HIV Infection and AIDS
HIV is already one of the most common venereal diseases. Its low infectivity has slowed its spread, but as an incurable disease with a long asymptomatic latency, its predicted equilibrium level is high. There is nothing unique about the problems posed by HIV as an STD (sexually transmitted disease). The widespread reliance on oral contraceptives and IUDs has contributed to the very high levels of other STDs such as gonorrhea and chlamydia. It is the catastrophic consequences of HIV, rather than its epidemiology, that commands our attention.
As HIV infection spreads in the United States, oral contraceptives, IUDs, and other nonbarrier contraceptives are no longer acceptable choices as the sole form of birth control for women outside long-term monogamous relationships. Although the known failure rates of condoms as birth control devices makes it dishonest to speak of “safe sex,” it is clear that condoms, combined with certain spermicides, appear to provide substantial protection against infection with HIV. It has already become a standard of care to counsel about the risk of HIV infection whenever contraception is discussed with a patient:
Historically, birth control and sexually transmitted disease control were closely linked. Abstinence and condoms were birth control options that also prevented the spread of sexually transmitted diseases. A changing attitude toward sex and improved contraceptive technology, however, has effectively severed the tie between birth control and control of sexually transmitted diseases. Users of intrauterine devices, birth control pills, and sterilization, though effectively protected from pregnancy, are still at risk of sexually transmitted diseases. AIDS has signaled the need to reintegrate these aspects of gynecologic care. When contraception is discussed, women should be informed about HIV transmission and how to lower the risk of sexual transmission. [ACOG Technical Bulletin 136. Ethical Decision- Making in Obstetrics and Gynecology. Nov 1989.]
Every patient must be counseled about the risks of HIV infection. Patients in long- term, monogamous relationships should be given the surgeon general’s AIDS information pamphlet and be informed that the disease is spreading in the population. These persons are not at risk if their relationship is monogamous, but studies repeatedly demonstrate that a significant percentage of apparently long- term, monogamous relationships are neither. Sexually active patients who have multiple partners over a period of years or those whose partners are not exclusive are at increasing risk of contracting HIV. These patients must be counseled that methods of birth control other than condoms subject them to a substantial risk of HIV infection. The patient may choose to accept this risk, but the medical care practitioner must be able to prove that the risk was assumed knowingly. The medical care practitioner must carefully document that the patient was counseled about the risk of HIV infection, that HIV infection leads to AIDS in both mother and child, and that HIV is increasingly a problem for heterosexuals.
An ethical question posed by HIV and contraceptive choice is the extent to which patient choice is swayed by medical care practitioner recommendations. Many patients rely on their medical care practitioner to let them know what is medically dangerous. If the medical care practitioner tells them to give up bacon and eggs forever because their cholesterol is elevated and the same health care practitioner continues to renew their oral contraceptive prescriptions, the implicit message is that HIV is less of a threat than a greasy breakfast. This does not mean that medical care practitioners should refuse to prescribe oral contraceptives for women who are not in long-term, monogamous relationships. It does mean that the medical care practitioner must take care that warnings about HIV are not lost in the general noise of good health tips and recommendations that are given each patient. Patients who engage in high- risk sexual activity must be helped to understand the seriousness of the threat of HIV infection. This information should be reiterated whenever contraception is discussed or a prescription for oral contraceptives is refilled.