Q&A: How to tackle HIV stigma within health care settings

“I cannot guarantee that 100%, or even 50%, of my professional colleagues will be nondiscriminatory,” says Dr. Ishwar Gilada, founder of India’s first AIDS clinic, talking with Devex about the treatment of people living with HIV.

As of 2019, 38 million people were estimated to be living with HIV, which can be transmitted via blood, semen, and vaginal secretion, and from mother to baby during pregnancy, delivery, and breastfeeding if the person is not on antiretroviral therapy. The virus can’t be transmitted through regular day-to-day contact, saliva, urine, tears, nasal secretions, or sweat.

Gilada said that despite being aware of the limited ways HIV can be transmitted, he’s seen first-hand the stigma and discrimination health care workers can elicit toward people living with HIV. Such treatment has the potential to impact the quality of care a person might receive.

Those who are most educated and qualified tend to be the most discriminatory, Gilada said. “If you apply that parameter then in health care settings [it’s] doctors, nurses, and technicians [who] are more discriminatory than other parts of society,” he said, blaming ingrained attitudes that override what health professionals know to be true of the virus.

Speaking to Devex, Gilada explained where the stigma comes from and how he works to tackle it within the health care setting.

This conversation has been edited for length and clarity.

In your experience, do you see stigma and discrimination of people living with HIV play out within health care settings?

We do not guarantee that all these health workers are really caring. Some come to the health care profession [out of a] commitment, some come by compulsion from family … I'm not a COVID specialist, but if a COVID patient comes, it’s my duty as a doctor to treat them. I will use a mask and a face shield to protect myself, but I will never turn them away.

Every profession comes with necessary risks. For example, pilots always risk flight accidents and mishaps, but they understand that risk is a necessary part of their job. Doctors need to understand that when they took the Hippocratic Oath, they pledged to treat everyone. They can’t pick and choose who to treat and who not to treat based on prejudices. Only if you do not have requisite expertise, then you can deny such treatments.

Why do you think such stigma and discrimination still exists, even in a health care setting?

Sometimes, health care workers have knowledge of HIV transmission and treatment, but they still project an attitude toward HIV-positive people. In fact, some HIV-positive people have never engaged in particularly dangerous activities and are simply unlucky. In many cases, the prejudiced health care workers could just as easily have exposed themselves to HIV with their personal lifestyle as the patients. We tell doctors, or any health worker, that you should provide care for a HIV-positive person the same way you’d want to be cared for if you became HIV-positive. We have to put them in the shoes of a HIV-positive person …

HIV is a very easy infection to handle now. Nobody has to die of HIV. They live a full life. In my opinion, they live a better life than non-HIV people because HIV-positive people are in regular touch with us, they have regular follow-ups, they are being checked for liver function, kidney function, heart function, etc. If you discriminate against them then you are creating a man-made calamity on the person.

What recommendations would you have for health care facilities about how they can tackle stigma and discrimination amongst their health care workforce?

Personally, as an HIV/AIDS doctor, I make it a point to shake hands or hug my patients with HIV to let colleagues and peers in my health care facility understand that HIV does not get transmitted by touch or hug.

When I conduct training programs, I make it a point to say that I’ve been working in HIV care for 35 years and am still HIV-negative because the risk of transmission between doctor and patient is incredibly low compared to other diseases. In the case of COVID-19, health care workers must use masks, face shields, and gloves to safely examine a patient. For HIV, it is safe to examine a patient without masks or gloves. That sends a clear message.

In my clinic, I also employed a HIV-positive [person]. She has been working with me for 15 years and the tea I'm drinking is made by her. Anybody who comes knows that she's HIV-positive. Once people come to know that this doctor has employed a HIV-positive person, that creates an understanding and also helps with countering any misconceptions.

People resign from their jobs or even stop their businesses when they’re HIV-positive, thinking it is risky to other people. I tell my patients, “you don't have to tell [anyone] that you are HIV-positive …” You’re inviting more stigma and discrimination by such voluntary disclosures…

There is no special precaution somebody has to take because of HIV. If there's no special precaution, you don't have to take special initiative to tell other people that you're HIV-positive. I fight about that with a lot of my colleagues.

Would you have a call to action for those working within the sector about how they can be a part of helping to provide quality care for persons living with HIV?

Quality care can be [provided] in a private setup like what we have here. This is a fully comprehensive HIV health clinic with counseling, testing, consultations of different types, all the tests, and medicines at a lower cost. This kind of set up is called positive discrimination. We care for patients with HIV in a manner [that could be considered] better than [care] for non-HIV patients treated elsewhere.

Secondly, integrate HIV care into the existing set up.

Thirdly, we should not write “seropositive” or “patient under ART” [on medical forms] … because patients' records can be checked by relatives and friends and then they come to know that this person is HIV-positive. Some patients don’t want to carry the label of HIV with them, so we also suggest transporting medicine from one box to another, which is not labeled, in their presence. That way they can prevent discrimination in their family.

I also tell them “don't carry my name card; don't carry a prescription with my name.” Being a doctor in the field of HIV for such a long period, people know my name as a HIV specialist. I use two different prescriptions: one is with my name and one is just a prescription and I write my first name rather than my second name, so people don't know. We have to take those kinds of preventions against discrimination. It’s more important than taking care of those who are already discriminated against.

Family members of a HIV-positive person need not cook, serve, or eat separately. The clothes can be washed together, barring items of personal hygiene like a toothbrush, tongue cleaner, shaving kits; and the rest of household items can be shared. HIV is not transmitted from most day-to-day routines. In no way should the HIV-positive person feel that she or he is treated differently and being dealt with separately. In fact, that creates a feeling of being stigmatized or discriminated against.   

Find out how Gilead is supporting HIV/AIDS patient-centric projects through its Asia Pacific Rainbow Grant.