A new HIV diagnosis and a husband who must not be told

Default position: confidentiality is the rule, not a courtesy. She is an adult with capacity; disclosing her status without consent breaches confidentiality, damages trust in the whole antenatal service, and may expose her to violence and loss of housing - which would also end her access to treatment and to prevention of mother-to-child transmission.

What I would actually do, visit by visit

1. Assess the risk honestly, and write it down. He has a history of a genital ulcer and a partner who was unwell; they are likely to have ongoing unprotected intercourse. This is a real, continuing risk of transmission to him and, through him, to others.
2. Offer assisted partner notification, not unilateral disclosure. Explain the options: she tells him herself, she tells him with me in the room, or the clinic contacts him with a neutral "you have been in contact with an infection, please come for testing" message that does not name her.
3. Give her a defined time frame (for example, two to four weeks) and further counselling, with condoms and advice on negotiating their use.
4. Practical protections: start treatment today so her viral load falls - an undetectable viral load greatly reduces risk; treat any sexually transmitted infection; explore her safety and finances and link her to a social worker or support group.
5. Bring in a senior clinician or the facility's ethics or legal focal person if she continues to refuse. Breaching confidentiality is a last resort, and in a setting where disclosure may cost her home and safety it requires a documented senior decision and knowledge of national guidance, not a unilateral choice by one clinician.

What would change my approach: a credible, specific threat that he intends to harm someone, or evidence that she is being coerced into refusing disclosure so that he can continue to expose others. Neither is present here.

Start today

• Tenofovir 300 mg / lamivudine 300 mg / dolutegravir 50 mg, one tablet once daily - a single-tablet first-line regimen with a high barrier to resistance and rapid viral suppression.
• Cotrimoxazole prophylaxis: her CD4 of 280 cells/µL is below 350, so give cotrimoxazole 960 mg daily until the CD4 has recovered on treatment.

Gestation and the choice of regimen

• Dolutegravir is now considered safe throughout pregnancy, including the first trimester. The early signal of neural tube defects was not confirmed in larger data, and the benefit of a regimen that suppresses the viral load quickly outweighs that theoretical risk. Gestation is therefore not a reason to use an inferior regimen or to delay treatment.
• If she were already on an efavirenz-based regimen and suppressed, she could continue it - but she is treatment-naive, so start with the best regimen.

Baseline and follow-up

• Baseline: haemoglobin, creatinine, liver enzymes, hepatitis B surface antigen, tuberculosis screen, CD4 (done), and a viral load.
• Repeat viral load in 3 months and again at 34–36 weeks. If the viral load is above 1000 copies/mL near delivery, plan for additional infant prophylaxis and discuss delivery options with the obstetric team.
• Prevention of mother-to-child transmission: infant nevirapine from birth, early infant diagnosis at 6 weeks, and counselling on exclusive breastfeeding with maternal adherence. Encourage her to deliver in a facility.
• Do not delay treatment to "sort out" disclosure; both tracks run in parallel.

Document at today's visit

• The test results and the post-test counselling given.
• Her explicit refusal of partner disclosure, in her own words, and her stated reasons (fear of being sent away, mother-in-law).
• The risk assessment: partner's genital ulcer history, likely ongoing unprotected intercourse, her statement that he has never been violent but that disclosure carries social risk.
• That assisted partner notification was offered in all its forms, that a time frame was agreed, that condoms and adherence advice were given, and that senior or ethics input was sought. This record protects her and protects you; it also shows that any later decision was reasoned rather than arbitrary.

If the husband later presents

• Tell him you cannot discuss any patient's information, without confirming or denying anything - including through tone, hesitation or who is called to the room.
• Offer him something that serves him directly: "I cannot discuss anyone else, but I can offer you HIV testing and a full sexual health check today, and it is free and confidential." Frame it around his health rather than her results.
• If he is aggressive, see him with a second staff member present and follow the facility's security procedure; her physical safety takes priority.
• If she is lost to follow-up, use the agreed tracing method (a neutral message or a community health worker contact) rather than sending a message that discloses her status to a relative or neighbour.
• Any decision to disclose without consent must come from the facility in-charge with reference to national guidance and, where possible, legal advice, and must be documented with the reason - it is never an individual clinician's informal choice at the reception desk.