The importance of informing appropriate healthcare workers should be emphasized. This includes midwives, general practitioners, health visitors and paediatricians.

The process of inpatient care should be explained clearly so that the women can be helped to inform ward staff explicitly about levels of disclosure to visitors. Depending on the setting, levels of disclosure of newly diagnosed pregnant women signaling pathway about their HIV status vary, and there are cultural factors that influence the patterns of self-disclosure to partners and other social network members [339, 341]. Disclosure should be encouraged in all cases but may be viewed as a process that may take some time [342, 343]. There are situations where a newly diagnosed HIV-positive woman refuses to disclose to a current sexual partner, or appears to want to delay disclosure indefinitely. This can give rise to very complex professional, ethical, moral and, potentially, legal situations. There is a conflict between the duty of confidentiality to the index patient and

a duty to prevent harm to others. Breaking confidentiality in order to inform a sexual partner of the index patient’s positive HIV status is sanctioned as a ‘last resort’ Bortezomib solubility dmso by the World Health Organization (WHO) [344] and General Medical Council (GMC) [345]. However, it is not to be taken lightly as it could Decitabine solubility dmso have the negative impact of deterring others from testing because of the fear of forced disclosure and loss of trust by patients in

the confidential doctor–patient relationship. Difficult disclosure cases should be managed by the MDT. It is important to accurately record discussions and disclosure strategy in difficult cases. Simultaneous partner testing during the original antenatal HIV test should be encouraged wherever possible as couples will frequently choose to receive their HIV test results together, providing simultaneous disclosure. Reassurance about confidentiality is extremely important, especially regarding family members and friends who may not know the diagnosis but are intimately involved with the pregnancy. Women from communities with high levels of HIV awareness may be concerned about HIV ‘disclosure-by-association’ when discussing certain interventions, including taking medication during pregnancy, having a Caesarean section, and avoiding breastfeeding. Possible reasons such as the need to ‘take vitamins’, or having ‘obstetric complications’ and ‘mastitis’ may help the women feel more confident in explaining the need for certain procedures to persistent enquirers [346]. Between 20% and 80% of newly diagnosed HIV-positive pregnant women may have partners who are HIV negative, depending on the setting [341, 347].