ANGOLA: To tell or not to tell, that is the tricky question

Maria Antónia* began to wonder about her husband's frequent trips to neighbouring South Africa, especially when he was away for 15 days without contacting her on one occasion. She decided to investigate whether he was going to South Africa to see another woman, but discovered that he was going to get antiretroviral (ARV) medication because he was HIV positive.

Miguel André's wife died in 2001, officially from typhoid fever, but before she died she told her child's godmother that she had AIDS. She never found the courage to tell her husband, but the news spread and soon everyone in Benguela, a coastal town in central Angola, was talking about it. André was the last to find out that his wife had been HIV positive.

Stories like these are repeated time and again in Angola, but fear of a partner's reaction, fear of being abandoned, fear of discrimination, even fear of shame, are just some of the reasons that prevent people living with HIV from telling those dear to them.

Many only discover the HIV status of their partners after they have died, and then learn that they are also infected, but it is often hard to know who infected whom, or how. An estimated 2.5 percent of Angola's 16 million people are living with HIV/AIDS.

To tell or not to tell?

The debate in Angola about the role of healthcare workers in disclosing the HIV status of their patients has been heated. On the one hand there are those who believe that health workers should do their utmost to find the spouses of patients living with HIV, as was once the case with syphilis, and there should be compulsory notification. Others say doctor-patient confidentiality should be preserved at all costs.

António Coelho, executive secretary of the Network of AIDS Service Organisations (known by the Portuguese acronym Anaso), feels there should not be mandatory notification of spouses, but rather awareness-raising to enable HIV-positive patients to tell their partners.

He stressed that by law "infected persons have the duty to inform those people with whom they have or intend to have sexual relations about their serological status."

But Catarina Saldanha, executive secretary of Mwenho, an association of HIV-positive women, believes that doctors should inform their patients' spouses.

Saldanha, who is HIV positive, told IRIN/PlusNews this was to protect the partners of people living with HIV, because the network of sexual relations is often not restricted to spouses, but extends to previous partners and extra-spousal relations.

She said some doctors in Angola were already doing this: they told patients that they could continue treatment only if their spouse or partner also came to the next appointment.

The country's network of people living with HIV/AIDS is calling for a compromise. "First, the doctor should exhaust every possibility of changing the infected person's behaviour. If this doesn't work, the doctor should make his position clear regarding intentional infection - that it is a crime punishable by law," said Noé Mateus, the network's executive secretary.

"But confidentiality can and should be discarded as soon as the physician realises that the infected person's behaviour places his or her spouse or others at risk of becoming infected."

The mysterious cassette tape

UNAIDS official Roberto Campos said confidentiality should be maintained in all instances, without exception. "People have to have the sovereignty to reveal their serological status to whomever they wish. They and they alone have this right, under any and all circumstances."

Campos stressed that because of the extremely high levels of stigma still associated with HIV/AIDS, doctors could place patients at risk of being publicly condemned by revealing their seropositivity. "Health professionals must be competent enough to give patients all the information they need to make the decision," he added.

António Feijó, the director of Hospital Esperança ("Hope" in Portuguese), a healthcare facility for HIV patients in the capital, Luanda, said doctors should encourage their patients to tell. "Notifying a patient's spouse about his or her serological status cannot be decided in an arbitrary manner ... It's immoral to treat one of them and leave the other's life at risk."

When she was 17, Suzana* married her first boyfriend. After 25 years of marriage her husband died in her arms, but she only learned that he had died of an AIDS-related illness when, during the funeral, she heard a cassette tape on which he confessed to being HIV-positive.

Her husband had given the cassette to a nephew, who thought it contained his wishes regarding his estate and it would therefore be appropriate to play the tape at the funeral.

With clearer rules covering confidentiality and HIV, the final message left by Suzana's husband could have been a message of love, or even about his estate, rather than a painful confession of his positive status.