BMJ  2004;328:1080 (1 May), doi:10.1136/bmj.328.7447.1080-a

reviews

Book

Mortal Secrets: Truth and Lies in the Age of AIDS

Much has been written about the psychological and social implications of HIV infection for individuals, their intimates, and their communities. Yet, perhaps surprisingly, Klitzman and Bayer are correct in their assertion that theirs is the first detailed study of disclosure, the process whereby individuals make their serostatus for HIV known to others.

Disclosure has important implications, both for prevention and for the success of therapeutic intervention. An HIV positive person who does not disclose may increase the likelihood of transmitting the virus to others—particularly sexual partners. In addition, they may be withholding from previous sexual partners information that might otherwise lead them to seek testing and, if necessary, treatment that might prolong their lives.

The nature of these implications means that it is easy to blame those who do not disclose. Yet, while the need for disclosure may seem straightforward to, say, a clinician sitting in his or her office or a public health official mapping the remorseless advance of the pandemic, this is an issue of daunting ethical and psychological complexity. Klitzman, a clinical psychiatrist, and Bayer, who specialises in medical ethics, are well placed to recognise this, and their book, based on empirical research with both HIV positive and (a few) HIV negative people, represents an attempt to raise awareness of the realities of living with HIV, and of just how daunting a process disclosure may be.

It is an aim that succeeds to an extraordinary degree. As one who has specialised in the social and cultural aspects of HIV/AIDS for 15 years, I imagined myself emotionally inoculated against first person accounts of those living with the virus. Yet so well thought-out is this study, and so well presented are the accounts of the participants, that I put the book down with a real—and rare—sense that my understanding had grown and my thinking about the ethics of HIV—in particular the responsibilities of those infected—had shifted.

Much of what the researchers discovered is not new. We have long known, for example, that "culturally sanctioned notions of male dominance place women at special risk for HIV." However, the examples given here put such bald statements into a new context, and make the social and cultural factors that shape the pandemic seem vivid and emotionally real. Such vividness serves powerfully to enhance understanding.

There are some minor irritations. The authors have an annoying tendency to fall back on the kind of lurid phraseology that activists have rightly drawn attention to as contributing to the stigmatisation of people with the virus. Thus we are told that mothers whose children were seropositive "harboured a lethal virus," while AIDS has made sex "an uncertain and dangerous quagmire." However, it would be mean spirited to dwell on such technicalities.

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University of the West of England, Bristol

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