HIV Diagnosis and a Pregnant Partner Who Does Not Know
A 27-year-old man is diagnosed with HIV at a voluntary counseling and testing site in Phnom Penh. His CD4 count is 210 cells/µL and he has no opportunistic infection. He is started on antiretroviral therapy. During counseling he says his wife, a 24-year-old schoolteacher who is 18 weeks pregnant, does not know his status. He has not disclosed to her despite repeated counseling over 2 months and begs the clinic not to tell her. He says he is afraid she will leave him and that his family will reject him. He works as a motorbike taxi driver and earns about USD 10 per day. He attends the clinic alone. The clinic has a trained counselor and can offer couple testing, but he has refused three appointments. His wife receives antenatal care at the same clinic.
1. What are your professional and legal obligations regarding confidentiality and disclosure here? Outline a stepwise approach.
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The default is confidentiality; I cannot disclose HIV status without consent except in narrowly defined circumstances under Cambodian HIV law and Ministry of Health guidance. The first step is to explore why he has not disclosed, address fears of stigma and violence, and offer assisted disclosure by a trained counselor, including couple testing. I would document these discussions. If he continues to refuse and his wife is at risk, especially because she is pregnant, the clinic should use the permitted partner-notification pathway: a trained provider contacts the partner without revealing the index case's identity where possible, offers HIV testing, and links her to prevention of mother-to-child transmission. Disclosure should be the least intrusive necessary to protect her. I would not tell her informally in the corridor or by phone. If there is immediate risk of harm, follow local law and consult the clinic's ethics or legal focal point. The aim is to protect the partner and the pregnancy while preserving trust.
2. His wife attends the same clinic for antenatal care and asks you directly, 'Has my husband been tested?' How do you respond?
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I would not lie, but I would not disclose his result without consent. I would acknowledge her concern, explain that I cannot discuss another person's medical information, and offer to see them together or to arrange a counselor. I would ask why she is asking and assess her own risk, then offer HIV testing to her today as part of antenatal care, regardless of his status. If she tests negative, I would explain the window period and the need for repeat testing. If she tests positive, I would link her immediately to PMTCT and treatment. I would encourage her to invite her husband to a joint session and offer assisted disclosure. If she is at risk and he still refuses, I would activate the partner-notification process rather than disclose directly. This respects confidentiality while not abandoning her.
3. What prevention of mother-to-child transmission and treatment steps are indicated for the couple and the infant?
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The wife needs HIV testing now and repeat testing if negative, because she is pregnant and at risk. If she is negative, she needs prevention counseling and repeat testing in the third trimester and at delivery. If she is positive, she should start lifelong antiretroviral therapy regardless of CD4 count, with a regimen active against her virus and safe in pregnancy; adherence and viral load monitoring are key. The husband also needs to continue his own ART and adherence support. Delivery should be at a facility with PMTCT services; infant feeding should be supported according to national guidance. The infant needs nevirapine prophylaxis from birth, early infant diagnosis by DNA PCR at around 6 weeks, and cotrimoxazole prophylaxis if indicated. The couple should receive counseling about safer sex and disclosure. Partner notification and PMTCT are linked: protecting the wife also protects the infant.