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“It doesn’t make sense to divide patients into ‘dangerous’ and ‘safe’”

E.V.A. launched a project to reduce medical specialists’ stigma towards HIV-positive patients

People with HIV need medical care unrelated to their HIV diagnosis: they have colds, fractures, and problems with their hearing or vision. In AIDS Centers, the necessary specialists are not always available, and in general medical institutions there can be a “special” attitude towards HIV patients. Doctors may use additional protective gear, try to pass these patients on to their colleagues, or reject treating them entirely. Most often this happens due to fear.

On the site there are materials for medical professionals including important facts about HIV, instructions for cases of contact with the virus during patient care, and personal stories of people with HIV.

We spoke with Natalia Vladimirovna Sizovaya, Deputy Chief Physician for Outpatient Care of the St. Petersburg State Budgetary Healthcare Institution “Center for the Prevention and Control of AIDS and Infectious Diseases” about stigma, stereotypes, and how we can fight them in the doctor-patient relationship.

N. V. Sizova

What do you know about the problem of stigmatization of people with HIV among doctors?

I remember the late 90s and the 2000s — then, doctors really were afraid of working with HIV-positive patients. Often they simply refused to treat them. I remember personally how these patients were just sent immediately from the emergency room to the Botkin hospital without any assistance. But now from my point of view, in Saint Petersburg the situation is getting better — in the last year there were certainly very few complaints from patients who were denied treatment due to their HIV status.

What helps reduce the level of stigma among doctors?

There are many factors. First, real work experience. Doctors now see more patients with HIV — and that is a chance to see an ordinary person with ordinary problems instead of some kind of stereotypical image dictated by myths from the 2000s. Second, the level of information is growing, largely due to the influx of young doctors. They are not blinded by stereotypes and have learned about HIV during their studies. But there are still doctors who do not know the basic information — so they have a completely unfounded fear of treating HIV-positive patients. We have many older doctors who have not been following the topic of HIV and simply maintain the opinion they formed 20 years ago.

So stereotypes about HIV are out of date?

Of course they are out of date. Because the situation itself has changed. Yes, in the 2000s, drug use was the key mode of transmission. But now, 77.9% of infections are sexually transmitted. This means that the virus has spread to the general population. Now a person with HIV is often an ordinary person, the same as anyone. And the more a doctor sees this with their own eyes, the less stigma they will have towards such patients.

What, in your view, are the key facts every doctor should know about HIV?

First of all, absolutely every doctor should understand that today a diagnosis of HIV infection implies the start of therapy. That is, we should begin to treat everyone immediately. If in the past, we waited for a person’s immunity to drop, now, antiretroviral therapy is prescribed without a period of observation. Second — if a patient is observed over the course of six months to have an undetectable viral load as a result of taking therapy, then they are safe and do not transmit HIV. This means that in the event of an exposure, whether it’s a cut or an injection with a used needle, there is no risk of infection. This is proven by a huge amount of research.

And what should a doctor do if there is an incident of exposure while working with a patient who has not reached a consistently undetectable viral load?

There are clear sanitary protocols — it is like the internal law for doctors that we all work by. In every medical institution there is an epidemiologist; immediately after exposure, the medical worker goes to them. Then the emergency statement is documented, and the situation should be described as clearly as possible: what happened, what was the nature of the contact and with which patient. Then the medical worker comes to us at the AIDS Center (on working days). On weekends, holidays, or during the night shift you can go to the emergency room at Bumazhnaya 12 or to the Botkin Hospital. Then our epidemiologists review the statement and assess the level of risk — there could be no risk at all, or it may be minimal. It often depends on the nature of the exposure and the viral load of the specific patient. For example, if a patient has been taking therapy for a long time, it means that there are minimal concentrations of HIV in his body. But if the epidemiologist believes there is a risk of infection, the medical worker will receive PEP, or post-exposure prophylaxis. It is a course of antiretroviral therapy given after unsafe contact with HIV and should be taken for one month. Two months after the exposure incident, one should get tested for antibodies. In any case, it’s important to take care of your safety and contact us as soon as possible. Ideally, immediately after the exposure, and according to the rules, within 72 hours.

How should a doctor work with an HIV-positive patient?

The same as with any other patient, of course. If a person is taking therapy, then most of their health problems have nothing to do with their HIV status. When a doctor treats [HIV-positive] patients differently, of course, he believes that he is proceeding from concern for his safety. But I believe that such care should be the absolute standard for all patients. I’ll give you an example. According to the rules, the patient’s card should not have any “special” marking. But earlier the situation was different — they put B-23 or a triangle to indicate hepatitis. And back then it was justified, because we worked without gloves and with reusable equipment, droppers and needles. But now the situation is completely different. Everything is disposable or subject to mandatory sterilization. And this makes it possible to protect yourself completely. It’s enough to follow a simple principle: working with any patient there is a chance of infection. And I’m not talking just about HIV — there are many other infectious diseases that are much more dangerous in terms of infection risk, for example, hepatitis. And the person may not even know they have it. So there is no point in evaluating and dividing patients into “safe” and “dangerous” — you need to follow the same rules with all patients and always take care of the safety of your own health.

How much can patients themselves influence the doctor’s attitude to them?

You know, it seems to me that patients with HIV sometimes have an element of self-stigmatization. Precisely because they know that they may encounter some improper attitude when seeking medical care, and they’re afraid and try to hide their status. It results in a vicious circle that can and should be chipped away from both sides. If doctors show a professional and human attitude towards all patients, then people with HIV will stop fearing stigmatization. As a result, more doctors will be able to see [HIV patients] with their own eyes and understand that there is nothing to be afraid of. And most importantly, when a medical worker understands HIV issues and knows all the facts, he can also help those patients with HIV who, for whatever reason, have not received therapy. And in each of these cases, it is saving someone’s life.

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