well
defined, and appear to
have some evidence of
excorations. The lesions
are non-specific.
This patient requires
further investigation.
Signature and Bleep number: Dr M Redmond MBBS MD FRCP
Consultant Dermatologist 1234

9. Differential Diagnosis
Tuberculosis +/-
Lymphoma
Glandular Fever
Seroconversion syndrome
Incidental intercurrent illness

10. Investigations
Serum:
 FBC showed a leucocytosis with an increased
PMN count
 U&E and LFT NAD
 Paul-Bunnell test negative
 HIV RNA present.
Blood film: Unremarkable
Sputum sample: Acid-fast bacillus on Ziehl-
Neelsen stain

11. Management
 Standard anti-tuberculosis treatment was commenced.
 The chest SHO called the sexual health clinic to inform
them of the gentleman’s diagnosis and for further advice.
 The specialist performed a further examination which did
not show any signs of oral candidiasis, hairy leukoplakia,
nor Kaposi’s sarcomas.
 It was decided that he had chronic TB, complicated by an
acute seroconversion reaction.
 He was asked to attend the sexual health clinic for 3
monthly follow-up with a consultant.

13. HIV information
 UK incidence rate of 11 per 100,000 population per year1
 ~25% of HIV positive individuals are unaware of their
disease
 Spread via bodily secretions
 Usually fits into three stages:
 Seroconversion reaction
 Latent period
 Eventual progression to AIDS
 Should be thought of as a chronic condition (e.g. DM)
 “Uncurable” – but manageable with treatment

14. “HIV does not make people
dangerous to know, so you can
shake their hand and give them a
hug – Heaven knows they need it.”
Princess Diana

15. Obstacles to disclosure...
 Being HIV positive is a highly stigmatised, sensitive
diagnosis with financial, social and psychological
implications2
 GUM notes are a closely guarded commodity and do not
usually leave the department!
 Part of patient autonomy is respecting their wishes not to
have intimate information shared freely3 – hence
encouraging the patient to disclose rather than via the
usual methods. But the patient might not be willing/able
to do this...

16. A brief reminder of Confidentiality
“A duty of confidence arises when one person discloses
information to another in circumstances where it is
reasonable to expect that the information will be held in
confidence.
 It is a legal obligation that is derived from case law;
 It is a requirement established within professional codes of
conduct; and
 It must be included within NHS employment contracts as a
specific requirement linked to disciplinary procedures.”4
It is not absolute5 – practitioners can disclose if:
 It is required by law
 The patient consents
 It is justified in the “public interest”

17. The Caldicott Principles
On transferring patient identifiable information, the
following principles should be considered6:
 The purpose should be justifiable
 Don’t use patient identifiable information unless
absolutely necessary
 Use the minimum necessary information
 Access should be on a strict “need to know” basis
 Everyone should be aware of their responsibilities
 The law should be understood and complied with

18. An interesting case...
[R. v Konzani 2005] 7
 Defendant was Malawian gentlemen
 Diagnosed with HIV in November 2000 – and counselled
about the risks of transmission
 Engaged in unprotected sex with 3 women – all of whom
were HIV negative prior
 He did not tell any of the women he was HIV positive, and
knew of the risks involved with his behaviour
 All three women later contracted the disease

19. And the result:
 Judge Fox QC found him guilty of three counts of grievous bodily
harm under s. 20 of the Offences against the Person Act 1861
“Whoever shall unlawfully and maliciously inflict any grievious bodily
harm upon any other person, either with or without any weapon or
instrument, shall be guilty of a misdemeanor, and shall be liable to
be kept in penal servitude” 8
 Konzani appealed – his defence was that by consenting to have
unprotected sexual intercourse with him, the three women were
implicitly consenting to all the associated risks
 The appeal failed. The judge agreed that there is implied consent
inherent to casual sex – but when one party is infected with HIV
then a higher standard of disclosure is required. (R v Dica [2004]9)

20. So what does this mean for us?
A patient with a new diagnosis of HIV should be10:
 Educated about the policy of confidentiality in the NHS
 Informed about record keeping, and sharing of health
information in the NHS
 Encouraged to share information appropriately with other
agencies (such as dental practitioners)
 Have a sensitive enquiry of potential workplace issues
 Counselled on the importance of contact tracing and
informing sexual partners

21. Breaking Confidentiality...
 If you’re a junior – don’t go it alone!
 Consider talking to a GUM specialist for their opinion
 It is highly recommended that you seek a medicolegal
opinion from your legal defence company and/or the
hospital legal team
 Document very carefully and contemporaneously as your
notes will be scrutinised!
 If appropriate, tell the patient what you intend to do4

22. References
1. HPA HIV in the United Kingdom: 2010 report (2010)
2. Bunn JY, Soloman SE. Measurement of stigma of people with HIV: a
reexaminatinon of the HIV stigma scale. AIDS Educ Prev. 2007
Jun;19(3):198-208
3. Art. 8 ECHR
4. Department of Health. Confidentiality: NHS Code of Practice (2003)
5. General Medical Council. Confidentiality (2009)
6. Caldicott F. Report on the review of patient identifiable
information.(1997)
7. R v Konzani [2005] EWCA Crim 706
8. S. 20 Offences against the Person Act 1871
9. R v Dica [2004] EWCA Crim 1103
10. British HIV Association Standards for HIV Clinical Care (2007)

23. Thank you for listening...any questions?