Health: Litigation of epidemic proportions: Aids is raising almost as many legal questions as it is medical ones. Angela Smyth reports

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AN AMERICAN jury awards dollars 2m to the ex-wife of a man who failed to tell her that he was HIV positive. . . . In Texas, a prisoner with Aids is charged with attempted murder after spitting on a warden. . . . A doctor from Minneapolis is sued for continuing to practise medicine without informing his patients that he is HIV positive. . . . In Wisconsin, a woman sues after being artificially inseminated with contaminated semen. . . . In Los Angeles, a manicurist is charged with discrimination for refusing to cut the toenails of a gay man.

In a country where 140,000 people have already died of Aids, the impact of the virus has reached the courts. Most cases involve discrimination, contaminated blood or malpractice, but more recently, judges have heard cases concerning everything from freedom of speech and child custody to libel and the contesting of a will.

In England last month, Susan Threakall, a Birmingham widow, began action against the pharmaceutical company Wellcome and the South Birmingham Health Authority, alleging that the Aids drug AZT hastened her husband's death. She is believed to be the first person in the world to sue over use of the drug.

'No other infectious disease in recent history compares with HIV in the ways it has affected our relationships with each other and with our social institutions,' says Lawrence Gostin, head of the US Aids Litigation Project at Harvard University. 'The cases not only impact on major institutions such as schools, health care and prisons but also reach into intimate personal relationships between families and lovers, doctors and patients, employers and employees.'

Contracting a disease used to be seen as chance or misfortune, yet in America it is not unusual for patients to seek out fault and with it liability, Mr Gostin says. Patients are not only demanding to know the HIV status of healthcare workers, they are also questioning their competence. Doctors who delay diagnosis or who are not apprised of the latest treatments are likely to be sued. In California, Dr Stephen Herman faces charges of negligence, conspiracy and fraud for discouraging patients from using AZT and instead recommending his own, unproven treatment. His patients claim that he may have taken years off their lives. However, recent research shows that even if AZT is used before symptoms appear, it may not delay the onset of disease.

Health professionals have been hit hard by litigation. Last year the death of Kimberly Bergalis, a 22-year-old woman in Florida who was reported to have contracted Aids from her dentist, sparked controversy over healthcare professionals' rights to continue practising if they are found to carry HIV. As a result of the case, some states are pushing for legislation obliging doctors to be tested for HIV and to disclose their status to patients.

The American Medical Association recommends that infected doctors who perform exposure-prone procedures should seek advice and protection from an expert review panel. Yet few doctors have done so. Disclosure of HIV-positive status can lead to job loss or demotion. Dr Hacib Aoun, a Baltimore cardiologist, was dismissed after a test tube of contaminated blood shattered in his hand and he contracted the virus. A pharmacist hired by Westchester County Medical Center, New York, was laid off when a hospital employee alerted management to the fact that the man was HIV positive.

Doctors in private practice see their business vanish overnight. Dr Philip Benson, a general practitioner in Minneapolis, was sued by 24 former patients when his HIV-positive status became known. Although he had not transmitted the virus, these so-called 'fear suits' demanded compensation for the emotional distress his ex-patients suffered through Aids tests.

Such actions reflect the exaggerated fear of HIV infection that exists in America, says Mr Gostin. The Centers for Disease Control, in Atlanta, Georgia, estimates that the risk of contracting Aids from an infected doctor is somewhere between one in 41,000 and one in 416,000. The World Health Organisation says there have been 60 cases of health workers infected by patients, two in the UK.

Now Americans are asking if doctors should not have a duty to disclose the status of HIV-positive patients to their sexual partners and people with whom they might share needles. Doctors face the dilemma of preserving their patients' right to confidentiality and satisfying the right to know of others who may also need treatment, says Mr Gostin. 'So far it is unclear legally who must be warned and under what circumstances. The discretion is left to the doctor and if he or she makes the wrong decision it could result in liability.' One day a court may see a patient suing a health centre for having informed his family of his HIV status, the next day, another patient's spouse may press charges because she was not warned that she may have the virus.

Lawyers and judges now have to grapple with some 500 new statutes inspired by the Aids epidemic. Aids law clinics, journals and courses have sprung up overnight, along with a proliferation of Aids law specialists. The US Public Health Service will soon offer workshops for judges on Aids and the law, a move that Mr Gostin approves of. 'Our ability to anticipate the rapidly changing social impact of the HIV epidemic is dependent on understanding the bitter disputes played out in the nation's courts,' he says. 'And an enlightened judiciary is essential.'

(Photograph omitted)