What do you do when you discover your domestic worker=20 is HIV-positive? A Johannesburg doctor, who cannot be=20 named for professional reasons, came across two=20 startlingly different cases
I am a doctor employed in one of the public hospitals=20 in Johannesburg. One of my duties is to consult with=20 patients in the hospitals’ so-called HIV clinic,=20 counsel them, monitor their disease and, where=20 possible, anticipate or, if too late, attempt to treat=20 the complications that may develop. Medical=20 complications are often less devastating and easier to=20 manage than social complications.
Patients are referred to the clinic from a variety of=20 sources. Probably the most common source is from the=20 hospital’s own ante-natal service, where screening is=20 routine. Another source is from the general medical and=20 surgical wards, where the HIV test would have been done=20 as part of the diagnostic work-up of a patient who has=20 been admitted with an acute illness.=20
Where possible, prior to actual taking of the blood=20 specimen to be tested, the patient’s informed consent=20 is obtained and pre-test counselling is given. This is=20 not always possible because, occasionally, the=20 condition of the patient is such that he or she is too=20 ill to communicate effectively and the test may be=20 necessary to confirm or exclude certain diagnoses, and=20 to treat the patient effectively.
EM was a young woman who I had seen previously and who=20 had known her condition for some time. On the occasion=20 of her recent visit, as on the previous occasion, the=20 patient’s employer accompanied her to the consultation.=20 This employer was fully aware of her maid’s diagnosis=20 and showed great concern about EM’s general state of=20 health. (How EM’s employer came to know about her=20 diagnosis was not clear.)=20
EM had recently developed “full-blown” Aids, and was=20 requiring regular treatment to stay as well as=20 possible. She in fact happily reported that she was=20 strong enough to work a couple of days a week, which=20 was very important to her. The madam, although=20 concerned about the possibilities of the virus being=20 transmitted to herself or her family, is very keen to=20 allow EM and her family to lodge with them as long as=20 is necessary and, while she has employed an additional=20 maid, she still allows EM to work. This relationship=20 seems as important to EM as any medical help that can=20 be offered to her. I find this situation personally=20 very encouraging, as we as doctors often feel helpless=20 in the face of this devastating disease and, if the=20 illness is compounded by impossible social=20 circumstances, the entire situation becomes very=20
Having said that, my very next patient illustrated the=20 other side of the coin. This was TK’s first visit to=20 our clinic. She had been referred to us by a GP in=20 private practice with a note: “Dear Colleague, Mrs TK=20 has been tested HIV-positive. Please could you take=20 over management.” He kindly included the laboratory=20 report with the serology result. He did not state what=20 his clinical reason for suspecting HIV infection was.=20
TK was not accompanied by her employer. TK claimed that=20 she did not know why she had been sent to the hospital.=20 On further questioning, it transpired that her employer=20 had taken her along to her GP for a blood test. TK said=20 that she had felt well and did not know why this test=20 was done and that no one had explained anything to her;=20 neither had her permission for the test been obtained.=20 TK’s employer had then contacted the GP, who gave her=20 the result and the referral note and TK was then given=20 five days’ notice to leave her room to make way for her=20 replacement. My own clinical examination of TK did not=20 reveal any obvious reason why HIV infection should have=20 been suspected.
If TK’s story is true, as it most likely is, the=20 implications of this are very worrying. How many madams=20 and their GPs are colluding to perform pre-employment=20 screening on their prospective maids? How many doctors=20 are performing the test without informed consent or=20 giving pre-test counselling? How many doctors are=20 disclosing the results of confidential information to=20 third parties without the permission of the person=20 concerned? How many maids are being summarily dismissed=20 from their jobs for being HIV-positive, even though=20 they are in excellent health and still able to perform=20 a full day’s work?=20
This situation constitutes a gross abuse of basic human=20 rights, from what is essentially an assault on the part=20 of the doctor, through to unfair dismissal on the part=20 of the employer.
The stark contrast between these two maid-and-madam=20 relationships reveals the immense gulf that still=20 exists between needing to learn to live with this=20 disease in our midst and what is really happening to=20 those suffering, both from the physical effects of this=20 desease and from the terrible ignorance that prevails,=20 both within the medical profession and among the=20 general public.