My patient, a 26-year-old native of the Dominican Republic, had been seeing me for only a few months when I determined that he had been infected with HIV. He didn't seem surprised but was close-mouthed about his sexual orientation or where he might have contracted the virus.
I began to caution "Miguel" about unprotected sex, but he insisted that he didn't have, or plan to have, a lover.
As his T-cell counts dropped and his viral counts rose, I referred him to an infectious disease expert who began treatment with anti-retroviral drugs. After several months of this treatment, the counts stabilized, and he remained relatively healthy, though he was frequently depressed.
Four years later, he sent "a close friend" to see me. The friend, also a Dominican, had been brought into the country three years before by Miguel, who had then helped him establish citizenship. Now the friend was returning the favor by marrying Miguel's sister so she could become a U.S. citizen.
The friend, "Carlos," and the sister had come to see me at the same time. In my visit with her, she immediately revealed that the marriage was in name only and that her husband was gay. I saw Carlos next, and he openly acknowledged being gay and asked me to test him for HIV as part of his routine blood work.
The test came back positive, and I called him back to my office to discuss the results. During that visit, Carlos readily admitted that Miguel was his lover -- and feared that he had unintentionally put Miguel at risk. At that point, I realized Miguel had never told his lover that he had the virus.
The truth slowly dawned on Carlos as well. Although initially afraid that Miguel would be angry, he then recalled that he had tested negative for HIV just nine months before. "Did Miguel give me this?" he asked. "Does he have it?"
"You have to ask him," I replied. "I can't say."
Although Carlos may have thought I was communicating the necessary truth by not denying it, I not only owed my patients confidentiality, I was bound by law from revealing one patient's information to another.
Carlos was surprisingly calm, saying he still loved Miguel despite having been seduced into becoming his condom-less lover years before.
My office nurse, who had spoken with Carlos and knew the circumstances, described Miguel's apparent silence on his HIV status as attempted murder. That comment caused me to examine the laws regarding HIV disclosure more closely -- and my own actions.
