The ethics of HIV testing and disclosure for healthcare professionals: What do our future doctors think?

Abstract

Aim: This study examined future medical professionals’ attitudes and beliefs regarding mandatory human immunodeficiency virus (HIV) testing and disclosure.

Method: A total of 54 US medical students were interviewed regarding mandatory testing and disclosure of HIV status for both patient and health care professional populations. Interviews were qualitatively analyzed using thematic analysis by the first author and verified by the second author.

Results: Medical students considered a variety of perspectives, even placing themselves in the shoes of their patients or imagining themselves as a healthcare professional with HIV. Mixed opinions were presented regarding the importance of HIV testing for students coupled with a fear about school administration regarding HIV positive test results and the outcome of a student's career. Third- and fourth-year medical students felt that there should be no obligation to disclose one's HIV status to patients, colleagues, or employers. However, most of these students did feel that patients had an obligation to disclose their HIV status to healthcare professionals.

Conclusion: This study gives medical educators a glimpse into what our future doctors think about HIV testing and disclosure, and how difficult it is for them to recognize that they can be patients too, as they are conflicted by professional and personal values.

Introduction

The overall aim of this qualitative study is to gain a deeper understanding of future doctors’ attitudes and beliefs regarding mandatory human immunodeficiency virus (HIV) testing and disclosure, and to explore current medical students’ personal biases and stigmas surrounding HIV testing and disclosure. Present and future doctors may face the challenges of having to not only request that patients disclose their HIV status, but also to decide whether to report one's own HIV status to patients, colleagues, and/or employing healthcare institutions. By examining and identifying some of the beliefs and attitudes surrounding such dilemmas, we believe this information can be of help to medical educators as they work with medical students and their clinical preceptors to resolve many of the social and ethical problems associated with the stigma of HIV disclosure, while improving the overall health of individuals and communities. In addition to the presentation and analysis of our data, we provide curriculum recommendations for ethics education for HIV testing and disclosure for medical students. First, we will provide descriptive background information on HIV testing and disclosure.

HIV testing

In the United States, there are several private and public HIV testing sites including free-standing clinics, hospitals, state health departments, and clinician offices. Every state, along with Guam, Puerto Rico, and the US Virgin Islands offers confidential testing, where a person's name is recorded with test results, and 45 states including Guam and Puerto Rico, offer anonymous testing, where no name is used or connected to test results (Center for Disease Control 2005). In reporting cases of HIV, almost every state uses names. Five states use name-to-code reporting and eight states only use codes. While it is important to test and report individuals with HIV to better understand the spread of the disease, to develop better safety and preventative measures, and to deliver needed healthcare to those who are afflicted, there are several ethical concerns about the procedures for testing and reporting. Globally, many efforts have been made to develop surveillance and reporting programs. For example, in 1999, a European HIV reporting system including 39 countries of the World Health Organization (WHO) European Region was developed for AIDS reporting. Persons who test positive are identified in various ways (e.g., names, codes/identification numbers) and reported by clinicians and/or laboratory personnel depending on the regulations of individual countries. D’Amelio et al. revealed that 27% of the 121 countries evaluated have legislative measures in place mandating HIV testing for vulnerable populations (e.g., commercial sex workers, men who have sex with men, injecting drug users; D’Amelio et al. 2001; Li et al. 2007). Worldwide, many individuals do not know the differences between anonymous and confidential testing,1 or if they are aware of mandatory testing and reporting programs, they may refuse to get tested, realizing with a positive result their names or identifying information may be reported. For those individuals who are living in states that do not give them the option for anonymity, they too are less likely to get tested. Recently, recommendations by the Center for Disease Control (CDC 2006) suggest that all adults and adolescents (ages 13–64) should be given voluntary, automatic, and routine HIV tests upon entering a healthcare facility so as to normalize HIV screening as a routine part of medical care. Marcia Angell argues there is a need for HIV testing to become more routine (Angell 1991). Using an “opt-out” approach, individuals may have the opportunity to decline testing, but healthcare workers (HCWs) are obligated to provide basic information about HIV, including what positive and negative test results mean. Although these recommendations may help to normalize the HIV screening process, there may be no options for anonymity, which may persuade individuals to opt-out, or even forgo medical attention altogether out of fear of being tested without prior consent.

Given the lack of knowledge about HIV testing, and the problems with anonymity, patients and HCWs alike, even when knowledgeable in HIV treatment and prevention, are often reluctant to get tested for HIV out of fear that positive test results will affect reputations, employment status and insurance benefits. Although previous studies have critically evaluated both patients’ and HCWs’ perspectives regarding HIV testing and disclosure (see, for example, Dixon-Mueller 2007; Galletly et al. 2008; Kagan et al. 2008; Tesoriero et al. 2008), there are few recent studies examining medical students’ perspectives (see e.g., Evans et al. 1993).

HIV disclosure

When tackling the issue of HIV disclosure, most studies focus on whether patients have a duty to disclose their HIV status to their partners and to healthcare professionals so as to acquire needed therapies and treatments, as well as to protect healthcare professionals from even the slightest possible exposure. Many critics conclude that patients do have a duty to disclose their HIV status to their partners, to anyone who may be susceptible to HIV transmission, or to those professionals who are obligated to provide care and treatment. Under this popular line of reasoning, supported by the CDC, the American Medical Association, among other health organizations, a public health ethic appears to take precedent over individual freedoms and the right to privacy. However, when tackling the issue as to whether HCWs also have a duty to disclose their HIV status to their patients (Perry et al. 2006), there is little consensus as to whether disclosure is valuable, especially given the low probability of transmission. In 1991, CDC recommended that infected HCWs with HIV or Hepatitis B should not perform exposure prone procedures unless they have “sought council from an expert review panel and [have] been advised under what circumstances, if any, they may continue to perform these procedures.” The CDC defined an exposure-prone procedure to include “digital palpitation of a needle tip in a body cavity or the simultaneous presence of the health care worker's fingers and a needle or other sharp instrument or object in a poorly visualized anatomic site.” And, even if the panels permit them to practice, it is recommended that HCWs must still inform patients of their serologic status (Gostin 2000). The American Medical Association's policy on HIV disclosure reads, “HIV infected physicians should disclose their HIV seropositivity to a public health officer or a local review committee, and should refrain from doing procedures that pose a significant risk of HIV transmission, or perform those procedures only with the consent of the patient and the permission of the local review committee.” Furthermore, “A physician who has HIV disease or who is seropositive should consult colleagues as to which activities the physician can pursue without creating a risk to patients” (Blumenreich 1993). Marcia Angell in “A Dual Approach to the AIDS Epidemic,” wrote that patients have a right to know whether a doctor or nurse who performs invasive procedures is infected with HIV. Infected HCWs should refrain from invasive procedures, or should expect to have reasonable alternative work (Blumenreich 1993). Nevertheless, the 1995 Clinton administration instructed CDC to review its guidelines that arbitrarily restrict HIV infected HCWs, which possibly lead to discrimination.

Critics, such as American Law Professor, Gostin, have proposed new national policies, emphasizing patient safety by ensuring that infection control procedures are systematically implemented in healthcare settings, which would focus on “safer systems of practice rather than excluding and stigmatizing infected healthcare workers” (Gostin 2000). Furthermore, Gostin argues that while a physician may choose to put the patient first by disclosing his or her status, the law should not require HCWs to disclose their HIV status, since it is an invasion of the privacy of the HCW, and a possible professional detriment to the therapeutic relationship following such an emotional and unsettling conversation with patients. That is, since the HIV infected HCW is also a patient, disclosure may be embarrassing and damaging to one's professional reputation. Besides the fear of discrimination and the view that disclosure is an invasion of privacy, Gostin and others believe that since the risk of HIV transmission from HCW to patient is too low to meet the legal standard for disclosure, informed consent guidelines and laws should not require HIV infected HCWs to disclose their status to patients. But if disclosure may be embarrassing and damaging to a HCWs medical career or transmission is too low to meet the legal standard for disclosure, it would seem as though patients, just as HCWs, should not be required to disclose their HIV status when seeking non-invasive care, which may not be relevant to the treatment and monitoring of HIV. Nonetheless, healthcare professionals purport, simply for preventing harm to self and other, the HIV status of patients should be known regardless of the level of harm in diagnosing, monitoring, or treating patients for related and non-related conditions and preventative care.

In the following study, these ethical issues are tackled by our medical student-participants – our future doctors, whose perspectives regarding HIV testing and disclosure for both patients and HCWs give us insight into their critical thoughts and ethical decision-making regarding personal and patient care, and whether guidelines such as those created by the CDC will be followed, or ignored, by our future physicians whether they practice nationally or internationally with different guidelines and laws.

Table

Practice points

Present and future healthcare professionals may face the challenges of having to not only request that patients disclose their HIV status, but also to decide whether to report one's own HIV status to patients, colleagues, and/or employing healthcare institutions. Given the lack of knowledge about HIV testing, and the problems with anonymity, patients and HCWs alike, even when knowledgeable in HIV treatment and prevention, are often reluctant to get tested for HIV out of fear that positive test results will affect reputations, employment status and insurance benefits. Differences were noted among pre-clinical students (first- and second-year students) and clinical students (third- and fourth-year students who have been fully exposed to patient care) with respect to the duty to patient care versus duty to oneself. By examining and identifying some of the beliefs and attitudes surrounding such dilemmas, this information can be of help to medical educators as they work with medical students and their clinical preceptors to resolve many of the social and ethical problems associated with the stigma of HIV disclosure, while improving the overall health of individuals and communities.

Methods

During 2006–2007, a total of nine focus groups, containing 54 volunteer student-participants (34 females and 20 males), ranging in ages 18–26, from two, four-year medical schools in the United States, were interviewed by the investigators of this qualitative study. Both medical institutions have an equal ratio of males and females enrolled (50 : 50); however, there is an unexplainable disproportionate number of female students who volunteered at each level of their medical education (years 1–4). All medical students were invited to participate via email invitations and in-person classroom announcements, both of which included an informational sheet describing the study and role of voluntary participants (e.g., students may freely accept or decline participating in the study, any student who participates may leave the study at any point). Full institutional review board (IRB) approval was obtained prior to the start of the study. Six focus groups, containing 30 first- and second-year students (19 females and 11 males) were interviewed during their non-clinical training at their respective medical schools. Three focus groups, containing 24 third- and fourth-year medical students (15 females and 9 males), were interviewed during their clinical training at their respective medical schools, with the exception of three, third-year medical students (3 males) who were interviewed during a psychiatry clinical rotation at a local hospital. All IRB guidelines and ethical procedures were followed (i.e., informed consent). All student-participants were asked a pre-established set of general, open-ended questions regarding mandatory testing and disclosure of HIV status for both patient and health care professional populations. The open-endedness of these questions, commonly used in qualitative research, prompted students to verbalize their interpretations of concepts (e.g., “compulsory” or “mandatory”) and freely give their opinions on difficult, ethical and professional issues, which enabled the investigators to gain data with a range of attitudes and beliefs. The pre-established, general questions used in the recorded interviews are as follows:

1. Do you think medical students should be tested for HIV? How about physicians? Other healthcare professionals?

2. Should HIV testing be voluntary or mandatory? Why or why not?

3. Do you think that patients should disclose their HIV status to their physician?

4. Are there any circumstances under which a patient should not disclose this information about their health status?

5. If a physician has HIV, do you think he/she should disclose this to his/her patients? Please explain why or why not.

These pre-established questions comprise the first part of this study; a separate set of questions focusing on current medical students’ perspective on and use of universal precautions comprise the second part of the study and findings are reported in a separate paper titled “The ethical and pedagogical effects of modeling ‘not-so-universal’ precautions”. Interviews for the first part of this study were conducted for 30–45 minutes, while focus group interviews for the entire project lasted 60–75 minutes. Investigators used a hand-held, digital audio recorder to record all interviews. Project investigators took hand-written notes during each focus group, alerting them to significant points and patterns of experiences, beliefs, and attitudes. All recorded interviews were transcribed. Names and other identifiers that were verbalized by students during the focus group sessions were not transcribed. Transcripts were qualitatively evaluated by the project investigators individually and then collectively to ensure that emerging themes in the data were objectively identified and analyzed using thematic data analysis, whereby repetitive themes emerged from students’ responses and meaning units were recorded and coded. The project investigators included the authors of this article, both of whom also conducted the focus groups at their respective institutions; the first author analyzed the data, and the second author verified the analysis. Data from students’ answers (from the above questions and discussion that followed) were divided into two significant categories: HIV testing and HIV disclosure.

Results

In general, there were no identifiable differences in the reports given by medical student-participants from the two medical schools. In addition, there were no identifiable differences in responses among males and females. However, there were significant differences among pre-clinical students (first- and second-year students) and clinical students (third- and fourth-year students who have been fully exposed to patient care) with respect to the duty to patient care versus duty to oneself. Although most students expressed their personal opinions, many students provided insightful, constructive, well-supported arguments surrounding HIV testing and disclosure, often placing themselves in the shoes of their patients or reflectively thinking on what it would be like to be a physician with HIV. The focus groups conducted were useful not only for the purposes of this study, but also for students’ medical education by giving them an opportunity to discuss and reflect upon a controversial topic in medicine and public health. Specific results from this study are divided into two primary sections, “HIV testing” and “HIV disclosure,” along with relevant sub-sections.

HIV testing

Do you think medical students should be tested for HIV? How about physicians? Other healthcare professionals?

In response to the first focus group question, first- and second-year students at both medical schools reported that testing can reduce the social stigma associated with HIV; by having every student experience the testing procedures from “a patient's perspective”, along with a formal education about HIV from clinical, psychological, and social perspectives, the stigma could be reduced and students would be better informed to help their patients and themselves in the prevention and treatment of HIV. The majority of students who supported HIV testing in medical school (or when they became licensed physicians) felt that testing for HIV is an important step toward physically and emotionally caring for themselves and their patients. They also recognized that attitudes and beliefs may positively change in ways that alleviate current stigma as HIV screening increases or becomes a normalized practice. However, not all students supported HIV testing for medical students and/or healthcare professionals.

A total of nine first- and second-year students at both medical schools feared the consequences of the HIV tests. Their greatest fear was that of the medical school or administration finding out about any risk factors (drug use0 or positive test results, which, they believe, would ruin students’ future medical careers. They expressed they would not be valued or accepted as an HIV professional, which interestingly, provoked students to think about what patients may feel and think with respect to their own professional lives. Students from both medical schools feared their privacy would not be protected and that positive results would show up on their permanent records. One male first-year student explained that he would not want to get tested for incurable STDs “because of the possibility of the school finding out.” Other students reported that because the transmission rate was so small, and universal precautions were in place, there would be no need to get tested. Twelve students at each stage in the four-year medical school curriculum explicitly argued that only those who are at risk for HIV should be tested, but that testing should be voluntary regardless of the risks to patients and colleagues. Students from both medical schools (approximately 75%, or 40 out of 54 clinical and non-clinical) reported that if healthcare professionals were tested positive for HIV, negative consequences, such as lawsuits, loss of medical licenses, and limited patient interaction, could occur. Rather than directly answering the focus group question, third-year students at both medical schools were inquisitive and asked about the benefits of knowing the results of an HIV test as it relates to the safety and protection of others. After re-directing their questions and answers (when dialogue got “off-track”) by asking how they felt about being tested as medical students, these third-year students felt that tests should be given to healthcare professionals only if there is a significant transmission rate from physician to patient. Two fourth-year students at one medical school added that “testing is expensive” and some people, especially medical students, may not be able to pay for the tests. The availability and accessibility of medical resources needed to test medical students and healthcare professionals alike was a general concern among the fourth-year students, as well as how information gained from the tests is going to be used (e.g., will information hurt your potential to get insurance). Overall, there was little concern regarding the possibilities of transmission of HIV from physician to patient.

Mandatory testing

Should HIV testing be voluntary or mandatory? Why or why not?

It was duly noted among first through third-year medical students at both institutions that the stigma becomes reduced when testing is mandatory. First-year students at one medical school indicated that mandatory testing may help more people get treatment. A first-year student at the second medical school indicated that “if we are not disclosing information about ourselves then I don’t think we can ask our patients to provide the information – no double standard.” Another student reported, “I think I would lean towards HIV testing be voluntary instead of mandatory. I really value having individual rights.” However, another first-year student stated, “I would say mandatory. It's just like…like our pap smears and we test for that annually, and it's not stigmatized. I don’t see why we couldn’t do the same thing with HIV. Encourage women and men to get their annual HIV test if they, or you know, at least every few years…”

Second-year students generally thought that so long as laws (or guidelines) were in place to protect discrimination, healthcare professionals and students should be mandatorily tested. A female second-year student, echoing the same sentiment, suggested that testing be anonymous and confidential if it were to be mandatory. Another second-year student felt that one would be more likely to pay attention [to universal precautions] if a person's HIV status were known. While first- and second-year students from both medical schools indicated the stigma would be greatly reduced with mandatory testing, third- and fourth-year students felt that discrimination would occur and the stigma would continue to exist, even though “HIV is no longer a death sentence.”

More than half of students (63%, or 34 out of 54 clinical and non-clinical) interviewed at both medical schools explicitly argued that individual rights are critical. If tests were mandatory, the right to privacy should be upheld to protect the student or healthcare professional from negative consequences, such as employment and insurance discrimination. These students also indicated that mandatory testing would be a waste of resources, since it is a common belief among students and healthcare professionals that “we do not typically engage in risky behaviors, such as unprotected sex, or fail to use universal precautions”.

Patient disclosure

Do you think that patients should disclose their HIV status to their physician? Are there any circumstances under which a patient should not disclose this information about their health status?

We found that first- and second-year students (approximately 73%, or 22 out of 30 non-clinical students) expressed that patients should disclose their HIV status to their physicians in order to educate oneself and to prevent the possibility of a misdiagnosis or wrong treatment regimen. A first-year student at one medical school indicated that HIV testing is a mandatory practice within the US military, so he has to get tested each year that he is enrolled with the military. However, many first- and second-year students indicated that because of the potential for discrimination, patients should not have to disclose their HIV status. One first-year student believed that it is the physician's responsibility to prevent the disease. First-year students from both medical schools suggested that if a physician or healthcare professional does not have to disclose their HIV status to the patient, then the patient should not have to disclose his or her status.

The general consensus among third- and fourth-year students at both medical schools is for patients to disclose their HIV status in order for healthcare professionals to properly treat their patients and for properly protecting themselves when working with HIV infected patients. Both groups of students recognized that the stigma associated with HIV would still exist regardless of patient disclosure. Most third- and fourth-year students (79%, or 19 out of 24 clinical students) articulated how transparency about one's disease and disease-related behaviors, or disclosure specifically, is an important patient duty; it is the patient's duty to protect the healthcare professional and to seek and adhere to treatment.

Physician disclosure

If a physician has HIV, do you think he/she should disclose this to his/her patients? Please explain why or why not.

First-year students at one medical school felt that if there is a risk, then the physician should disclose his or her HIV status. First- and second-year students at both medical schools believed that it is up to the physician to disclose. One first-year student at another medical school exclaimed that I am “too shocked even to imagine” this could happen to a physician. Another first-year student believed that so long a physician can practice medicine, disclosing such personal information to a patient is acceptable. A third student believed that disclosure should depend on the specialty of the profession. A male second-year student at one medical school “would feel guilty” if he did not disclose his HIV status to patients.

Those first- and second-year students who believe that physicians should not disclose their HIV status to patients explained that “the patient is not caring for the doctor,” or that it is “not professional to disclose personal things.” Some first- and second-year students indicated that due to the potential loss of clients, a physician should not disclose his or her HIV status. A second-year student stated “if you are an HIV surgeon you wouldn’t be making the money because you would be limited to only surgeries that involve only HIV patients.”

One third-year student suggested that physicians disclose their status in order to send the message to patients that they too need to take precautions. Another third-year student reported “We need to learn personal responsibility not just with universal precautions but with whatever status we have.” A fourth-year student at one medical school placed himself in the shoes of his patients and reported, “If I was a patient, I would want to know no matter what kind of doctor [was treating me].” Six students questioned why even discuss HIV as a threat, since the threat is so slim and prophylaxis is available. Knowing hepatitis was a greater threat, these students could not understand why HIV is still an issue. Three out of 10 fourth-year medical students believe the patient has a right to know. The majority of third- and fourth-year students believe that disclosure will not help the healthcare professional or his or her patients, since the risk of transmission is very slim.

Discussion

In this study, we explored how medical students feel about HIV testing and disclosure, and sought to understand some of the dilemmas they may face as future healthcare professionals. Due to the qualitative nature of this study (i.e., using open-ended questions in a focus group format), our medical student-participants considered a variety of perspectives, even placing themselves in the shoes of their patients or imagining themselves as a healthcare professional with HIV. Regarding duty to patients versus duty to oneself, when placed in the physician's shoes, third- and fourth-year medical students consider the consequences (to themselves) more than patient care, but emphasized patient obligations and responsibilities in being transparent about their disease and disease-related lifestyles and behaviors. First- and second-year students emphasized the importance of testing to provide better care to patients; they placed themselves in their patient's shoes, and were more empathetic to the emotional and social needs of patients compared to the third- and fourth-year students. The investigators attribute this difference to the lack of clinical training among first- and second-year students, who are idealistic in providing good care to patients and have not (yet) developed jaded or cynical attitudes, which we witness in more clinically-oriented students, interns, and residents. Also, third- and fourth-year students generally have more exposure to the business and legal practices related to medicine, and confront justice issues such as resource allocation and availability (one reason why these students may have considered the cost of compulsory testing).

Some students describe their unresolved conflicts between their personal freedoms and professional obligations. For example, medical student-participants, in identifying one of the core ethical dilemmas of HIV testing and disclosure, report that anonymity is important in the preservation of privacy and personal freedom, but question how these values should be balanced against the greater good of society. These ethical issues are tackled by our medical student-participants – our future doctors, whose perspectives regarding HIV testing and disclosure for both patients and HCWs give us insight into their critical thoughts and ethical decision-making regarding personal and patient care, and whether guidelines such as those created by the CDC will be followed, or ignored, by our future physicians. Mixed opinions were presented regarding the importance of HIV testing for students coupled with a fear about school administration regarding HIV positive test results and the outcome of a student's career.

Regarding HIV disclosure, some of our medical student-participants recalled the case of Dr. David J. Acer, an American dentist who was believed to have infected his patients with HIV in the late 1980s, but immediately dismissed this case, since accidental transmission of HIV from doctor to patient was never proven (Tuboku-Metzger et al. 2005). Given the lack of evidence showing a risk of transmission from a HCW to a patient, our third- and fourth-year medical students felt that because the risk was so slim, there should be no obligation to disclose one's HIV status to patients, colleagues, or employers. However, most of these students did feel that patients had an obligation to disclose their HIV status to healthcare professionals due to a greater risk of transmission.

Many physicians, in general, feel the most essential thing in life is to continue practicing medicine and that disclosing their HIV status would have negative outcomes, including permanent loss of employment (Gerberding 1996; Fost 2000; Gostin 2000, 2002; LeBlanc 2002; Weiss et al. 2005). Based on our collected data, many of the medical students interviewed were also afraid of the possible negative outcomes for disclosing such a highly stigmatized disease. However, some students, especially those in the early stages of their medical training, thought that some of these negative outcomes could be prevented if medical students are tested before making career decisions that could affect themselves and their future patients (e.g., choosing to practice psychiatry instead of surgery). A few medical student-participants thought that HIV disclosure could benefit the therapeutic relationship, others thought patients should not be privy to HCWs personal information, but that employers should be made aware so as to monitor safety practices. Some physicians, who have disclosed their HIV status to their department chairs or others in authoritative positions, felt a sense of relief and were able to practice medicine without stigmatization and discrimination, and without affecting patient care. For example, one Chicago psychiatrist explained, “I felt that though completely asymptomatic, informing my department heads that I was HIV sero-positive was the only way to keep work related stress at more manageable levels … I only share the information about my being HIV+ during the course of treatment when a patient clearly needs the example of a role model and slow progressor living productively with HIV to provide a contrast to their hopelessness regarding their own diagnosis.” (Shernoff 1996).

In closing, this study helps medical educators understand students’ mindset, opinions, and beliefs about HIV testing and disclosure. For those medical schools who already have this topic integrated into their ethics curriculum, their faculty may want to compare and contrast the goals and objectives for their lectures and courses with the depth and breadth of perspectives shared by students in this study. For schools where this is not currently an ethics topic, we encourage their faculty to derive innovative methods for exploring students thinking about and discussing these issues, especially the effects of HIV on the healthcare professional as patient. Learning opportunities should be provided to medical students across the curriculum to address the dilemmas regarding HIV testing and disclosure as it is important to self-care of physicians, patient care, and to the practice of medicine. It is important that medical educators create safe forums for students to discuss their perspectives, feelings, and attitudes surrounding HIV testing and disclosure, and to provide up-to-date information regarding HIV transmission and rules governing when and how to report possible transmission (e.g., needle sticks). Furthermore, medical education should recognize the need to teach students about caring for themselves in addition to caring for patients. Most of our students participating in this study had not thought about how their own health, or absence of health, could affect patient care and their career choices as physicians. By educating students about their own personal health and well-being, we as medical educators have the power to change the clinical environment, guiding our students to become more professionally and personally responsible for themselves and their patients, to seek help and guidance without fear (e.g., to report a needle stick without fear of being reprimanded by superiors), and to recognize that disclosure in some instances is a moral obligation to both patient and self. Although the sample size was small, and the context of pre-clinical and clinical training provided needed support in understanding the possible differences among these student groups, this study gives medical education a glimpse into what our future doctors think about HIV testing and disclosure, and how difficult it is for them to recognize that they can be patients too, conflicted by professional and personal values and fearful of the consequences in their professional lives. Medical education needs to acknowledge that our future doctors may be or become patients with a highly stigmatized disease, to create an environment that neither discriminates patient nor professional, and to guide students in recognizing and resolving conflicting personal and professional values and interests.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

Notes

1. Anonymous testing uses code numbers to identify your test. Your name is never used. You use the code to get your results. You are the only person who knows your results. With anonymous testing, you have complete control in deciding who to tell and when. With confidential testing, your name is recorded and linked to your test results. Even though this information is kept private, others may have access to this information, including health care providers, your insurance company, and the health department.