http://timesofindia.indiatimes.com/Thirupuram/A_first_Kerala_reserves_post_for_HIV_positive/articleshow/3358186.cms

I appreciate that you gave me a view from a doctor’s percpective. I came to know of a few things that I was not so aware of.

Just to make clear, I was not blaming the doctors for the discrimination against HIV patients at the hospital. In fact, I was pretty much touched to know that there are doctors who risk thier lives for such patients. When I say that hospitals are asking patients to go to voluntary organisations, I did not intend that they are acting on social stigma ( though I cannot completely agree that there is no social stigma involved) . What I was giving were possible suggestions that could make lives better for HIV patients and the private voluntary organisations, one of them being that hospitals take intitiative about it.

The risks involved in taking care of such patients is not underestimated, and that is why I suggested special departments with special doctors and counsellors for these activities. I believe that in a private voluntary organisations too, they might be operating with pretty much as little resource as a hospital can afford in terms of equipements and safety?

I completely understand what you told about the impracticality of each patient being tested for HIV before delivery. Yes, indeed it is a a bad situation for the doctors.

Like I said, doctors need not be forced to treat patients. There are already doctors willing to work for them…at least from what I know. We don’t even need them in plenty like we might require for a general hospital. And, not all hospitals need to set up HIV departments. Only main hospitals which can afford to treat such patients are suggested to. They need not be many, but it can make a remarkable significance I feel. For instance, one HIV department for each district? Are you aware of any such departments running at district or state level? Imagine if there were no voluntary organisations to care for HIV patients in the name of safety, I wonder where would these patients go for any help at all!

Like discussed earlier in the article, I can agree that it is at the administrative part that things need to be changed in this case. Agreed that our country has very few resources to spend on such departments when there are many dying of other diseases. Yet, the fact remains that there are still HIV patients in large numbers who need care, counselling and medication and they need a place from where they can get these. HIV , unlike many other diseases, is not a kind of situation where giving medicines would suffice. It requires a good deal of emotional and mental support too…not only for the patient, but also for the families of the patient. And if they can’t be in a place where they can get all these, I wonder how is it going to help the situation in any way. When hospitals cannot provide a support to such patients, what is happening is that these patients turn to fake practitioners or fake medicines as a deperate measure for a cure and this becomes a bigger social problem.

Further reference: Pandya, S. K., 1997: Patients testing positive for HIV: ethical dilemmas in India. Indian Journal of Medical Ethics, 5 (2).

2. in gov hospitals , they usually dont discriminate against hiv patients as far as i know..and in a country where resources are scarce and u need most efficient use of resources, when prorities are taken into consideration, there are many other facilities that need to be added up, which are more cost effective in improving the health of public and which should be considered first. so hiv depts etc wil come lower down in the list only..there are much much more kids dying of diarrhea and malnutrition than aids, and it is preventable also.. so u should think which area govt should focus on..
it is not easy to check all pts for hiv b4 delivery esp in govt setup.. in JIPMER where i studied, most pts were from lower strata of society, who wil come to the hosp directly for delivery, without any pre natal checkups. and hiv tests takes one day to come out( they cant afford rapid tests),so cant know their status b4 delivery..so all of the deliveries are done without of course taking universal precautions, and v used to get pricked a lot doing episiotomy suturing under bad lights..had to conduct some deliveries without gloves also..so if one of us turned hiv positive who is to take the blame?

3.there are of course doctors who do alot for hiv patients ,and it is unethical not to give them care, but when safety of a doctor is compromised i feel a doctor can decide for himself,and u cant put blame on him.

4. and from the point of view of the hospital adminisrator,
a)he may hav some doctors who wouldnt want to treat hiv patients,whom he cant force them to treat because of b)
b)may not hav enough funds to provide adequate precautionary measures,or may find it not cost effective
c)may think why to take the trouble, for eg if one of the staff becomes hiv +ve he wil hav to answer for it.

so basically i feel this is a problem of managing resources in a cost effective way rather than an issue of discrimination and social stigma.. social welfare should be the first ethical rule, so when more welfare can be gained wit less intervention,it is to be done rather than something with less to gain with more use of resources.

Thank you very much for a thoughtful response. It is right that while writing the article, the HIV patients were shown more empathy than the doctors. Yet, let me cover some of the issues that you told, and what I think.

1. I understand that a patient cannot be tested HIV without his consent or his status revealed without his consent. The issue here is not whether we are checking patients for HIV. The issue here is what is happening to the patients who are tested positive for HIV. Particularly women in labour. The problem that arises here is that, once these patients are tested positive, they are shown the door and asked to go to private organisations like Freedom Foundation(FF) for aid and help. Now, understand that there are not many organisations like FF that is established exclusively to take care of HIV patients. As a negative result, such organisations are seeing more incoming patients than what they can take or care for. These organisations run on their own money, donations and a little of what the government provides them with . I had been to FF and I saw how it is to have 30 in patients, 700 outpatients and 25 orphans when you have the funding for just a 10 bed facility. Do you think it is ethical on the hospitals’ part to show such a discrimination to HIV patients when the whole purpose of the hospital is to take care of them? Or, is the hospital’s part of duty over once it tests a patient for HIV?

2.About making departments without revealing status to the public. Like I said, the issue here is not if we are checking patients for HIV and sending them to HIV department. The issue is how are HIV positive patients are dealt with. A person who goes to private organisations will also be in the same boat as a person being treated in the HIV department of the hospital.

3. I understand that there is a risk factor for the doctors. Just to clear things up, even in organisations like FF, we have real doctors and nurses caring for the HIV patients. We do have doctors who are willing to work for such people and that too risking their lives. So, setting up a department for such patients in the hospital is not a far reaching idea.

4. Understood that once a hospital has an HIV department, the general public will be scared to use the hospital. Well, I don’t think any intelligent hospital will mix up the HIV department with the general department. When I say a department for HIV patients, I mean, that it should have specialised care, specialised doctors, specialised treatment or even a special building. A doctor dealing with HIV patients will not perform a general surgery or even deal with general patients. It is as good as having an FF in the hospital.

5. About hospitals being negligent. It is not an answer to say that a hospital cannot open an HIV department because it is negligent in its procedures. I think it is better to say that they should be more careful and apt in their procedures and open an HIV department. If the government hospitals are bad in following procedures, I think it is their fault and they are the ones to be corrected first. Don’t you check a woman’s blood for HIV before she is taken into delivery room? If not, then start checking. If rules need to be changed, then take steps to change it. What needs to be done is to make way for better functioning than to sulk back saying that it does not function well.

6. If the major private hospitals can open a small HIV department with specialised care and doctor, I think the concentration of patients in small private organisations will be reduced. This way, the patients can also get a better treatment and I think over time, the hospital will only increase its value in society. I agree though that in the initial period, there might be some bad responses, but I feel, being a doctor or hospital is not just about business, but also about the welfare of all people in the society and probably that should be the first ethical rule.