Clinical ethics issues in HIV care in Canada: an institutional ethnographic study

Abstract

BackgroundThis is a study involving three HIV clinics in the Canadian provinces of Newfoundland and Labrador, and Manitoba. We sought to identify ethical issues involving health care providers and clinic clients in these settings, and to gain an understanding of how different ethical issues are managed by these groups.MethodsWe used an institutional ethnographic method to investigate ethical issues in HIV clinics. Our researcher conducted in-depth semi-structured interviews, compiled participant observation notes, and studied health records in order to document ethical issues in the clinics, and to understand how health care providers and clinic clients manage and resolve these issues.ResultsWe found that health care providers and clinic clients have developed work processes for managing ethical issues of various types: conflicts between client-autonomy and public health priorities (“treatment as prevention”), difficulties associated with the criminalization of nondisclosure of HIV positive status, challenges with non-adherence to HIV treatment, the protection of confidentiality, barriers to treatment access, and negative social determinants of health and well-being.ConclusionsSome ethical issues resulted from structural disadvantages experienced by clinic clients. The most striking findings in our study were the negative social determinants of health and well-being experienced by some clinic clients – such as experiences of violence and trauma, poverty, racism, colonization, homelessness, and other factors affecting well-being such as problematic substance use. These negative determinants were at the root of other ethical issues, and are themselves of ethical concern.

“A gente vive em cima da corda bamba”: experiência de profissionais da saúde que trabalham com o HIV/aids em uma área remota do Nordeste brasileiro

“…Dessa maneira, as relações sociais naquela cidade se construíam, em geral, com base em vínculos familiares e de amizades, gerando ligações de afetividade e compadrio. Tendo em vista esses aspectos, a literatura tem apontado evidências de que, em cidades pequenas e em áreas rurais, a experiência de perda de privacidade -especialmente quando envolve o HIV/aids -é aumentada 12,13,29 .…”

“…Em estudo etnográfico desenvolvido em três clínicas especializadas em HIV/aids, no Canadá, que atendiam a pessoas residentes em áreas urbanas, suburbanas e rurais, os profissionais frisaram a existência de uma economia das relações espaciais dentro das clínicas, por parte das PVHA, dada a possibilidade de serem reconhecidas por "alguém que conhece alguém que conhece alguém". Diante disso, os participantes da pesquisa criavam estratégias como consultas e exames com hora marcada, existência de vários espaços para espera de atendimentos, de maneira que se evitassem encontros e olhares denunciativos 13 .…”

“…Tais aspectos mostram-se relevantes, pois as necessidades e preocupações específicas dos contextos de áreas remotas tendem a permanecer inauditas ou desconhecidas no nível macro ou nacional dos sistemas e políticas de saúde 9 . Além disso, a literatura tem chamado a atenção para os índices de estresse ocupacional entre profissionais que atuam nesses cenários 11 e as peculiaridades do manejo do sigilo e da confidencialidade sobre a soropositividade em áreas remotas 12,13 . Diante disso, teve-se como objetivo compreender a experiência de profissionais da saúde que trabalham em um SAE, num contexto de área remota no Nordeste brasileiro.…”

Ethical Decision-Making of Health Professionals Caring for HIV-Infected People in Hunan, China: A Qualitative Study

“…Ghanaian scholars Dapaah and Senah also noticed an overt and covert violation of patient con dentiality by healthcare workers in HIV clinics [7]. In the same vein, the research team of Kaposy has determined some prominently discussed ethical issues are occurring in HIV clinics, such as con icts between client autonomy and public health priorities, di culties associated with the criminalization of nondisclosure of HIV positive status, etc [8]. Facing numerous ethical issues in AIDS care, the way health professionals deal with these issues becomes critical.…”

“…Although EDM competence has been assessed among a variety of health care providers, including dentists [13] (İlgüy, İlgüy, & Oktay, 2015), physicians and nurses [14] (Pettersson, Hedström, & Höglund, 2018), health professionals in AIDS care rarely receive such attention. The team of Kaposy brie y outlined how Canadian health care providers and clients in HIV care manage different ethical issues [8], but without further exploration of why.…”