Abstract

Introduction: This study aimed to assess healthcare professionals’ knowledge and stated attitudes regarding medical confidentiality in the context of HIV, and to describe PLHIV perceptions of confidentiality at Labé Regional Hospital. Conclusion: Healthcare professionals showed heterogeneous knowledge and stated attitudes regarding HIV-related medical confidentiality, while most PLHIV reported that confidentiality was respected and opposed its future lifting. These descriptive findings do not establish that disclosure to partners or relatives is legally authorised or appropriate without reference to the applicable Guinean legal and ethical conditions.

Keywords

Medical Confidentiality, HIV/AIDS, People Living with HIV (PLHIV), Healthcare Professionals, Ethical Dilemma, Disclosure, Guinea

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1. Introduction

HIV remains a major public health problem worldwide, having caused the deaths of some 44.1 million people to date. Transmission continues in every country in the world. It is estimated that around 40.8 million people will be living with HIV by the end of 2024, 65% of whom will be in the WHO African Region [1]. In 2024, approximately 630,000 people died from HIV-related causes and 1.5 million people acquired HIV infection. There is no cure for HIV infection. However, through effective prevention, diagnosis, treatment, and care, including for opportunistic infections, HIV infection has become a manageable chronic condition, and those affected can live long and healthy lives [1]. In Guinea, according to data from the 2018 Demographic and Health Survey (DHS), the national prevalence rate is 1.5%. Of approximately 120,000 people living with HIV, 4300 AIDS-related deaths were recorded in 2018. Prevalence is higher among women (1.6%) than men (1.3%), with women representing 52% of all adults living with HIV. Among young people aged 15 to 24, HIV prevalence is 0.9% [2]. The fight against HIV in Guinea remains a crucial public health issue. Despite progress made through the national HIV/AIDS program and the efforts of local organizations, significant challenges persist. Stigma and discrimination continue to hinder the exercise of human rights, particularly access to information and essential HIV prevention and treatment services. Adolescent girls and young women remain disproportionately affected by HIV, particularly in sub-Saharan Africa [3]. While the medical situation has greatly improved, social normalization appears to be progressing more slowly, as HIV/AIDS continues to be associated with stigma, discrimination, and social rejection [4] [5]. Those affected face a difficult dilemma: disclose their infection in order to receive support in their daily lives with the illness, at the risk of discrimination, or conceal their infection to preserve their status as discreditable [6], while foregoing the various forms of support they could benefit from. The fear of discrediting thus places control of HIV-related information at the heart of managing the daily lives of HIV-positive individuals and establishes it as the pivot around which relationships with those around them are organized [4] [7]. The African socio-cultural context presents an additional ethical and legal challenge [4]. Healthcare professionals have a particular obligation to ensure respect for the rights of people living with HIV/AIDS and for the rights of the community. They must especially respect medical confidentiality, a fundamental principle observed by physicians practicing within the Romano-Germanic tradition since the Hippocratic Oath [8]. Modernity and tradition, secularism, freedom of religion, and interreligious dialogue are characteristics of Guinean society. The legislation is of French origin, inherited from decolonization in 1958. These laws have been progressively replaced and adapted to the Guinean context. Thus, the family code incorporates the specificities of Guinean society, allowing Muslims who so wish to practice polygamy. In the absence of studies on HIV and medical confidentiality in Guinea, it seemed important to assess the level of knowledge on this issue, hence the purpose of this study. The objectives of this work were to evaluate the implementation of medical confidentiality by doctors and nurses caring for people living with HIV/AIDS (PLHIV), to determine patients’ perceptions regarding the safeguarding of medical confidentiality, and to identify the specificities of medical confidentiality in the context of HIV, both among medical staff and patients.

2. Materials and Methods

The study took place at the Labé Regional Hospital. This healthcare facility is located at the secondary level of the Guinean healthcare system. It serves four prefectural hospitals (Mali, Koubia, Lélouma, and Tougué). Its mission is to provide care, training, and applied action research in the fields of general medicine, general surgery, pediatrics, gynecology, and dentistry, as well as to respond to emergency situations. This system, implemented by a multidisciplinary team, offers 24/7 care for patients from these four prefectures in the Labé administrative region. In addition, the hospital has a forensic medicine unit whose role is to support the Labé judicial system. This service produces medical certificates and reports that serve as evidence in legal proceedings.

2.1. Type of Study

This was a cross-sectional and descriptive study that took place from July 1^st to December 31^st, 2024.

2.2. Study Population

The study population consisted of health professionals (doctors and nurses) and people living with HIV (PLHIV).

2.3. Inclusion and Exclusion Criteria

All doctors and nurses working at Labé Regional Hospital during the study period and available at the time of data collection were eligible. PLHIV receiving care at the hospital during the study period were eligible if they consented to participate. Participants who were unavailable or declined participation were excluded. Recruitment was intended to be exhaustive among eligible and available participants. The source records available for this revision do not document the total number approached, the number eligible before consent, or the number who refused; therefore, participation and refusal rates cannot be reported and selection bias cannot be excluded.

2.4. Ethical Considerations

The study was reviewed and authorized by the management of Labé Regional Hospital prior to data collection. Participation was voluntary, and all participants were informed about the purpose of the study and were free to participate or decline without any consequences for their care. People living with HIV (PLHIV) participated freely in the study.

To ensure confidentiality and protect sensitive information related to HIV status, an anonymous survey form was specifically developed for data collection. No names or other information that could directly identify participants were recorded on the questionnaires. The collected data were treated confidentially and used solely for the purposes of the study.

2.5. Data Collection and Assessment of Legal Knowledge

Data were collected using two structured and anonymous questionnaires developed for the purposes of the study: one for healthcare professionals and another for people living with HIV (PLHIV). The questionnaires were self-administered. French was the main language of communication. When necessary to facilitate participants’ understanding, communication was also conducted in Guinean national languages, including Pular, Malinké, Susu, Kissi, and Guerzé.

For healthcare professionals, legal knowledge was assessed using three items relating to the Hippocratic Oath, the Guinean Penal Code, and the Code of Medical Ethics. A scoring system was defined before data collection. Each correct response was assigned one point, resulting in a total score ranging from 0 to 3. A score of 0 was classified as “no knowledge”, a score of 1 - 2 as “partial knowledge”, and a score of 3 as “perfect knowledge”. Based on these predefined criteria, 15/83 (18.1%) healthcare professionals had no knowledge, 57/83 (68.7%) had partial knowledge, and 11/83 (13.2%) had perfect knowledge of the legal and ethical references assessed.

3. Results

3.1. Healthcare Professionals and Medical Confidentiality

3.1.1. Characteristics of Healthcare Professionals

Of a sample of 230 participants, 83 (36.1%) were healthcare professionals. The 31 - 60 age group represented the largest group (63.9%), with a mean age of 36.37 ± 9.99 years. Males were more represented (54.2%) than females (45.8%), resulting in a sex ratio of 1.1 (Figure 1). Regarding professional category, paramedical staff constituted the largest group (50/83, or 60.2%), compared to 39.8% (33/83) for medical and paramedical staff. Actors with five years of service or less represented 49.40% followed by those with 6 to 12 years of service (27.71%) with extremes of 0.16 and 35 years and an average of 7.6 ± 7.4 years (Figure 2 & Figure 3).

Figure 1. Characteristics of the people surveyed.

Figure 2. Distribution of actors according to the number of years of service of the actors.

Figure 3. Distribution according to the practice structure of the healthcare professional.

3.1.2. Knowledge of Legal Texts

We found that the majority of our respondents had a partial knowledge of the legal texts (68.7%), or 57/83, while 18.1% (15/83) had no knowledge at all. Only 13.2% (11/83) had a knowledge that could be considered perfect (the legal texts on which the healthcare professionals were questioned were the Hippocratic Oath, the penal code, and the code of ethics).

3.2. Healthcare Professional Practice Structure

The distribution of the studied population by structure showed a predominance of actors from the maternity service 17/83 (20.5%) followed by actors from general medicine 15/83 (18.1%) and those from pediatrics 11/83 (13.2%).

The qualification of our respondents was dominated by nurses in 48.2%, followed by doctors (37.4%) of cases.

Regarding religion, Muslims represented 92.8% compared to 7.2% Christians. As for ethnicity, the Fulani were the majority (57.8%), followed by the Malinke (15.7%), the Kissi (10.8%), and the Susu (7.3%) (Table 1).

Table 1. Actors’ attitudes towards a husband who would want to know the results of his wife’s test and a mother who would want to know the test of her adult daughter.

Regarding medical confidentiality and HIV within the family, more than half (60.2%) stated that the results should not be communicated to the parents, while 66.3% believed it was not possible to inform them. Concerning the approach taken by healthcare professionals when faced with a mother who wanted to know the results of her adult daughter’s HIV test, 28 out of 83 (33.7%) healthcare professionals felt it was possible to inform the parents of an adult daughter about the results of the HIV test. For 55 out of 83 (66.3%), it was not possible to inform the parents (Table 2).

Table 2. Actors’ attitudes towards a wife from a polygamous household who is unaware of her husband’s HIV status and towards an HIV-positive polygamous husband who refuses to inform his wives, one of whom is his sister.

Regarding medical confidentiality, HIV, and polygamy, healthcare professionals were more likely (56.6%) to believe that a husband with a positive HIV test should not inform his wives of his results. However, they believed they could inform their sister if she was one of the wives of a polygamous, HIV-positive husband who refused to tell his other wives (80.7%) (Table 3).

Table 3. Attitudes of healthcare professionals towards a case of levirate marriage* with a person living with HIV who refuses to disclose their status.

Levirate marriage is when the younger brother of a deceased man marries the widow of his deceased older brother and assumes responsibility for the deceased’s children. Sororate marriage is when a younger brother marries the younger sister of a deceased wife.

In the context of medical confidentiality, HIV and levirate marriage, the actors stating that they reveal the status of the person living with HIV to their partner were in the majority (37.4%) (Table 4).

Table 4. Distribution according to the opinion of healthcare professionals on lifting (removing) or not lifting medical confidentiality in cases of HIV/AIDS.

Regarding healthcare professionals’ opinions on lifting medical confidentiality in cases of HIV/AIDS, 32/83 (38.56%) were against lifting it, 28/83 (33.73%) were in favor, and 23/83 (27.71%) did not specify an opinion. Among those opposed, 20/32 (62.5%) cited avoidance of stigmatization. Among those in favor, the most frequently cited reason was reduction of the risk of infection (20/28; 71.4%).

The majority of health professionals surveyed (63.13%) felt that priority should be given to the right of uninfected people to be informed about the diagnosis of PLHIV, while 36.87% felt that the latter had a right to the preservation of their secrecy.

3.3. People Living with HIV and Medical Confidentiality

Concerning PLHIV opinions on their right to medical confidentiality when there is a risk of intentional transmission to a partner or third party, 65/147 (44.2%) believed that they retained this right, 63/147 (42.9%) believed that they did not, and 6/147 (4.1%) did not express an opinion. Responses for 13/147 participants (8.8%) were not accounted for in the available reporting and are therefore reported as missing rather than assigned to another category (Table 5).

Table 5. Distribution of people living with HIV according to their opinion on the current respect for medical confidentiality by healthcare professionals and the future possibilities for lifting medical confidentiality.

Most people living with HIV (PLHIV) stated that doctors respect medical confidentiality (87.07%) within the framework of current practices. Regarding the possibility of lifting medical confidentiality in the future, the majority of PLHIV were not in favor (78.91%), with the reason given for maintaining confidentiality being fear of stigmatization (109/116; 93.97%). Only 12.92% of PLHIV were in favor of lifting medical confidentiality, the main reason given being to prevent the spread of the disease (13/19; 68.43%).

4. Discussion

In this study, we assessed the implementation of medical confidentiality by physicians and nurses caring for people living with HIV (PLHIV) and then determined patients’ perceptions regarding the safeguarding of medical confidentiality. Confidentiality is a necessary condition for patient trust. It represents the very essence of the relationship that must exist between a physician and their patient, who must be certain that all information entrusted to their physician, and over which they have complete control, will be strictly protected “under the seal of confidentiality” [9]. According to Manga Fombad [10], despite its widespread recognition, medical confidentiality, as a legal and ethical principle, has never been considered an absolute rule. Well-established exceptions exist that allow, under certain appropriate and relatively well-defined circumstances, for the disclosure of a patient’s health status. These exceptions represent potential compromises rather than ideal solutions.

4.1. Healthcare Professionals on Medical Confidentiality

In this study, 36.1% of participants were healthcare professionals. Among them, 68.7% had some knowledge of the relevant legal texts, compared to 18.1% who had no knowledge at all. The legal texts on which the healthcare professionals were questioned were the Hippocratic Oath, the penal code, and the code of ethics. When asked, “What attitude would you adopt towards a husband who demands the results of his HIV-positive wife’s test?”, more than half (60.2%) stated that the results should not be disclosed to him, while 39.8% of healthcare professionals believed it was possible to inform the husband. It is precisely this sense of necessity that is invoked by some regarding informing the partner or close relative of an HIV-positive patient who refuses to inform that person themselves or to take the necessary measures to avoid infecting them. Can a doctor faced with such a situation invoke the state of necessity and inform the partner concerned himself? When questioned on this issue, the French National Academy of Medicine [11] expressed support for the possibility, in exceptional circumstances, of a physician disclosing a patient’s HIV-positive status to their partner(s) when the patient refuses to disclose it themselves. However, the French National Council of Physicians [12] took a position firmly opposed to such disclosure, emphasizing that maintaining the patient’s trust in medical confidentiality was the most effective way to encourage HIV-positive individuals to inform their partner(s). The French National AIDS Council, in an opinion issued on May 16, 1994, considered in the same vein that The disadvantages of accepting a breach of medical confidentiality in the context of AIDS outweighed the advantages, and it was important to do everything possible to ensure that members of the medical profession helped HIV-positive individuals assume their responsibility towards their partners [13]. The disclosure of information concerning a person’s HIV-positive status has not given rise to a specific exception to medical confidentiality provided for by law. Therefore, if a person living with HIV wishes to keep their illness confidential, the doctor, as well as all those involved in their medical, social, or administrative care, must respect this decision [9]. In Guinea, Article 367 of the Penal Code stipulates that “The disclosure of confidential information by a person entrusted with it by virtue of their position or profession, or by reason of a temporary function or mission, is punishable by imprisonment for 6 months to 1 year and a fine of 500,000 to 2,000,000 Guinean francs, or by one of these two penalties alone” [14]. Our results show that more than a quarter of our stakeholders do not understand the legal framework that defines medical confidentiality. Healthcare personnel treating people living with HIV should receive refresher training on the legal foundations of medical confidentiality at least once a year throughout their professional development. In Botswana, many categories of staff associated with the CHBC (community home-based care) program have adopted a code of ethics imposing on their members the ethical obligation not to disclose confidential information relating to patients infected with HIV/AIDS. These codes of ethics do not in themselves have the force of law; at most, they reflect the position of a given profession regarding the minimum standards of conduct that its members are expected to observe. Healthcare professionals are expected to comply with their professional codes of ethics and to respect patients’ confidentiality; breaches of confidentiality may have ethical and legal consequences [15]. Medical confidentiality in the context of HIV infection presents a particular challenge in African settings. In many traditional African societies, women are entirely dependent on their husbands. No decision can be made without their consent [16]. The lack of financial independence only reinforces this dependence, as it is the husband who pays for hospitalization [17], which leads him to want to know all the information that might shed light on his wife’s health. He considers this a legitimate right.

Regarding the attitude adopted by healthcare professionals towards a mother who wants to know the results of her adult daughter’s HIV test, 66.3% of healthcare professionals believe it is not possible to inform the parents, compared to 33.7% who believe it is. Our results differ from those of Soumah in Senegal [7], who reported that 92.5% of healthcare professionals felt it was possible to inform the parents of an adult daughter about the results of an HIV test, and for 7.5% of professionals, it was the doctor’s duty to inform the parents. We believe that medical confidentiality must be maintained regardless of the pressure exerted by the family of a person living with HIV to know the patient’s serological status. Disclosure of medical information between a mother and her daughter is prohibited, as it is subject to the same professional confidentiality as that of any adult patient. A doctor cannot disclose information without the explicit consent of the patient, despite the distress some families experience due to the lack of awareness surrounding the illness afflicting their loved one. The choice to inform their family must be left to the patient, as disclosure by the doctor without the patient’s agreement can have harmful consequences such as discrimination, marginalization, and abandonment of the patient by their family [7]. Thus, according to Sow Sidibé [18], Africans function within the framework of an extended family that cares for the young, the elderly, and the sick. Individual interest gives way to a sense of community, solidarity, interdependence, and collective responsibility for the community’s survival. Furthermore, regarding medical confidentiality, Black African cultural values prioritize the principle of “shared secrecy”. Disclosing a medical secret within the family is not considered a violation of medical confidentiality, and therefore reprehensible, but rather an act of trust towards the group. To the question, “What is your” What attitude should doctors adopt towards a polygamous, HIV-positive husband who refuses to inform his wives? We collected the following responses: 56.6% of respondents believe they should not inform wives about the results, while 43.4% believe wives should be informed about their husband’s results. Based on the above, the question arises: what recourse does a doctor have when a patient possesses information (HIV-positive serology, risk of a transmissible disease, etc.) that should be shared with a third party in order to protect that party? In Guinea, Article 4 of the code of ethics stipulates that “professional secrecy, established in the interest of patients, is binding on all doctors under the conditions established by law. Medical confidentiality covers everything that comes to the doctor’s knowledge in the exercise of their profession, that is to say, not only what has been confided to them but also what they have seen, heard, or understood”. Under French law, medical confidentiality is the rule, and information concerning a patient’s health may only be disclosed to third parties under legally defined circumstances and, where applicable, with respect for the patient’s wishes [19]. The physician, however, cannot disclose this information, in accordance with medical confidentiality and the need to preserve the relationship of trust with the patient, which is essential for providing care [20]. Consequently, since no exception to medical confidentiality regarding HIV is provided for by law, the physician and all persons involved in the patient’s care are bound by medical confidentiality and must respect the patient’s decision not to disclose their serology [9]. Epidemiological studies show that a small number of HIV-positive patients do not disclose their status in the short or long term. If the patient refuses or has difficulty disclosing their status, the only option is to continue and strengthen dialogue and support. Knowing one’s HIV status helps limit the spread of the epidemic because it allows people to take precautions to protect themselves and their partners. Clinical teams managing HIV care emphasize that educating patients to become responsible actors in their own health is essential. The path of dialogue, persuasion, support, and assistance with disclosure must be maintained [20].

Regarding medical confidentiality, HIV, and levirate marriage, the majority (37.4%) of healthcare professionals stated that they disclosed the HIV-positive partner’s status to their partner. Among those surveyed, 16.9% believed that the law authorized physicians to make this disclosure. According to Soumah et al., for the majority of healthcare professionals (46.7%) who gave their opinion on the problem posed by levirate marriage in our societies when the HIV-positive partner discloses their status to their partner, the physician can, according to medical ethics, attend the consultation at the request of the individuals involved and provide them with clarifications and useful advice in the circumstances [7]. Levirate and sororate marriage, which exist in certain African customs, may perplex non-indigenous populations. However, it is important to understand that these traditions were evidence of group solidarity in the face of the death of one of its members. The younger brother of the deceased, who is expected to marry his deceased older brother’s wife, takes over the financial and estate management of the deceased. Marriage is traditionally understood in many African societies as an alliance between two families or lineages, and practices such as levirate marriage may contribute to the continuity of family ties after the death of a spouse [21]. Regarding the opinions of healthcare professionals on lifting (eliminating) medical confidentiality in cases of HIV/AIDS, the majority were against lifting it (38.56%). Among them, 62.5% believed that this would prevent stigmatization. For those in favor of lifting it (33.73%), the most frequently cited reason was reduction of the risk of transmission (20/28; 71.4%). The majority of healthcare professionals surveyed (63.13%) felt that priority should be given to the right of uninfected individuals to be informed of the diagnosis of people living with HIV (PLHIV), while 36.87% believed that PLHIV had the right to maintain confidentiality. These problems affect society as a whole, but they also alter the relationship between healthcare providers and patients. Healthcare professionals must treat their patients but also, as public health actors, ensure that the infection does not spread [7]. The emergence of HIV/AIDS has raised important ethical and legal issues in the relationship between healthcare professionals and patients, particularly regarding confidential disclosure, patient autonomy, and the protection of third parties [22] [23].

4.2. Perspectives on Medical Confidentiality among PLHIV

In this study, we gathered the opinions of 63.9% of people living with HIV. on the current respect for medical confidentiality by healthcare professionals and the future possibilities for lifting medical confidentiality. Among them, 87.07% stated that the physician respects medical confidentiality within the framework of current practices. Regarding the possibility of lifting medical confidentiality in the future, the majority of people living with HIV (PLHIV) were not in favor (Table 5). The reason given for maintaining confidentiality was fear of discrimination. Only 12.92% of PLHIV were in favor of lifting medical confidentiality, the main reason given being to prevent the spread of the disease. In his study, Fall reported that 54% of PLHIV had consented to sharing confidential information, compared with 46% who had not [24]. In our study, despite the risk of infecting their partner or a third party, the majority of PLHIV believed they had the right to do so.to medical secrecy (44.3%). This may be due to the social pressure some people living with HIV (PLHIV) experience in response to derogatory remarks from some relatives about HIV/AIDS. Furthermore, the silence surrounding their HIV-positive status becomes increasingly difficult to bear over time, as PLHIV need not only financial assistance but also psychosocial support. This includes the need to feel heard and understood, the opportunity to express their fear of death and the disability caused by the disease, and above all, the assurance of being supported throughout their illness [7]. International guidelines on HIV/AIDS and human rights recognize that the right to privacy of people living with HIV includes respecting the confidentiality of all information related to their serological status [25].

5. Limitations

This cross-sectional study relied on self-reported data collected through questionnaires. Therefore, healthcare professionals’ responses primarily reflect their knowledge and stated attitudes toward hypothetical situations and cannot be used to establish their actual practices regarding the maintenance or lifting of medical confidentiality. Furthermore, the cross-sectional nature of the study does not allow causal relationships to be established.

In addition, the available data did not allow us to determine precisely the total number of eligible individuals who were approached or the number who declined to participate. Consequently, participation and refusal rates could not be calculated, which may have introduced selection bias.

Finally, for the question concerning PLHIV’s right to medical confidentiality in situations involving a risk of intentional HIV transmission to a partner or third party, responses from 13 of the 147 participants (8.8%) were not recorded. These responses were therefore treated as missing data and were not assigned to any other category.

These limitations should be taken into account when interpreting and generalizing the findings of this study.

6. Conclusion

This descriptive cross-sectional survey identified heterogeneous knowledge and stated attitudes among healthcare professionals regarding HIV-related medical confidentiality. Among PLHIV, 128/147 (87.07%) reported that physicians respected confidentiality, while 116/147 (78.91%) opposed a future lifting of medical confidentiality; fear of stigmatization was the principal reason reported among opponents (109/116; 93.97%). These questionnaire findings describe reported knowledge, hypothetical attitudes and patient perceptions; they do not demonstrate actual disclosure practices in clinical care. Training on medical confidentiality, HIV-related stigma, counselling and the applicable Guinean legal and ethical framework should be strengthened. Any consideration of disclosure to a partner or relative must be assessed against the specific legal and ethical conditions in force in Guinea.

Conflicts of Interest

The authors declare no conflicts of interest regarding the publication of this paper.

References