Humanistic reflections on specialized HIV care service

Abstract

The physicians’s attitude towards diagnosis and clarifications to the patient infected by the human immunodeficiency virus is based mainly on personal perception and humanistic experience. The objective of this study was to report the experience of medical students from the sixth period of the Centro Universitário Metropolitano da Amazônia, in Belém, Pará, Brazil, during classes of the Clinical Skills module (Infectious Axis) at the Center for Attention on Acquired Infectious Diseases. After providing outpatient care and discussing clinical cases for five months and considering biopsychosocial issues, the students realized a need for humanization in this area. The experience expanded the knowledge acquired in class and allowed the delivery of comprehensive care to the patient, in addition to encouraging more humanistic and critical training of these health professionals.

Education, medical; Aids serodiagnosis; HIV antigens; Infectious disease medicine; Humanization of assistance

Resumo

A postura do médico em relação a diagnóstico e esclarecimentos ao paciente infectado pelo vírus da imunodeficiência humana baseia-se principalmente na percepção pessoal e experiência humanística. O objetivo deste estudo foi relatar a experiência de estudantes de medicina do sexto período do Centro Universitário Metropolitano da Amazônia, em Belém/PA, durante as aulas do módulo de Habilidades Clínicas (Eixo Infectologia) no Centro de Atenção à Saúde em Doenças Infecciosas Adquiridas. Depois de prestarem atendimentos ambulatoriais e discutirem casos clínicos por cinco meses, os estudantes se deram conta da necessidade de humanização nessa área, considerando questões biopsicossociais. De modo geral, a experiência ampliou os conhecimentos adquiridos nas aulas e permitiu aplicar o cuidado integral ao paciente, além de estimular formação mais humanística e crítica desses profissionais de saúde.

Educação médica; Sorodiagnóstico da aids; Antígenos HIV; Infectologia; Humanização da assistência

Resumen

La actitud del médico respecto al diagnóstico y la aclaración de la condición del paciente infectado por el VIH está relacionada con la percepción personal y la experiencia humanística. El presente estudio tuvo el objetivo de presentar la experiencia de estudiantes de medicina del sexto período del Centro Universitário Metropolitano da Amazônia, en Belém, Pará, Brasil, durante las clases del módulo Habilidades Clínicas (Eje Infectología) en el Centro de Atención de Enfermedades Infecciosas Adquiridas. Los estudiantes ofrecieron atención ambulatoria y tuvieron discusión de casos durante cinco meses y pudieron advertir la necesidad de humanización en esta área debido a problemas biopsicosociales. La experiencia brindó la oportunidad de ampliar los conocimientos adquiridos durante las clases y aplicar una atención integral al paciente, y estimular la capacitación de profesionales de la salud con un perfil humanístico y crítico.

Educación médica; Serodiagnóstico del sida; Antígenos VIH; Infectología; Humanización de la atención

The human immunodeficiency virus (HIV) was first recognized in 1981, with the manifestation of diseases related to the failure of the immune system ¹ . Immunodepression develops from the action of retroviruses of the family Retroviridae: two viruses in this family have been identified as causing; HIV-1 and, later, HIV-2. In addition to making the infected individual more susceptible to opportunistic diseases that would not normally manifest in healthy people, HIV favors the appearance of neoplasms, especially when associated with co-infections by oncogenic viruses ¹ , ² .

According to data published by the Joint United Nations Programme on HIV/Aids (Unaids) 20.9 million people had access to antiretroviral therapy (ART) by June 2017 ³ . Non-adherence to this treatment is related to increased mortality, as well as morbidity and mortality, resistance to medication, increased potential for transmitting mutations resistant to available drugs, and non-viral suppression. As for the factors associated with treatment adherence, socioeconomic status, stigma, and lack of information are the most influential ³ , ⁴ .

The introduction of ART has greatly changed the perception of the disease: while the diagnosis was perceived as a fatal situation in the past, it is currently understood as a chronic health condition. This change in the perception of the disease allowed for the improvement in the quality of life of those living with it, contributing to interpersonal and occupational relationships, and especially to these patients’ physical and mental health ⁵ , ⁶ .

HIV-related stigma affects patients’ quality of life and can result in physical and psychological impairment, considering that poor care and poor prognosis may compromise treatment effectiveness. The patient must feel comfortable when seeking help from health professionals, that is, those responsible for ensuring, guiding, and treating virus carriers adequately and ethically ⁷ , ⁸ .

The lack of information that reaches health professionals regarding HIV and its clinical management, as well as the proper posture for diagnosis and clarification of the condition to the patient, are related to personal perception, contact with the subject during graduation, and experience in dealing with patients with the pathology ⁹ . Contact with HIV positive people during academic life expands knowledge not only about the disease but also ethical conduct, strengthening the doctor-patient relationship.

Highlighting bioethical aspects, this article reports the experience of medical students (authors of the article) during the activities developed in the practical classes of the Clinical Skills module (Infectious Axis) at the Center for Attention on Acquired Infectious Diseases (Casa Dia), in Belém, Pará, Brazil.

Experience report

This work is based on the view of the authors – medical students at the Centro Universitário Metropolitano da Amazônia (Unifamaz) – on the practical classes at Casa Dia taught during their sixth period. Organized as an internship, the experience was monitored by infectious disease physicians and followed a previously prepared schedule for five months – from August to December 2018 – and included outpatient care, discussion of issues related to infectious diseases, and clinical cases.

Casa Dia, a specialized service of the Unified Health System (SUS), has been serving patients in the city of Belém since 1999. The service is provided by a multidisciplinary team and includes outpatient care to people with HIV, offering antiretroviral chemoprophylaxis for victims of sexual violence and occupational accidents, as well as outpatient care for patients with viral hepatitis.

Most of Casa Dia’s patients are referred by the Testing and Monitoring Center (CTA), but also by basic health units, accredited hospitals in Belém, municipal emergency rooms, and the private health care network.

Discussion

During the internship, medical students realized the need to humanize these patients’ care, since these individuals are more vulnerable within the biopsychosocial context and, thus, more subject to family and social discrimination. Among other points, it is worth highlighting respect while questioning patients about their sexual orientation, sensitivity when asking about the possible form of contagion, the trust established for the patient to be able to talk about drug use, number of partners, and other risk situations.

As for the main opportunistic diseases, seborrheic dermatitis, oropharyngeal candidiasis, hairy leukoplakia, cytomegalovirus retinitis, herpes simplex, herpes zoster, and pulmonary tuberculosis can be mentioned. The students realized the importance of recognizing them as a possible first manifestation of HIV infection and, therefore, requesting HIV serology upon these diseases’ diagnosis, especially in the case of tuberculosis.

During the internship, many patients coinfected with HIV and syphilis were also noticed. Syphilis in these patients reveals possible sexual risk behavior and failures in the prevention system. Therefore, it is essential that health professionals diagnose and fight syphilis early, since, unlike HIV, it is a curable disease.

From the clinical cases met during internship, it was possible to infer several factors related to the psychological and social conditions of the patients that interfere with adherence to ART, such as denial of the disease, low education level, large amounts of pills (in some programs), the fact that the partner does not know about the patient’s condition, adverse effects, lack of transportation conditions to collect the medication, difficulty in being able to leave work to attend routine appointments and renew the prescription.

In addition to arousing interest towards knowledge in the area, the five months of practical classes left students more prepared to care for people with HIV, clarify doubts about the form of transmission, explain their CD4+ T lymphocytes count and viral load exam, highlight the impact of ART on morbidity and mortality and deal with several biopsychosocial issues. Some subgroups, however, were unable to analyze more serious and relevant clinical cases for future clinical practice, such as patients with syphilis or tuberculosis, since they were chosen at random.

The experience followed the principles of bioethics, as recommended by the National Curricular Guidelines (DCN) for medical courses ¹⁰ . From this perspective, it is undeniable that it stimulated the training of health professionals with a more humanistic, critical and thoughtful profile, sensitizing and preparing future professionals to face the different health realities of the Brazilian population.

Final considerations

Considering the quality of the humanistic experience lived and contribution to the students’ teaching, it can be said that the practical classes at Casa Dia allowed them to expand and put into practice the knowledge acquired in theoretical classes of the Infection and Inflammation module. Practical classes also helped them to better deal with shyness and insecurity when approaching the patient, an individual who needs medical care and even words of comfort.

Also, these practical classes promote reflection on comprehensive care, with a view to medicine that not only heals pathologies but is more humanized and respects each patient’s individuality. In this sense, it is suggested that other universities adopt this activity, both to improve the ethical training and the principles of bioethics of future professionals to deal with patients in situations of great social vulnerability, as well as to meet the requirements of the DCN of the medical course and society in general.

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Publication Dates

• Publication in this collection
  30 Mar 2020
• Date of issue
  Jan-Mar 2020

History

• Received
  7 May 2019
• Reviewed
  20 Nov 2019
• Accepted
  21 Nov 2019