Stigmatization and discrimination against people living with HIV as social barriers to access dental care

Размещено на http://www.allbest.ru/

Stigmatization and discrimination against people living with HIV as social barriers to access dental care

Belyakova A.S., Candidate of medical Sciences, associate Professor; Kozlova M.V. Doctor of medical Sciences, Professor, Honored doctor of the Russian Federation, head of the Department of dentistry by Central State Medical Academy of the Department of Presidential Affairs, Pchelin I.V. Director; Barsky K.A. Program Manager of the «Steps» Fund

Abbreviations

HIV - human immunodeficiency virus

WHO - World Health Organization

PLHIV - people living with HIV

AIDS - Acquired Immune Deficiency Syndrome

UNAIDS - Joint United Nations Program on HIV / AIDS

Abstract

The article presents an analysis of the data of sociological research, the purpose of which was to show the prevalence of stigma and discrimination against patients with HIV infection at the dental attendance. According to the results of a voluntary face-to-face individual anonymous survey of 1268 people, living with HIV, aged 18 years and older, there was a high level (66.7%) of stigma and discrimination in medical organizations providing dental care. Fear of stigma has been a key factor in reducing the willingness to disclose HIV status. 36.5% of respondents do not believe in the principle of confidentiality, they are out of concern for the disclosure of the diagnosis and the consequences associated with it. In this regard, only 22.4% of those interviewed for dental care reported having HIV infection. 29.9% of respondents were asked to take an HIV test - 60% of them voluntarily, 15% in an ultimatum form, 25% of patients were under pressure.

A large number of acts of discrimination were revealed in the form of a negative attitude of a physician to patients with HIV infection (25% of cases) and refusal to treat oral diseases (41.7% of cases). According to the results of the survey, the doctors, having learned about the positive HIV status of the patient, refused mainly (94%) dental surgery (tooth extraction and dental implantation). There was a high proportion of people (64.2%) who postponed the visit to the dentist due to social concerns related to their HIV status. The data of the presented study actualize the necessity for development and realization of programs to eradicate stigma and discrimination towards people living with HIV in order to timely provide qualified medical dental care, improve oral health and the quality of life of these patients.

Key words: HIV infection, people living with HIV, stigma, discrimination, dentistry.

Резюме

Стигматизация и дискриминация людей, живущих с ВИЧ как социальные барьеры для доступа за стоматологической помощью

Белякова А.С., Кандидат медицинских наук, доцент кафедры стоматологии; Козлова М.В. Доктор медицинских наук, профессор, Заслуженный врач РФ, заведующий кафедрой стоматологии ФГБУ ДПО «Центральная государственная медицинская академия» УД Президента РФ, Пчелин И.В., Председатель; Барский К.А. Руководитель программ Регионального благотворительного общественного фонда борьбы со СПИДом «Шаги»

В статье представлен анализ данных социологического исследования, целью которого явилась оценка уровня распространенности стигматизации и дискриминации по отношению к пациентам с ВИЧ-инфекцией на стоматологическом приеме. По результатам добровольного очного индивидуального анонимного анкетирования 268 человек, живущих с ВИЧ в возрасте 18 лет и старше, отмечен высокий уровень (66,7%) существования стигмы и дискриминации в медицинских организациях, оказывающих стоматологическую помощь. Страх перед стигмой являлся ключевым фактором, снижающим готовность раскрыть ВИЧ-статус. 36,5% респондентов не верят в соблюдение принципа конфиденциальности, опасаются разглашения диагноза и последствий, с этим связанных.

В этой связи только 22,4% опрошенных при обращении за стоматологической помощью сообщали о наличии у них ВИЧ-инфекции. 29,9% опрашиваемых было предложено пройти тест на ВИЧ, из них 60% в добровольном порядке, 15% в ультимативной форме, на 25% пациентов оказывалось давление. Выявлено большое число актов дискриминации в виде негативного отношения врача к пациентам с ВИЧ-инфекцией (25% случаев) и отказа в лечении заболеваний полости рта (41,7% случаев). По результатам анкетирования, врачи, узнав о положительном ВИЧ-статусе пациента, отказывали в основном (94%) в хирургическом стоматологическом лечении (операции удаления зуба и дентальной имплантации). Отмечалась высокая доля лиц (64,2%), которые откладывали поход к стоматологу из-за социальных опасений, связанных с их ВИЧ-статусом. Данные представленного исследования актуализируют необходимость разработки и осуществления программ по искоренению стигмы и дискриминации по отношению к людям, живущим с ВИЧ с целью своевременного оказания квалифицированной медицинской стоматологической помощи, улучшению здоровья полости рта и качества жизни данной категории пациентов.

Ключевые слова: ВИЧ-инфекция, люди, живущие с ВИЧ, стигма, дискриминация, стоматологическая помощь.

Introduction

Modem global trends are focused on improving health and maintaining a high level of life quality of the population. However, people living with HIV (PLHIV) face many barriers to accessing medical services (including dental care). Despite some efforts to reduce stigma and discrimination due to HIV, these social phenomena continue to spread in relation to both the disease itself and HIV patients [16].

Stigma is a quality or a characteristic of an individual, which is defined by him as unacceptable, negative. UNAIDS (The Joint United Nations Programme on HIV / AIDS) characterizes stigma as a dynamic personality depreciation process that results in discrimination -- any form of exclusion or restriction of a person based on his real or perceived HIV status. Discrimination can occur in intentional action or inaction, and is directed against those who are stigmatized. Integration of external (negative perception from the society) and internal (negative selfperception) stigma often leads to adverse mental and social consequences. Shame, inferiority, social isolation can lead to the development of depression until the occurrence of suicidal thoughts [7].

Studies on stigma and discrimination when seeking medical help indicate their high level (from 36 to 59.3%) in relation to PLHIV [4, 6]. Fear of condemnation, rejection, humiliation, refusal of treatment and / or changes in attitudes on the part of health workers, as well as concerns about confidentiality may entail concealment of the diagnosis, which makes it difficult to diagnose and treat various kinds of concomitant pathology in this population group. In this regard, 54-73% of PLHIV are afraid to disclose their HIV status to a doctor [6, 15].

Up to 45.9% of HIV-positive cases of medical care became a serious problem [6]. The health care worker's own infectious safety is one of the reasons for fear of treating an HIV-infected patient, discriminatory unprofessional behavior that violates human rights, which can result in reduced quality of services provided and denial of treatment [5, 9].

Stigma and discrimination present in the medical environment, are generally recognized barriers to PLHIV access to prevention and treatment, associated with their low accessibility of the health services they need [5]. According to the report on the study of the stigma index in the Russian Federation, 22% of respondents decided not to visit medical institutions, 17% postponed seeking medical help [4]. According to the results of the meta-analysis of H.A. Gesesew (2017) PLHIV who experience a high level of stigma are 2.4 times more likely to tolerate the start of treatment until their condition becomes seriously worse [15].

One of the main indicators of general health, wellbeing and quality of life is dental health, which WHO defines as a condition characterized by the absence of chronic pain in the oral cavity and in the face, infections and oral ulcers, periodontal diseases (gums), caries, tooth loss and other diseases and disorders that limit a person's ability to chew, smile, and talk, as well as his psychosocial well-being [11]. Due to the prevalence of stigmatization and discrimination of HIV-infected people in health care organizations, there is a disparity in the level of oral health and access to dental care, which is recognized as unfair and illegal in modern society [12, 13, 19].

M. Choromanska, D. Waszkiel (2006) noted a higher (up to 71%) percentage of missing teeth in the group of HIV-infected people in comparison with patients without immunodeficiency, the number of people using dentures was twice as high as the control group. Reconstruction of the dentition of the upper and lower jaws was necessary in 46.94% of cases [10]. In 30-80% of PLHIV, primary manifestations of HIV infection are observed in the form of various diseases of the oral mucosa, which, due to etiology and pathogenesis (including a tendency to relapse, a high degree of malignancy), occupy an important place in the structure of dental morbidity [2]. Timely provision of quality medical dental care to PLHIV can significantly improve oral health and the quality of life of this category of patients.

Thus, it is relevant to study the current state of the problem of stigmatization and discrimination of PLHIV when applying for dental care.

The objective of the study is to assess the prevalence of stigma and discrimination in relation to patients with HIV infection at a dental appointment.

Materials and methods. On the basis of the social-information center of the Regional Charitable Foundation for the Fight against AIDS “Steps”, a voluntary individual anonymous questionnaire was conducted for 1268 people living with HIV aged 18 years and older who have applied for dental care in the last 12 months. The questionnaire contained questions with pre-defined answers.

Statistical analysis of the data was carried out in the software STATISTICA 6.0 (StatSoft, Ink., USA).

Results

According to the obtained data, 77.6% of survey participants did not report their HIV status before dental treatment (34.6% of patients do not consider this necessary; 63.4% are afraid of poor attitude of health workers; 34.6% believe that they know the doctor that HIV infection may have a negative impact on the quality of treatment, 36.5% do not believe in the principle of confidentiality, fear of disclosure of the diagnosis and consequences associated with this).

At the same time, 66.7% of HIV-infected people noted that when they applied for dental care, if their status was disclosed, problems related to refusal of treatment (41.7%) and negative doctor attitudes (25%) arose. According to the results of the survey, the doctors, having learned about the positive HIV status of the patient, refused mainly (94%) dental surgery (tooth extraction and dental implantation).

When requesting dental care, 29.9% of respondents were asked to take an HIV test, of which 60% voluntarily, 15% in the ultimatum form, and 25% of PLHIV were under pressure.

An analysis of the structure of needs in dental care revealed that 37.3% of respondents applied for the treating teeth; 53.7% about tooth extraction; 25.4% for dental implantation; 11.9% for orthopedic treatment; 28.4% for professional hygiene.

There was a high proportion of people (64.2%) who postponed their visit to the dentist due to fears related to their HIV status (stigmatization, refusal of treatment, disclosure of diagnosis, etc.).

Discussion

A sociological study showed that despite the commitment to protecting human rights and political initiatives aimed at eliminating stigma and discrimination at all levels and in various areas of activity, the prevalence of these sociological phenomena in the medical (dental) environment remains high today (up to 66.7%).

Fear of stigma, stigmatizing beliefs, supported by cases of negative attitudes on the part of medical personnel, adversely affect readiness to disclose HIV status. Only 22.4% of respondents reported having HIV infection when seeking dental care.

A serious problem is the increase in the number of acts of discrimination in the form of a negative attitude of the doctor (25% of cases) to patients with HIV infection and refusal to treat oral diseases (41.7% of cases) to this group of patients. Prohibiting, hindering and refusing PLHIV to access the necessary range of medical services within the competence of a doctor contradicts modern knowledge of public health and international standards that recognize equal rights to health care and medical care for all people regardless of their HIV status. 40% of respondents encountered violations of the principle of voluntary testing for HIV when applying for dental treatment.

Fears of PLHIV in connection with their status affect their unwillingness to receive the necessary dental care, which is manifested in the postponement and repeated postponement of a doctor's appointment in 64.2% of cases. Late initiation of treatment may contribute to a greater prevalence of dental pathology (including acute inflammatory processes) in HIV- infected patients as compared with patients without immunodeficiency. Thus, early detection and timely, high-quality rational medical care are an important component in maintaining dental health and a high level of quality of life for PLHIV.

A high level of fear of disclosing a diagnosis of HIV infection was noted (36.5%). Violation of the principle of confidentiality can lead to various negative consequences in all aspects of a person's life with HIV and its environment, dramatically increasing its degree of social vulnerability. Along with discrimination at the level of institutional organizations (at workplaces, in medical institutions, educational institutions and social services), a large number of cases were reported when significant psychological pressure was put on people because of their positive HIV status; the avoidance of these people by family members, peers and society as a whole; negative attitudes and degrading human actions were manifested; there were threats to health and life [3, 8]. Such illegal actions can greatly increase vulnerability and exacerbate the effects of HIV infection, which, in turn, reduces the effectiveness of the response to the epidemic.

In accordance with the Russian legislation, the violation of the rights of people living with HIV, including disclosure of the diagnosis of the disease, the results of medical examinations and treatment regimens entails the administrative and other responsibility of the medical worker. However, today, along with the knowledge of the majority of PLHIV about the existence of legal documents defining the obligations of the state regarding their protection, fear of public stigma and its consequences prevails, which prevents the appeal of this category of persons to the appropriate instances of violation of their rights.

Overcoming stigma and discrimination against HIV-infected people in the health care system can be enhanced by increasing the level of knowledge of healthcare professionals on HIV / AIDS. Today, antiretroviral therapy allows for recovery of the immune status with maximum suppression of viral replication in cells of the immune system (undetectable viral load) and the absence of clinical manifestation [1]. Successful treatment of HIV infection (reducing the level of viremia to an undetectable level) is highly effective in preventing transmission of the virus, as confirmed by randomized, multicenter studies and controlled clinical trials [14, 18].

Education, focused on developing the competence of HIV / AIDS in health care workers (training in epidemiology, prevention of modern methods of treating HIV infection, occupational risks, etc.), informing about the negative effects of discriminatory actions is an important condition for increasing the tolerance to PLHIV that It has a significant impact on the ability to provide qualified assistance to this category of patients and to improve the quality of medical services provided.

A feature of the professional activity of the dentist is direct contact with biological fluids (blood, saliva), which accompany most dental procedures, which is a risk factor for HIV transmission. Therefore, the need to increase the level of social guarantees and the provision of means to comply with universal security measures and prevent HIV infection in the workplace are of particular importance.

It should be noted that despite all the problems and obstacles, 35.8% of PLHIV continue to seek dental care, strive for optimal oral health and try to overcome the difficulties associated with their diagnosis of HIV infection.

Conclusion

Thus, today there is a high level of stigma and discrimination associated with the problems of HIV infection in the segment of medical organizations that provide dental care. Given the particular seriousness of the consequences of these social phenomena, it is necessary to intensify efforts to weaken the stigmatizing attitude and discriminatory behavior towards PLHIV by health professionals at the dental reception, as well as to raise awareness of modern methods of treating and preventing HIV infection, including areas of occupational hazards.

stigma discrimination infection dental

References

1. Human immunodeficiency virus-medicine: a guide for doctors, edited by N.A. Belyakov, A.G. Rakhmanova. SPb.: Baltic medical educational center; 2011. (in Russ).

2. Gazhva S.I., Stepanyan T.B., Goryacheva T.P. Prevalence of dental diseases of the oral mucosa and their diagnostics // international journal of applied and fundamental research. 2014. No. 5-1. Pp. 41-44. (in Russ).

3. Living with HIV in Eastern Europe and the CIS: consequences of social exclusion / United Nations development Programme (UNDP).

4. The stigma index the people living with HIV in Russia: a study Report / by the Levada Center.

5. Ioannidi E.A., Chernyavskaya O.A., Kozyrev O.A. Some ethical and legal aspects of the problem of providing medical care to people living with HIV / AIDS / / Bioethics. 2013. No. 1. Pp. 41-46. (in Russ).

6. Ruziev M.M., Bandaev I.S., Son I.M., Raupov F.O. Results of sociological research to identify forms of stigmatization and discrimination of persons living with HIV infection in Tajikistan / / Social aspects of public health. 2018. No. 1. Pp. 1-10. (in Russ).

7. Stigma, discrimination and human rights violations related to HIV: Case studies of successful programmes / joint United Nations programme on HIV/AIDS (UNAIDS).

8. Cheshko N.N., Pokhodenko-Chudakova I.O., Zhavoronok S.V. Manifestations of HIV infection in the oral cavity and maxillofacial region. The provision of specialized care, professional prophylaxis: proc.-method. benefit. Minsk: Belarusian state medical University, 2012. (in Russ).

9. Brondani M.A. Phillips J.C., Kerston R.P., Moniri N.R. Stigma around HIV in dental care: patients' experiences // J. Can. Dent. Assoc. 2016. 82. g1.

10. Choromanska M., Waszkiel D. Prosthetic status and needs of HIV positive subjects // Adv. Med. Sci. 2006. Vol. 51(1). P. 106-109. (in Russ).

11. Continuous improvement of oral health in the 21st century- the approach of the WHO Global Oral Health Programme: World Oral Health Report / World Health Organization

12. Dougall A. Martinez Pereira F., Molina G., Eschevins C., Daly B. Faulks D. Identifying common factors of functioning, participation and environment amongst adults requiring specialist oral health care using the International Classification of Functioning, disability and health // PLoS ONE. 2018. Vol. 13(7).

13. Equity, social determinants and public health programmes / World Health Organization.

14. Fleming T.R. Antiretroviral Therapy for the Prevention of HIV-1 Transmission // JAIDS. 2016. Vol. 375. P. 830-839.

15. Gesesew H.A. Tesfay Gebremedhin A., Demissie T.D., Kerie M.W., Sudhakar M., Mwanri L. Significant association between perceived HIV related stigma and late presentation for HIV/AIDS care in low and middle-income countries: A systematic review and meta-analysis // PLoS ONE. 2017. Vol. 12(3).

16. Hatzenbuehler M., Phelan J., Link B. Stigma as a fundamental cause of population health inequalities // Am. J. Public Health. 2013. №103(5). C.813-821.

17. Reznik D.A. Oral manifestations of HIV disease // Top HIV Med. 2005. Vol. 13(5). P. 143-148.

18. Safren S.A. Adherence to Early Antiretroviral Therapy: Results from HPTN 052, A Phase III, Multinational Randomized Trial of ART to Prevent HIV-1 Sexual Transmission in Serodiscordant Couples // Journal of Acquired Immune Deficiency Syndromes. 2015. Vol. 69(2). P. 234-240.

19. Watt R.G. Heilmann A., Listl S., Peres M.A. London Charter on Oral Health Inequalities // J. Dent Res. 2016. Vol. 95(3). 245-247

Размещено на Allbest.ru