Dr Bob,

I am a physician who recently diagnosed a prostitute with HIV/AIDS. Whilst she won't admit it I suspect she is a drug user as well. She is 25, with a high viral load, she claims she takes her meds (I think she misses some due to her drug habit). I feel that I am losing an uphill battle in that she will continue to become resistant to meds and keep acquiring either new strains of the virus (through IDU or unprotected sex) or OI's. She works privately out of a runned down apartment - which in itself is entirely legal in this city. I give her extra condoms and when I ask her if she uses them 100% of the time she says 'mostly'. I asked her what she means by this and she says 'sometimes I don't when the client is willing to pay a lot extra. However, is it legal for her to practise unsafe sex when she is knowingly has AIDS, let alone HIV. How would you proceed?

Hello,

Your patient presents a difficult problem. Certainly I would continue to try to work with her to address her drug problem, adherence issues and HIV prevention/transmission concerns by involving social services and AIDS support networks, if she is amenable. I don't know where you are writing from, but AIDS is a reportable condition by law. Consequently, if she qualifies for that diagnosis, contacting the county or state health officers to discuss options would not be betraying any doctor-client privileges. HIV-positive status (non-AIDS) names reporting has also been passed into law in many states. This may also afford you the legal parameters to involve the local health authorities.

Finally, this type of scenario is a reminder to the readers of this forum that HIV prevention and protecting your own health must ultimately be your own personal responsibility.

Dr. Bob