POLICY REGARDING WARDS FOR HIV+ PATIENTS:

SEPARATE, COMMON, OR A COMBINATION?

This note presents my thoughts, based on visits to a number of hospitals in Northern India and conversations with many doctors, on the issue of whether there should be separate or common wards for patients that are co-infected with HIV. It was originally written as part of a discussion on this issue on the electronic forum SEA HIVNET [Message 2391] and can be viewed at http://www.hivnet.ch:8000/asia/sea-aids/
Overall, I believe that the issue is complex in South and South East Asia (S&SEA) or wherever resources are tight, and one needs to weigh in the pros and cons of either recommendation. I believe that the choice should be left to the individual hospital. Their decision should be based on consideration of their human, material, and infrastructure resources. The most important point is that HIV+ patients should be given the same level of care as any other patient, and we should not jeopardize that goal by creating rules that are hard to implement.
Even though HIV transmission is not air borne, patients come to hospitals for treatment of opportunistic infections, many of which can be transmitted via aerosol, or sloppy handling of feces and other bodily fluids. Careless handling of blood can of course transmit HIV itself. Most hospitals in India (and South and South East Asia in general), as far as I am aware of, do not have resources to adopt UNIVERSAL SAFETY PRECAUTIONS, or provide isolation of patients, of the kind that are routine in the developed countries. Faced with these realities it is hard to give one answer that will apply to all circumstances. So let me state some of the pros and cons that should be factored into the decision making process.
Patients co-infected with HIV/AIDS have very weak immune systems and are therefore prone to catching infections easily. In S&SEA hospitals, wards are usually [over]crowded, and isolation between patients is very poor. So HIV/AIDS patients may end up picking up additional opportunistic infections and then retransmitting these to others. To avoid such cycles of disease transmission, advocacy for separate wards makes sense.
TB and HIV form a deadly combination and are highly correlated in S&SEA. Having patients with a variety of communicable diseases including some with HIV/AIDS in common wards may result in the transmission of infections to all patients. This would be especially bad if even one patient had multi-drug resistant TB. To avoid the possibility of such occurrences, having separate wards would be better.
In many hospitals, a very significant fraction of the doctors and nurses do not pay adequate attention to HIV/AIDS patients, and in fact avoid treating them. Having separate wards may help filter the staff -- those who feel comfortable dealing with HIV/AIDS may opt to work in wards with HIV/AIDS patients for additional financial incentives. Also, these doctors and attendents should be taught to be more careful in adopting universal safety precautions, and thus avoiding accidents. (I am not justifying this two tier approach, but only pointing out that such a strategy for reducing risk may be the most practical.) On the other hand such a "division of staff" may leave inadequate or no staff to care for HIV/AIDS patients. Also, having made such voluntary division, doctors/staff not opting for working in HIV/AIDS wards may assume that they have no responsibility as HIV care is not part of their job, and thus refuse to help in HIV wards even in times of emergency.
Having separate wards, but without a clear division of doctors and staff assigned to each of them, or of responsibility, may relegate HIV/AIDS patients to getting less attention -- the staff could easily make the excuse of being preoccupied in other wards. Thus, there could be less staff around or ready to help even in times of emergency.
Relegating HIV/AIDS patients to separate wards may lead to increased stigma and isolation. On the other hand, if separate wards are well-managed, there may be a growth in the community spirit between the caretakers, the patients and their family as seen in San Francisco [Message 2377 on SEA-HIV net].
The public outcry based on irrational fear in case of common wards may create tensions between patients and their caretakers. Also, privacy could be compromised, but this could happen in either case.
Having separate wards may require duplication of effort and resources. For example an HIV+ patient with Herpes Simplex caused encephalitis would need to be in a "Stroke intensive care" facility/ward. But if HIV/AIDS positive people have to be confined to separate wards, then the required facilities for managing patients with "strokes" would have to be duplicated. Since HIV+ in-patients often need such critical life saving resources, having common wards based on the medical condition, and not on the HIV status, may be more appropriate and feasible.
Many hospitals and public health facilities already display very poor implementation of directives from the Government. There is very little accountability and monitoring of the health care system in general. In addition, private hospitals cannot be required to treat all diseases. Under such conditions it is not very useful to "mandate" rules specifying how hospitals should treat and care for HIV+ patients. Imposing such rules would just help promote corruption and disrespect for laws of the country.
In short, in my opinion there is no simple answer that will work in all circumstances. I believe one has to examine both the resources and the attitude of the doctors and the staff, hospital by hospital. One has to start with the assumption that the hospital management has the interest of the all patients at heart, and makes decisions in consultation with their doctors and staff, and with a realistic assessment of their resources. In the absence of such reasoned decision, either choice can prove "bad". Therefore, if such good faith does not exist, then our first job is to educate the doctors/staff/management to make decisions that are right for their circumstances and provide care rather than mandating they follow some rule they are not convinced of. Our goal should be to have hospitals give proper care for HIV+ patients, and leave details of how to do it best up to them. Thus, separate wards, common wards, or a combination of these two extreme possibilities are all valid possibilities depending on the nature of the opportunistic infection, circumstances, and resources.