Non-consented HIV testing by Belgian general practitioners

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Diagnostic HIV testing without the patient's consent is unethical and illegal [1,2]. This paper reports on the proportion of non-consented HIV tests (NHT) in Belgian general practice and the circumstances in which these tests are performed. Data were recorded from 1993 to 2000 in the Belgian network of sentinel general practitioners (GPs). The network is representative of Belgian GPs, and has been a reliable surveillance system for more than 20 years [3,4]. Since May 1988, every adult patient who has asked his GP for an HIV test has been recorded on a weekly registration form. Since 1993, questions about patient consent have been included. SPSS-PC 10 (SPSS Inc., Chicago, IL, USA) was used for analysis and statistical processing. In total, 292 GPs recorded 11 660 requests for an HIV test (52% by women). The mean age of the tested individuals was 33.2 years. Information about patient consent was available for 3628 tests. In total, 453 tests were performed without patient consent. This corresponds to 3.9% of all tests performed and 14% of the tests for which information is available about patient consent. The proportion of NHT decreased during the early 1990s from approximately 17% to less than 8%, and has increased since 1996 to approximately 12% in 2000. The proportion of NHT is 30% in the age group below 15 years, 40% in the age group above 64 years, and between 10 and 15% in the other age groups. For 29% of the NHT no risk behaviour was detected, and for 43% the existence of risk behaviour was unknown. In 28% of all NHT the patient declared him or herself to be at risk of HIV. Eighteen per cent of the HIV tests among patients originating from an endemic region were NHT and 15% of the tests in homosexual men were NHT. Twenty-three per cent of the NHT were performed on patients with suggestive symptoms. NHT was also popular as part of a check-up (21%) or during antenatal care (13%). Eleven per cent were carried out for an administrative reason, 8% in prospect of a new relationship and 8% among patients awaiting a surgical intervention. The proportion of NHT performed according to the motivation for the test is displayed in Table 1.Table 1: Proportion of non-consented HIV tests according to the motivation for the test in percentages (N = 3421).In total, 36% of all GPs performed at least one NHT. HIV tests returned positive for 1.5% (n = 7) of the NHT and for 0.5% (n = 23) of the consented tests. The Belgian medical deontology and law state that patients should be informed about the results of an HIV test. In this context, the proportion of NHT is astonishing. So is the proportion of physicians performing HIV tests without informed consent. A national telephone survey among hospital staff members in the USA revealed a similar problem [5]. A registration in Minnesota (USA) confirmed that only 10% of test requests were documented in the medical record [6]. The proportion of NHT in our study is remarkably lower. However, the comparison with the Minnesota study is difficult because it reports data on written notification and our study reports on non-specified oral or written consent. It is likely that most of the patients tested without consent did not receive the necessary pre-test counselling. NHT was popular in the context of preoperative and prenatal care. The argument that HIV testing is necessary to protect healthcare workers is improper. The knowledge of the patient's HIV status provides a false sense of security and there is still a window period during which the virus cannot be identified. Another delicate point in this study is the high proportion of NHT among patients consulting for administrative reasons or for a control in view of a wedding, a new relationship or a general check-up. Patient authorization for a blood test does not imply that physicians have the authorization for an HIV test. The Belgian Medical Council and the Belgian authorities should remind physicians once more about the unacceptability of NHT. Instead of performing HIV tests without consent, physicians should invest more time in pre-test counselling, especpecially in patients with a higher risk or with suggestive symptoms of HIV. In most of these cases valuable opportunities to provide risk-reduction counselling were missed. Acknowledgements The authors would like to thank all participating sentinel practitioners for their daily efforts over many years, Henk Van Renterghem for his contribution to the dataset, and Karolien Vantomme, Marianne van Winden, Neeltje Blommaert and Rinaldo Lauwers for their contribution to the text.