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Should I disclose? Medical Student entering this Fall
Jul 12, 2011

I am beginning medical school this August, and I am deciding whether or not to disclose my HIV status to my medical school or not in their pre-matriculation medical history questionnaire due before orientation starts in August. I have read through your biography and interviews and was wondering if I may seek your advice. I have extensively researched the web into the medical and legal implications of HIV disclosure to medical schools, and ran across a posted response on the matter by Dr. Joel Gallant, a preeminent HIV epidemiologist at Johns Hopkins. In it an HIV positive pre-medical student posed the same question (although he was just applying to medical schools at the time).

In the response to the student, he said there are two things to look at: the medical considerations, and the legal considerations. Medically, disclosure is probably unnecessary, since it poses little risk to patients, but that it might be best to avoid a career that involved doing open procedures, but even then the risk to a patient is probably greater from being sleep deprived or hung over than from having HIV, especially if one is on effective therapy with undetectable viral loads (which I have been undetectable all 2.5 years I have known I was positive from strict adherance to my ARV therapy, and I had a quick and full immune reconstitution).

Legally, however, Dr. Gallant stated that a public controversy could stir again if a case of HIV infection somewhere occurred via transmission from physician/dentist to patient; but even so, there might be protection by the fact that disclosure is not currently required in most states or institutions. He went on to give an example of a medical student who had a horrendous time after he disclosed his status early on and suffered HIPAA violations from administration and his information leaked out (an unintentional, yet very real possibility). He lost control of his medical information and it became a big deal, having special arrangements setup around him and training modifications put in place. Receiving a residency position was a struggle for him, even though he was able to do it.

Dr. Gallant ultimately recommended that if he were HIV positive and a medical student he would:

1) Would not disclose or make any decision during your first two years, where there is little or no contact with patients anyway. 2) Would never lie if directly asked about your HIV status on an official document 3) Would not tell anyone, if no one asked.

I inherently agree with him on all the points he may have made. Medically I do not believe there is a risk involved (certainly since I seem to be stable/undetectable, have been relegated back to 6-month appointments for follow-ups, and pose no immunological risk to any patients. And while I initially wanted to disclose my status out of what I thought was the moral thing to do, I quickly became savvier to how devastating things can become through several medical students' posted responses and nightmare stories.

My question to you pertains to the legal side of things. In Dr. Gallant's points he made, he suggested that one never lie if directly asked about HIV status on an official document. Well, I have a medical history questionnaire which is to be turned in ASAP before orientation early August. It is where my questions mainly lie. Specifically these 4 questions:

1) If I take any medications? 2) Have any chronic illness? 3) If I answered YES to any of the above questions, please comment below.

Then, a GP must review this history and complete a physical with lab bloodwork for the usual vaccinnations (HepB, RRM, Varicella). My GP I have gone to for 3 years , under careful consideration, told me "he has no documentation in his office of any chronic illnesses I have 'if I caught his drift' ". I do want to underscore that he under no circumstances took this matter lightly (nor should he have). But at the same time, he is trying to look out for my best interests. At the same time, I am not sure whether I should put him in such a precarious position, and have just in case scheduled a physical exam with another GP I have not seen before also.

My questions to you are: 1) What is your opinion on the matter of disclosing HIV status to medical schools before matriculation, during the first two years, the last two years, and with residency applications? 2) Do you think I can choose to not disclose my status and not put it on my medical history questionnaire, or is that a legal form "directly asking about my HIV status"? 3) Would you ask your GP you have known for three years to sign it (and get it and the bloodwork in sooner), or would you go with the GP you have not seen yet (whose appointment is set-out a week from now and would push labwork back a week)? 4) When, if ever, do you think I have to disclose my status? (I see it as a chronic manageable condition not unlike diabetes or ADHD, which I also have just recently been diagnosed for). In fact, they are thinking of relegating HIV medicine over to family physicians now because it is considered a chronic manageable condition, now aren't they?

Thank you sincerely for any advice you may have in advance! On a personal note, I am very inspired by your work in HIV medicine and work on this forum and am interested in infectious disease/HIV medicine myself, amongst other niches.

Response from Dr. Frascino

Hi.

In general I agree with Dr. Gallant's comments, particularly "never lie."

The medical questionnaire asked about medications and chronic illnesses. If you are on antiretrovirals, you'll need to list these. Since they are used only for treatment of HIV, you'll be disclosing your HIV-positive status. Likewise for the question regarding chronic illnesses, you'll need to list HIV disease if you are going to tell the truth. One option would be to consult an HIV-knowledgable lawyer and have him write a cover letter explaining your very reasonable concerns about disclosing your HIV status. The letter and questionnaire can be sent to the dean of the medical school. Special arrangements to assure confidential information remains confidential can then be out into place.

Regarding your specific questions:

1. I don't believe you have an option not to disclose based on the questionnaire discussed in your question. I recommend honesty, possibly with some legal cover as discussed above.

2. No, I don't believe you can choose not to disclose and still answer these questions honestly.

3. I would work with the GP you've been seeing and ask him to work cooperatively with your HIV specialist and lawyer as needed.

4. As indicated above, if you answer the medical questionnaire honestly (which I strongly recommend you do), your HIV status will be disclosed.

Good luck.

Dr. Bob



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