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Graduate Student Journal of Psychology                                                                         Copyright 2009 by the Department of Counseling & Clinical Psychology  
2009, Vol. 11                                                                                                                    Teachers College, Columbia University                          
 
 

HIV/AIDS-Related Ethical Dilemma of Confidentiality 
  

Cristnei Aquino 
American School of Professional Psychology at 

Argosy University/Schaumburg 
 

Martha J. Secker 
American School of Professional Psychology at 

Argosy University/Schaumburg 
 

NicoleJoAnne Wood 
American School of Professional Psychology at 

Argosy University/Schaumburg 
 

The Centers for Disease Control and Prevention (2006) estimates over 1 million people are living with 
HIV/AIDS in the U.S. with 40,000 new infections reported yearly. Given the pervasiveness of 
HIV/AIDS, it has become almost inevitable that mental health professionals will come into contact 
with affected patients. As a result, mental health professionals often face ethical dilemmas specific to 
this population, such as the knowledge of one’s HIV/AIDS status and unsafe sexual practices. This 
dilemma is raised when a clinician becomes privy to one’s HIV-positive status, but the partner is not 
yet informed. Treatment poses complex legal issues as mental health professionals are faced with the 
uncertainty of reporting potential danger, while facing the ethical issue of confidentiality that is central 
to the field. In addition, an overview of the screening, progression, and treatment of HIV/AIDS is 
included.  

 
Human1Immunodeficiency Virus (HIV) was first 

identified in the United States in the 1980s and has since 
affected millions of people worldwide. In the United States, 
people of color seem to contract the disease in 
disproportionate rates. While several advances have been 
made that have aided in a better understanding of the 
disease, a cure has not yet been reached. Mental health 
professionals serve a crucial purpose in the treatment of 
those with HIV/AIDS, but at the same time, face certain 
ethical dilemmas in this context. 

As such, this paper outlines the ethical dilemma of 
confidentiality when working with individuals with 
HIV/AIDS. Because of the gravity of HIV, mental health 
professionals seem to be in a predicament if, and when, they 
gain knowledge of their client’s unsafe sexual behavior, as 
this could potentially put others in danger. A review of the 
literature suggests there is no clear solution to this dilemma, 
and often mental health professionals are subject to abiding 
by ambiguous or contradicting state laws and ethical codes. 
This paper highlights some of these laws and ethical codes to 
demonstrate the problem and discusses some of the related 
clinical implications. 
 
What is HIV/AIDS? 

 
HIV is an incurable disease that attacks one’s immune 

system, thereby making it difficult to fight off infections. If 
the immune system becomes exceedingly compromised, 

                                                         
Correspondence:  Cristnei Aquino 
American School of Professional Psychology at Argosy 
University/Schaumburg, 999 N. Plaza Drive, Suite 111,  Schaumburg, 
IL 60173-5403 or cristneiaquino@comcast.net 

acquired immune deficiency syndrome (AIDS) can occur 
and an opportunistic infection can prove fatal. Not every 
individual who is diagnosed with HIV develops AIDS. 
However, research evidence supports that all persons who 
develop AIDS initially had HIV (Anderson & Rowe, 2006). 
AIDS occurs when a person’s T cell count drops below 200 
per cubic millimeter and when an opportunistic infection 
results (Kukoleck, 2008).   

In order to become infected with HIV, one needs to be 
exposed to an infected other’s bodily fluids, including blood, 
semen, vaginal fluid, and saliva. The most common ways for 
HIV to be spread among people is through risky behavior, 
including unprotected sex or sharing needles during 
intravenous drug use. Unprotected sex can include anal, oral, 
or vaginal intercourse. The Centers for Disease Control and 
Prevention (2008) reports that male-to-male sexual contact is 
the transmission category resulting in the highest number of 
AIDS cases in 2007 alone and through 2007 from the 
beginning of the epidemic. This is likely the reason 
HIV/AIDS has been stigmatized as a “gay person disease.” 
However, the high-risk heterosexual contact transmission 
category elicited the second highest number of estimated 
AIDS cases in 2007 (Center for Disease Control and 
Prevention, 2008). Therefore, it is fair to say that HIV/AIDS 
is a disease that can affect anyone.  

Upon contraction of HIV, the symptoms of HIV can 
initially be elusive. Soon after infection has occurred, one 
can experience flu-like symptoms and easily dismiss them as 
such.  After this, much time can pass where the infected 
individual does not exhibit any symptoms but his or her 
body is rapidly producing antibodies to combat the virus that 
is quickly spreading throughout the body (Klimas, O’Brien 
Koneru, & Fletcher, 2008). In order to confirm that one has 

52 



HIV/AIDS-RELATED ETHICAL DILEMMA OF CONFIDENTIALITY 
 

 53

HIV, one must be tested for the presence of antibodies to 
HIV in the bloodstream. The caveat in this, however, is that 
antibodies can take awhile to develop. The CDC reports that 
detectable antibodies, on average, take two to eight weeks to 
develop from time of initial exposure. If one is tested for 
HIV shortly after exposure, they may not test positive for 
HIV antibodies because his or her body is still in the phase 
of creating those specific antibodies. This type of test would 
not be indicative of HIV in this situation, producing a false 
negative result. In most cases, HIV antibodies can be 
detected within three months of exposure. However, there 
have been rare cases noted where it took six months for HIV 
antibodies to be developed (CDC, 2009a). Also, it is 
important to note that when one is tested for HIV, multiple 
tests are done to ensure accuracy of the findings (Anderson 
& Rowe, 2006). If HIV is diagnosed, appropriate treatment 
is critical. 

HIV is now treated with medications known as highly 
active antiretroviral treatment (HAART). HAART 
medications are actually combinations of different classes of 
antiretroviral medications which act on the virus at various 
stages of its life cycle (Klimas et al., 2008). These 
combinations of medications have markedly slowed the 
progression of HIV to AIDS for many. Up until this, the 
average time span for HIV to develop into AIDS was seven 
to ten years (Anderson & Rowe, 2006). HAART 
medications have increased life expectancy and overall 
quality of life for those infected with HIV/AIDS (Liu et al., 
2006).    

In spite of this, people of color, specifically African 
Americans, have a disproportionately higher incidence rate 
of contracting HIV and AIDS (Klimas et al., 2008). Some of 
this appears to be due to educational level and 
socioeconomic status, and hence, a lack of resources. A 2004 
study by Ebrahim and colleagues, found that these disparities 
may be due to a significantly lower level of knowledge about 
HIV among African Americans and Latinos than Whites, 
even though these ethnic groups were tested for HIV at a 
significantly higher rate. Moreover, people of color have 
been shown to develop AIDS as a result of HIV at a 
significantly higher rate than Whites, even when matched for 
education and SES (Anderson & Rowe, 2006). 

Ultimately, HIV and AIDS can have major impacts on 
one’s interpersonal and intrapersonal relationships; therefore 
one’s sociological and psychological well-being can be 
affected. HIV infection is highly correlated with depression. 
Because of this, an interdisciplinary approach to treating 
someone with HIV is paramount. Mental health 
professionals can play a major role in the functioning and 
well-being of those infected with HIV/AIDS. 
 
Who is affected by HIV/AIDS? 
 

According to the CDC (2006), 49% of those living with 
HIV are African Americans, 30% Caucasians, 18% 
Hispanics, 1% Asian/Pacific Islander, and <1% American 
Indian/Alaska Native (see Table 1). More specifically, males 

account for 73% of those living with HIV whereas women 
account for 26% (CDC, 2006). The CDC (2008) recently 
reported the estimated new HIV/AIDS infections by 
transmission category in 2006. Fifty-three percent of new 
HIV infections were transmitted by male-to-male sexual 
contact; 31% from high-risk heterosexual contact; 12% from 
injection drug use (IDU); and 4% from male-to-male sexual 
contact and IDU. The CDC (2008) also broke down 
estimated new infections by age in 2006:  34% ages 13-29; 
31% ages 30-39; 25% ages 40-49; and 10% ages 50 and 
over.  
 
Table 1 
HIV/AIDS in the United States (2006) 
 

Gender  Race/Ethnicity  Age  

Male 73% African Americans 49% <13 <1% 

Female 26% Caucasian 30% 13-24 15% 

  Hispanic/Latinos 18% 25-34 26% 

  Asian/Pacific Islander  1% 35-44 32% 

  

American    

Indian/Alaska Native 
<1% 45-54 20% 

    55-64 6% 

    > 65 2% 

Note. Data obtained from: Center for Disease Control and Prevention 
(2006).  
Retrieved from: http://www.cdc.gov/hiv/resources/factsheets/us.htm  
 

According to the American Psychological Association’s 
(APA) Standard 2.01, Boundaries of Competence, mental 
health professionals have an ethical obligation to ensure that 
they are competent in the area in which they provide 
services. This includes and is not limited to culture, 
ethnicity, gender, and sexual orientation (APA Ethics Code, 
2002). Since research indicates that African Americans and 
gay and bisexual men of all races continue to be most 
severely affected by HIV/AIDS, it is important for mental 
health professionals to be aware of the cultural, familial, and 
community norms and values pertinent to their patients 
(CDC, 2006). One example of how this can be accomplished 
is by attending seminars or conferences regarding cultural 
diversity. 

A 2002 study by Low-Beer and colleagues examined 
prevalence rates of HIV/AIDS in relation to sexual 
orientation, socioeconomic status, and education among a 
large sample of men from the west end of Vancouver, 
Canada. The study surveyed a total of 1,176 men; 300 men 
identified as being either gay or bisexual. About 16% of 
those men, who identified as gay or bisexual, reported being 
positive for HIV. The results of the study indicated that, in 
general, gay or bisexual men who were HIV-negative had 
more education, higher rates of full-time employment, and 



AQUINO, SECKER & WOOD 
 

 54 

higher incomes than the HIV-positive participants. The data 
collected from this study is presented in Table 2 (Low-Beer 
et al., 2002).  

 
Table 2 
Comparison of Sociodemographic Characteristics between 
Gay and Bisexual HIV-positive (n = 47) and HIV-negative 
men (n = 237) in Vancouver’s West End 

 
Characteristics    HIV-positive [n (%)]       HIV-negative [n (%)] 
Age 

 Median  38  37 

 

Education 

> 12 years  44 (94)  228 (97) 

< 12 years  3 (6)  8 (3) 

 

Full-time Employment 

 Yes  19 (40)  187 (79) 

 No  28 (60)  50 (21) 

 

Income 

> 20,000  31 (66)  198 (85) 

 < 20,000  16 (34)  36 (15) 

 
The CDC (2009b) reported a study that showed a 15% 

increase in HIV/AIDS diagnoses from 2004-2007 in 34 
states. These 34 states all have long-term HIV/AIDS 
reporting. The CDC suggests four possible reasons for this 
increase: (1) the increase may be the result of changes in 
state reporting regulations. Some states have now included 
reporting all viral loads and CD4s during laboratory tests. (2) 
More people are getting tested for HIV/AIDS due to 
increased emphasis on the benefits of early testing. The CDC 
reports that the testing rates are higher for pregnant women, 
people who engage in behaviors that are known HIV risks, 
young people (ages 18-34), and African Americans. (3) 
There may be instability in the data. (4) There may be an 
actual increase in HIV/AIDS infections. The CDC has 
identified specific subgroups that have shown the greatest 
increase in HIV/AIDS diagnosis. There has been a 26% 
increase in HIV/AIDS diagnoses among men who have sex 
with men (MSM). The Centers for Disease Control and 
Prevention states that “although it is difficult to determine 
whether the increase in diagnoses represents a true increase 
in incidence, a recent CDC analysis indicated that HIV 
incidence among gay and bisexual men has been increasing 
since the early 1990s” (CDC, 2009). Along with increases 
among all racial/ethnic groups, there has been a 9% increase 
seen among high-risk male heterosexuals, and a 14% 
increase among females. Increases in HIV/AIDS diagnoses 
were seen in 28 out of the 34 states included in this study. 

Although increases were seen the most in the southern states, 
estimates per region were not included (CDC, 2009b).  

A recent CDC (2008) report used an extended back-
calculation model to show the estimated number of new HIV 
infections. Figure 1 is taken directly from the August 2008 
CDC report “Estimates of New HIV Infections in the United 
States.” As can be observed from the figure, the estimated 
number of new HIV infections have drastically decreased 
since the mid-to-late 1980s, but have slowly risen from the 
early 1990s and have since began to level off.   
 

 
Note: Estimates are for 2-year intervals during 1980–1987, 3-year intervals 
during 1977–1979 and 1988 –2002, and a 4-year interval for 2003–2006.
 
Figure 1. Estimated number of new HIV infections, 
extended back-calculation model, 1977–2006  

 
Ethical and Legal Issues 

 
The Ethical Principles of Psychologists and Code of 

Conduct (APA Ethics Code, 2002) serve as the mental health 
professionals’ reference for professional standard of care. 
The HIV/AIDS-related ethical dilemma of confidentiality 
involve ethical Principle A: Beneficence and 
Nonmalficience, and APA Standard 4.01: Maintaining 
Confidentiality.  
 
Principle A: Beneficence and Nonmaleficence 
 

The ethical principle of beneficence refers to being kind 
and doing good for others. Furthermore, the principle 
involves “respecting the dignity and worth of the individual” 
(Hughes & Friedman, 1994, p.2). Under this principle, 
mental health care professionals are required to provide 
compassion for their patients infected with HIV/AIDS 
(Hughes & Friedman, 1994).  Regardless of the clinician’s 
theoretical orientation, mental care professionals strive to 
provide quality care while maintaining and valuing the 
person, content, and therapeutic relationship.  

The principle of nonmalficience means “do no harm” 
and requires mental health care professionals to “attempt to 



HIV/AIDS-RELATED ETHICAL DILEMMA OF CONFIDENTIALITY 
 

 55

                                                        

prevent harm to clients and third parties as long as doing so 
does not present the professional with significant risks or 
costs, and the benefits that clients or others would receive 
are not outweighed by the risks or costs incurred by the 
professional” (Melchert & Patterson, 1999, p.180). If a 
treating clinician shares the commonly held view that 
avoiding harm to others is a more compelling responsibility 
than the responsibility of benefiting patients, then they are 
likely to breach confidentiality when faced with the 
HIV/AIDS-related ethical dilemma of confidentiality 
(Melchert & Patterson, 1999). However, there are mental 
health professionals who err on the side of confidentiality 
and will not, unless mandated by state law, break mental 
health professional-patient confidentiality. It is argued that 
those mental health professionals who break confidentiality 
to protect and avoid harm to third parties are causing more 
harm than good as there is a possibility that breaking 
confidentiality “could result in harm to the client, who may 
experience extreme distress at the violation of trust, and, 
possibly, rejection by the threatened partner” (Hughes & 
Friedman, 1994, p.3). 

Here lies the core of the ethical dilemma: should mental 
health care professionals maintain confidentiality or should 
they risk confidentiality and possibly cause harm to their 
patients to protect unsuspecting sexual partner(s)? To some 
mental health professionals, resolving this ethical dilemma is 
rather simple, but to others it is a complicated and often 
times, an unclear and painstaking process. Resources for 
mental health professionals in this circumstance appear to be 
limited to the APA Ethics Code and state laws. Both 
literature and the Ethical Principles of Psychologists and 
Code of Conduct (APA Ethics Code, 2002) maintain that 
legal mandates supersede ethical guidelines. However, not 
every state has a law surrounding the issue. Therefore, it is 
the clinician’s responsibility to resolve this ethical dilemma.  

 
Maintaining Confidentiality (APA Standard 4.01) 
 

The Ethical Principles of Psychologists and Code of 
Conduct (APA Ethics Code, 2002) address confidentiality in 
Standard 4.01: 

 
Psychologists have a primary obligation and take 
reasonable precautions to protect confidential information 
obtained through or stored in any medium, recognizing 
that the extent and limits of confidentiality may be 
regulated by law or established by institutional rules or 
professional or scientific relationship.  

 
The APA has specified their position on breaching 

confidentiality with an HIV/AIDS patient. They state that 
“no legal duty to warn should be imposed, and if such 
legislation is imposed, disclosure by the therapist should 
occur only after (a) a known partner is identified to be at 
risk, (b) the partner is not himself/herself aware of the risk, 
and (c) the patient has not been willing to tell that individual 

directly” (Huprich, Fuller, & Schneider, 2003).2 The 
Tarasoff ruling states that “when psychotherapist determines, 
or pursuant to the standard of his profession should 
determine, that his patient presents a serious danger of 
violence to another he incurs the obligation to use reasonable 
care to protect the intended victim against such danger” 
(DiMarco & Zoline, 2004, p.69).   

The Tarasoff ruling in 1976 is a major legal aspect that 
demands attention when addressing the HIV/AIDS-related 
ethical dilemma of confidentiality. Although some situations 
may meet the Tarasoff requirement for duty to warn, some 
argue that the issue of HIV/AIDS is simply not applicable. 
However, as important as the Tarasoff ruling is, many states 
have not adopted Tarasoff, thus placing professional 
responsibility on the treating mental health professionals to 
resolve the dilemma (Corey, Corey, & Callanan, 2007). 
Those advocating for the maintenance of confidentiality 
argue that clinical mental health professionals are non-
medical professionals, and therefore, “cannot legitimately be 
held responsible for making an assessment of dangerousness, 
since the diagnosis is a medical one” (DiMarco & Zoline, 
2004, p.69).  This view is in stark contrast to mental health 
professionals who maintain that it is their responsibility to 
breach confidentiality and reveal the danger that results from 
some patients that may not honestly disclose their 
HIV/AIDS status. These mental health professionals actively 
advocate breaching confidentiality in such situations to 
protect others from potential harm (DiMarco & Zoline, 
2004). The best course of action on ethical dilemmas is often 
achieved after a careful evaluation of personal and 
professional values and review of the ethical guidelines and 
legal mandates.     

Confidentiality is viewed as an essential component in 
therapeutic relationships. Mental health professionals often 
reassure patients that the therapeutic relationship and the 
therapeutic environment is safe, open, and most importantly, 
confidential. The literature states that “without assurance of 
confidentiality, patients may be hesitant to seek treatment 
because of fear of stigmatization” (Chenneville, 2000, 
p.661). As previously stated, breaches of confidentiality may 
cause harm to patients. Research shows that the “ultimate 
question is not whether to breach confidentiality but rather 
how to protect third parties without destroying the 
therapeutic alliance between clinician and client” 
(Chenneville, 2000, p.661). In terms of the HIV/AIDS-
related ethical dilemma of confidentiality, the literature 
encourages mental health professionals to consider less 
intrusive means of dealing with the HIV/AIDS-related 
ethical dilemma of confidentiality, such as persuading the 
patient to self-disclose to their sexual or needle sharing 
partner(s) (Corey et al., 2007).  

 
2 Although this article was written before the publication of the 
APA’s 2002 Ethics Code, the authors indicate that their analysis 
“have not been substantially altered by the 2002 Ethics Code 
revisions” (Huprich et al., 2003). 



AQUINO, SECKER & WOOD 
 

 56 

Generally, confidentiality (APA Standard 4.01 
“Maintaining Confidentiality, APA 2002) should be 
maintained except in circumstances in which a patient’s 
behavior poses physical danger to others or one’s self. Since 
mental health professionals have a legal duty to protect and 
warn, it is imperative that mental health professionals are 
familiar with the ethical guidelines and legal mandates. 
Mental health professionals’ duty to warn and protect is 
“especially difficult because counselors face not only ethical 
and legal issues surrounding confidentiality of client 
communications but also specific statutory prohibitions 
against disclosures of HIV information” (Corey et al., 2007, 
p.252). Each state differs in their statutory prohibitions. For 
instance, Pennsylvania law mandates that mental health 
professionals “may not break confidentiality to warn that a 
client poses a threat to others through HIV/AIDS” (Corey et 
al., 2007, p. 252). On the other hand, some states (e.g. 
Montana and Texas) provide legal protection for mental 
health professionals who break confidentiality to warn third 
parties of possible harm (Corey et al., 2007). There is no 
apparent consensus on what most states legally mandate 
regarding disclosure of HIV/AIDS to a monogamous partner. 

A recent study by Pabian, Welfel, and Beebe (2009) 
showed that an average of 76.4% of surveyed mental health 
professionals were incorrect when asked to select the one 
statement that most accurately described their state’s law 
regarding duty-to-warn. The study also found that the mental 
health professionals had inaccurate interpretations of 
situations involving duty to warn. It is important that mental 
health professionals continue to educate themselves 
regarding ethical and legal dilemmas.  

While the “duty to warn” concept is generally accepted 
in the mental health care field in the areas of homicidal and 
suicidal intent, and child and elder abuse, some mental 
health care professionals argue that “the risk that HIV-
positive clients pose to others is fundamentally different” 
and consequently, “HIV-positive clients’ rights to 
confidentiality outweighs the benefits of breaking their 
confidentiality to warn third parties of their possibility of 
contracting HIV” (Melchert & Patterson, 1999, p.180). 
Similar to Principle A: Beneficence and Nonmaleficence, the 
ethical dilemma becomes whether to maintain confidentiality 
or break it to protect third parties from possibly contracting 
HIV/AIDS. In fact, a person is at risk for contracting HIV 
when engaging in unsafe sexual behavior, it is not certain 
that the person will indeed contract HIV. Therefore, it is hard 
to conclude that imminent physical injury will occur 
(Huprich, Fuller, & Schneider, 2003). The literature suggests 
that mental health care professionals should advise and 
actively work with their patients to either terminate their 
risky sexual and needle sharing practices or inform the 
potential victim(s) (Melchert & Patterson, 1999). The 
American Psychiatric Association Ad Hoc Committee of 
AIDS Policy (1988) further specified that is it ethically 
permissible to notify an identifiable person if the patient 
refuses to self-disclose to a partner(s) in which unsafe sex 
practices are being employed (Melchert & Patterson, 1999).   

Mental health professionals need to make various 
decisions when assessing risky behaviors among their 
HIV/AIDS patients, including breaching confidentiality to 
reveal the HIV/AIDS status to a partner and how to discuss 
the importance of safer sex practices. To aid mental health 
professionals in making these decisions, Knapp and 
VandeCreek (1990) suggest three levels of risky behavior. 
‘Low-Risk Behavior’ is casual contact where breaching 
confidentiality may not be an issue. These behaviors include 
kissing, human bites, and tattoos. ‘Intermediate-Risk 
Behavior’ is engaging in safe sex, but without informing the 
partner of the risks involved. ‘High-Risk Behavior’ is unsafe 
sexual contacts and sharing needles (Knapp & VandeCreek, 
1990). This rating system can be used to help mental health 
professionals make decisions about breaching confidentiality 
by helping them decide which situations are the most serious 
and perhaps more likely to necessitate a breach in 
confidentiality.  

 
Current Beliefs of Mental Health Professionals 
 

Burkemper (2002) found that, in regards to maintaining 
confidentiality with an HIV/AIDS patient, professional 
ethics (as opposed to legal considerations) were most 
important to mental health professionals. Palma and Iannelli 
(2002) studied if biases held by mental health professional 
trainees affect their therapeutic reactivity to confidentiality 
with HIV/AIDS patients. They found that trainees held the 
highest level of therapeutic reactivity towards heterosexual 
male patients and the lowest level of therapeutic reactivity 
towards heterosexual female patients. The authors describe 
therapeutic reactivity or one’s willingness to breach 
confidentiality as a shift in willingness to maintain 
confidentiality. Their research also found that trainees 
emphasized the patient’s safe or unsafe sexual behaviors, as 
well as the gender and sexual orientation of the patient, when 
making their decisions regarding confidentiality. The study 
gave evidence of a bias in regards to therapeutic reactivity 
when the patient is gay or lesbian. Although the data shows 
that trainees were the most reactive towards male 
heterosexual patients and least reactive towards female 
heterosexual patients, a bias appears evident when 
considering reactivity towards gay male and lesbian female 
patients (Palma & Iannelli, 2002). The information gathered 
in Palma and Iannelli’s 2002 study indicated that work needs 
to be done to lessen the biases of mental health 
professionals. 

Although no nationwide study was found, a 2001 study 
by Simone and Fulero looked at a group of Ohio mental 
health professionals to determine if they would breach 
confidentiality with their HIV/AIDS patients and found that 
their sample was strongly split on the issue. These mental 
health professionals “tended to stigmatize patients who 
became infected through IV drug use and homosexual 
contact more than they stigmatized patients who became 
infected through heterosexual contact and blood 
transfusions” (Simone & Fulero, 2001, p.433). As 



HIV/AIDS-RELATED ETHICAL DILEMMA OF CONFIDENTIALITY 
 

 57

knowledge of AIDS increased, the level of stigma towards 
AIDS patients decreased, which in turn decreased the 
likelihood of breaching confidentiality. Although the mental 
health professionals did well on the AIDS Risk Knowledge 
(ARK) scale, they received a lower score on tests regarding 
the legal and ethical knowledge related to “duty to protect.” 
A lower score regarding legal and ethical knowledge 
regarding liability concerns was found to correspond with 
increased likelihood of breaching confidentiality. However, 
it is important to note that only 17% of respondents reported 
having experience with HIV/AIDS-infected patients 
(McGuire, Nieri, Abbott, Sheridan, & Fisher, 1995; Simone 
& Fulero, 2001). 

 
Clinical Implications 

 
There are several steps a mental health professional can 

take before breaching confidentiality to ensure the safety of 
their patient and others. An important therapeutic tool when 
working with HIV/AIDS patients is psychoeducation 
(Huprich et al., 2003). The mental health professional can 
recommend that the patient inform their partner about their 
HIV status or encourage them to refrain from engaging in 
sexual activity with their partner. If the patient refuses to do 
either of these steps, the mental health professional can then 
advocate for practicing safe sex. Gray and Harding (1988) 
suggest a “process of helping the patient take responsibility 
for informing a sexual partner(s).” This process includes 
educating the patient about the specific transmission 
processes and current medical advice, consulting with the 
patient’s primary care physician, and actively supporting the 
patient when they rehearse difficult communication 
situations (Gray & Harding, 1988). 

Whereas the Ethical Principles of Psychologists and 
Code of Conduct (APA Ethics Code, 2002) attempts to 
provide psychologists with clear guidelines by which to 
abide, mental health professionals are often faced with 
uncertainty as a result of the contradictions that arise 
between legal mandates and ethical codes. Given that the 
HIV/AIDS-related ethical dilemma of confidentiality is of 
concern in clinical practice, the following are 
recommendations for mental health professionals treating 
HIV/AIDS infected patients (Corey et al., 2007): 

 
1. Discuss limits to confidentiality at the onset of 

treatment. 
2. Possess awareness of state laws in regard to disclosure. 
3. Possess awareness of ethical guidelines. 
4. Possess sufficient self-awareness in regard to one’s 

attitude, biases, and prejudices. 
5. Mental health professionals should speak openly about 

their concerns over their patient’s behavioral practices. 
6. Utilize consultation and supervision. 
7. If the clinician decides to break confidentiality to protect 

identified and unsuspecting third parties of their risk in 
contracting HIV/AIDS, the clinician should advise their 
patient prior to disclosure both the purposes of 

maintaining rapport and to attempt to obtain the 
patient’s permission. 

8. Always follow statutory guidelines. 
 

Before breaching confidentiality, the following is suggested 
for consideration (Hook & Cleveland, 1999):  

 
1. Maintain current knowledge of the medical dimension 

of HIV/AIDS, including transmission. 
2. Encourage patients to be retested to ensure an accurate 

diagnosis. 
3. Maintain current knowledge of relevant existing state 

laws.  
 

Conclusion 
 

Although confidentiality in therapeutic relationships is 
valued and protected, there are situations in which a breach 
in confidentiality may be necessary and/or mandated by law.  
Confidentiality with a patient who has HIV/AIDS has been 
debated for years. When breaching confidentiality, it is 
important for mental health professionals to take reasonable 
precautions, seek consultation and supervision, and refer to 
and review state laws and professional ethical guidelines. 
These are some of the resources available for mental health 
care professionals to aid them in this difficult situation. 

 
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