ARTICLE
Stigma of HIV positive expressed through veiled prejudice

INTRODUCTION

The term stigma was created by the ancient Greeks to refer to signs in the body that meant something bad about the morale of those who presented them. People who had particular requirements, approved by the society, were called by Goffman¹ as "normal." On the other hand, attitudes that the "normal" showed, many times without thinking, with people with a stigma, were discriminatory. An ideology to explain the danger they represent, using specific stigma terms, as retarded¹ or crippled, and nowadays "aidético" for individuals with acquired immune deficiency syndrome.

Prejudice is a way of thinking in which the person comes to a conclusion that prejudges, and the term "veiled" relates to what is hidden, obscure or concealed. Thus, we can understand the concept of veiled prejudice as the one that people know, but deny having it². Currently, in Brazil, there are laws that punish discrimination and prejudice against HIV-positive individuals³, and probably many people hide their true feelings for fear of punishments that they might have to suffer.

Few works have sought to observe the patient's perception regarding the subject addressed.

OBJECTIVE

To observe the discriminatory attitudes of the Unified Health System (SUS) users concerning the dentists and other seropositive individuals, as well as their perception of the possibility of being infected with some kind of disease during odontological treatment.

METHODS

The research was approved by the Human Research Ethics Committee within the standards required by Resolution 466/12, under the case number FOA-02411/2011.

The study is a descriptive, transversal character research, with a quantitative approach. Initially, the Secretary of Health of the municipality was contacted to be informed about the purpose of the study, and the subsequent use of the data collected to obtain their support for the research. Subsequently, the adjustment of the questionnaire was accomplished by a pilot study to a different Health Centers (HC) of the municipality.

The study population was composed of the users of the public system of oral health in the city of Araçatuba, São Paulo, Brazil, which was informed of the goals as well as the confidentiality of the information. Individuals who have agreed to participate signed a free consent term.

The map of the city was split in five sectors, one central and four peripherals, with the purpose to obtain a sample of HC patients with different socioeconomic characteristics.

The interviews were conducted by a trained researcher so that the questions had no influence on the answers.

A period of two months for data collection was stipulated, occurring between January and February 2014. The interview was conducted in a private room, inside the HC, in the day scheduled for the patient, every day of the week, causing no interferences in the normal local activities.

The instrument of data collection consisted of a semi-structured questionnaire, composed of open and closed issues, with questions on demographic factors such as gender, age, and education; the perception of the risk of acquiring some type of illness during the dental treatment; concern with the cleaning and sterilization of the material; personal protective equipment used by dental surgeon; perception of a disease whose transmissibility is biggest (AIDS or hepatitis); acceptance and preference of care after a patient with AIDS or a convict; and agreement to be treated by a dentist with AIDS.

A group of inmates were included due to the existence of prisons in the neighboring towns and because these individuals receive dental treatment in the Public Health System. Studies show that there is a high rate of inmates that show sexually transmitted diseases; among them, positive serology for HIV and syphilis, in addition to injectable drug use and blood transfusion history^4,5, encouraging discriminatory attitudes toward those groups of individuals.

The collected data were tabulated by the Epi Info^TM 7, statistically analyzed by BioStat 5.0⁶ software, through the test for comparing two proportions with a significance level of 5% and presented in absolute frequencies and percentages.

RESULTS

The research universe was composed of 254 individuals, and 54 (21,3%) of them did not accept to participate in the survey, even after they were informed of the confidentiality of the data obtained, which denotes the taboo involving the subject under study. Of those individuals surveyed, 143 (71.5%) were women. Concerning the individual acceptance or non-acceptance to be treated after a patient with AIDS or a convict, 142 (71%) said that they accept the treatment after a HIV- positive patient and 160 (80%) after a convict. However, when questioned about the preference for treatment before or after an HIV-positive patient or a convict, 93 (46.5%) preferred the treatment before an HIV-positive individual, and 60 (30%) before an inmate.

Among the individuals interviewed, 162 (81%) informed that they accepted to be treated by a HIV positive dentist.

Regarding the possibility of acquiring some type of infection in the dental office, 171 (85.5%) believed that it could occur, and 166 (83%) were concerned whether dental material was autoclaved; however, 147 (73.5%) did not know how it was performed.

There was a significant statistical difference between individuals who initially accepted treatment after a HIV-positive patient or a convict, and those who claimed to prefer to be treated before them.

DISCUSSION

The different forms of stigma and discrimination in relation to HIV/AIDS occur due to the characteristics of the disease that manifest themselves causing large impacts in the lives of the carriers⁷, resulting in the self-stigmatization, where individuals tend to accept the society's negative beliefs and isolate themselves from social contact, which is considered the most difficult stigma to overcome⁸.

Usually, we can observe the prejudice through the declination of the treatment by the dental surgeon to the immunodeficiency carrier patient, with the most absurd motives, such as: "I'll take a vacation for an indefinite period" or "I have a problem with my equipment." Regarding other health professionals, the bad service to the virus carrier is justified by the possibility that the professional might acquire the disease⁹. The difficulty to obtain service in the health area for HIV carriers is 11.7 times greater. Despite the professionals in this area are much more informed about the disease, they are unprepared to deal with this situation⁹.

Our research showed that some of the interviewers prefer the treatment before a convict, and this occurs due to the stigma that revolves around this population. It is estimated that 20% of the Brazilian convicts are HIV carriers, which is the result of overcrowded, precarious, and unhealthy jails, which make prisons a favorable environment for the spread of epidemics and infection, especially due to the occurrence of homosexuality and sexual violence practiced among the inmates as well as the use of injectable drugs¹¹.

Sometimes prejudice is not shown in a clear way. A research carried out with adolescents asked about their way of discrimination, and one of the answers was the following: "I don't do anything, I don't exclude nor treat bad, but I'm always distrustful," demonstrating that prejudice is not evident, but it is expressed in a veiled way¹², which probably occurs due to the punishment that the individual may suffer, as the Brazilian law 12,984 prohibits all forms of discrimination¹³. According to this law, discrimination against carriers of human immunodeficiency virus and AIDS patients is a crime punishable by up to four years in prison and fine³.

The prevention of cross-transmission of the AIDS virus and hepatitis is a crucial aspect in odontology, where preventive measures must be used during treatment¹⁴. A survey carried out with students of odontology showed that it is the main danger to the patient, as they confessed to failing in the cleaning and the decontamination of material and equipments used during the procedures¹⁵; this highlights a failure in the training of future professionals.

There is a real risk, though minimal, of health professionals transmitting AIDS virus to their patients. This is an extremely delicate issue, because on one side there is the concern of the patient whether he is at a minimal risk of acquiring the disease from the dentist, and on the other side there is the right of the professional to preserve his serology, protecting himself from personal, professional, and social discrimination¹⁶.

As for the possibility of contracting some type of infection in the dental office, most of the interviewers believed that it could occur, in corroboration with another study¹⁶, and many individuals showed concern as to whether the dental materials were sterilized, as many of them did not even know how the sterilization was performed. This interest derives from the concern about HIV transmission in the dental office, by the social representation that the disease presents and that is linked to behaviors not accepted by the society, hatching the misconception of "risk groups"¹⁷. It is important to point out that regarding accidents this risk is small, and depends on the type of accident and the patient's viral load. The risk of HIV infection is much smaller than the risk of hepatitis virus infection, with estimates 0.3% for HIV, 1% to 10% for hepatitis C and 40% for hepatitis B¹⁰.

Despite the consistent efforts of the Ministry of Health to disseminate the guidelines regarding the disease through the national program for STD/AIDS¹⁸, lack of access to information and knowledge concerning HIV contamination and transmissibility causes the attitudes of the population to stay attached to myths, beliefs, emotions, and discussions of everyday life, not taking into consideration the scientific knowledge, which provides information of the true ways of transmission and prevention of the disease.

Further studies need to be carried out involving larger populations, so that the existence of different forms of prejudice to users of the Public Health System in relation to HIV-positive individuals can be confirmed. The implementation of educational strategies should be proposed to eradicate any form of discrimination.

CONCLUSION

Although the result of the research cannot represent the opinion of all the users of the Public Health System, the study suggests that there is prejudice and discrimination in relation to HIV carriers, often expressed in a veiled manner and also the perception of the possibility of acquiring some kind of infection during odontological treatment.