A 10-year-old boy is brought to the office by his grandmother for a new patient visit. The boy has a known diagnosis of HIV infection acquired perinatally from his mother and has been taking highly active antiretroviral medications since infancy. The grandmother is the patient's legal guardian; his mother died from complications of AIDS several years ago. While the patient is having his vital signs measured, the grandmother explains that she has not revealed the diagnosis to the patient because she wants "to let him live a normal childhood." Although the patient has been compliant with his HIV medications, he believes they are vitamins. Vital signs are normal. Weight is at the 45th percentile for age. Cardiopulmonary and abdominal examinations are unremarkable. Viral load is undetectable with a CD4 lymphocyte count of 780 cells/mm³. Speaking privately with the pediatrician after the examination, the grandmother reiterates that she does not want to disclose the patient's diagnosis. Which of the following is the most appropriate response?

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Persons with perinatally acquired HIV infection are now living longer into adulthood due to advances in antiretroviral therapy. Parents and guardians of children living with HIV often avoid disclosing the diagnosis to them in an attempt to preserve normal childhood experiences. Other common fears associated with diagnosis disclosure include concern for a changing family dynamic and worry over the parents' HIV statuses becoming public. Adolescence is a period when developmental maturation is associated with increasing autonomy. Adolescents may ask questions about their own health and begin exploring sexuality. For this reason, it is recommended that children know and understand their HIV diagnosis by adolescence. Disclosure at this time fosters trust and autonomy, increases medication compliance, and decreases the risk of unknowingly transmitting the virus. However, it is appropriate to respect family members' concerns and give them time to prepare themselves for the potential emotional and psychological responses. The provider should encourage the family to develop a plan with a timeline for the conversation to occur. The discussion with the patient is a process that involves joint participation between the family and the provider using open-ended questions and offering support to the patient. The full burden of how to disclose serious information should not fall on the family, particularly in cases of chronic disease with increased morbidity and mortality rates (Choice C). (Choice A) Discontinuing care that is medically necessary is inappropriate and harmful to the patient. (Choice B) Failure to address the need for diagnosis disclosure increases the risk of infection transmission and medication noncompliance. (Choice D) Coercing disclosure through threats creates distrust and harms the relationship between the family and the provider. Educational objective: Disclosure of an HIV diagnosis to a child with perinatally acquired infection should occur by adolescence to foster patient autonomy, increase medication compliance, and prevent transmission. The provider should respect the family's concerns and offer joint participation in establishing a timeline and plan for disclosure. References: HIV disclosure: parental dilemma in informing HIV infected children about their HIV status in Malawi. (http://www.ncbi.nlm.nih.gov/pubmed/26167257) Disclosing HIV status to HIV positive children before adolescence. (http://www.ncbi.nlm.nih.gov/pubmed/22875352)

A 10-Year-Old Boy Is Brought to the Office by His