Abstract

Introduction

The history of Acquired Immunodeficiency Syndrome (AIDS) in Brazil has been marked by sociocultural responses related to fear, prejudice and social injustice due to distorted conceptions or misunderstandings regarding the form of transmission and contagion of the Human Immunodeficiency Virus (HIV), the etiologic agent of AIDS. The epidemics took shape in the means of communication, and before it had, in fact, affected the life of a significant number of people, the social response was panic and fear¹.

The evolution in the natural history of HIV infection, from the initial asymptomatic stages to the advanced stages (AIDS), is characterized by continuous and progressive immunological deficiency, which can be monitored and measured in terms of reduction in the counts of circulating T lymphocytes (CD4+). It was observed that zidovudine (AZT) reduced the amount of circulating HIV and increased the amount of organic defense cells, reducing opportunistic infections. In 1996, a new class of highly active drugs was discovered, which increased the survival of HIV-infected individuals².

At the beginning of the epidemics, only a few dentists assisted HIV-seropositive patients due to fear of the unknown. Subsequently, the number of professionals determined to assist such patients gradually increased, due to awareness-raising and to the adequacy of biosafety measures³, an efficient Dentistry protocol that advocates that every individual should be treated as potentially infected, as it is impossible to clinically differentiate infected asymptomatic patients from non-infected patients⁴.

In the undergraduate program, it is fundamental to provide explanations about the ethical posture of future dentists concerning HIV infection⁴, and the Universidade Estadual de Montes Claros (Unimontes – State University of Montes Claros) has been trying to meet the social and ethical demands of the users of oral health services. The university’s goal is the technical, professional and humanistic education of its students⁵. As it believes that the existence of a scenario of practice for professional education is important, and that changes in paradigms and in students’ attitudes are equally relevant, the Dentistry program of Unimontes offers a space that provides dental care for HIV/AIDS-seropositive patients. But what attitudes have the students been having?

Based on this presupposition, this study aimed to investigate the expectations and perceptions of the Dentistry students of Unimontes, regarding the assistance provided for patients living with HIV/AIDS.

Methodology

This is an ethnographic study that employed the techniques of participant observation and semi-structured interviews. It was conducted with the Dentistry students of Unimontes enrolled in the discipline Integrated Clinic IV, offered in the ninth semester of the program. The clinic offers dental care to HIV/AIDS-seropositive patients referred by the Centro Ambulatorial de Especialidades Médicas Presidente Tancredo Neves (CAETAN – Outpatient Center of Medical Specialties) and by the Centro de Testagem e Aconselhamento do Alto São João (CTA – Testing and Counseling Center).

Initially, a pre-observation was performed: the first contact with all the 22 students during a discussion group that was held in the discipline, whose theme “Ethical aspects in dental care provided for HIV/AIDS patients” was discussed by all. The participant observation carried out by one of the researchers occurred during the second semester of 2011, on the days in which dental care was offered to HIV/AIDS-seropositive patients. This is provided by students at a dental clinic of Unimontes every Tuesday - the scenario of this study. Each pair of students assists approximately two patients in a period of four hours, under the supervision of three professors from the discipline. The observation was registered in a notebook used as a field diary, in which everything that was experienced was registered.

Receiving the individual in the natural research environment (health settings) is a fundamental element to mobilize the interviewer’s interest when s/he observes the details of verbal and non-verbal language⁶. Because it studies subjects within the settings, ethnography can be a very powerful tool to the understanding of these intense and complex dialogs that are the practices⁷. In this sense, the method based on field research enabled to conduct the study face-to-face with the participants, interacting with them during a period of time, while they performed their routines.

At the end of the semester, after the observation process, the same researcher conducted semi-structured interviews with nine Dentistry students who were randomly chosen, six women and three men. The ages varied from 21 to 34 years. This number of students depended on data recurrence, which refers to the sensation of saturation evaluated by the researcher⁸. Sample size depends on the characteristics of the group that is being studied. If the population is diversified, the number of interviewees must be sufficient to provide a general view of different elements. In a purely homogeneous group, one single person can be considered a legitimate sample⁹.

The ethnographic interview is interactive and open-ended, and it is also possible to conduct it in a semi-structured way. It is an in-depth interview, that is, “it aims to delve into meanings, to explore nuances” ⁹ (p.62). The “questions should not be trapped into a list; rather, they should serve as a script to the main subjects of the conversation” ⁹ (p.62).

The script used to conduct the interviews was constructed based on the situations that had been observed in the daily routine of the clinic for HIV/AIDS-seropositive patients, such as: preparing the materials, approaching patients at the waiting room, approaching them during the anamnesis, posture during clinical assistance, cleaning the materials.

The interviews, conducted at a private room, were recorded upon the informants’ proper authorization and transcribed simultaneously. Data analysis consisted of the detailed reading of all the transcribed material, as well as the identification of the meanings shared by the informants and observed in the repetition of subjects. In the analysis, the data obtained from the field diary were added to the data provided by the interviews, in order to identify the empirical categories of this study.

The participants were identified by letter E, followed by the number of the order of the interview, letter M for male or F for female, and the age. Data collection was carried out in compliance with ethical and legal aspects, according to Resolution no. 196, released in 1996 by the National Health Council, which regulates research with human beings. The research was approved by the Ethics Committee of the Universidade Estadual de Montes Claros under no. 3054/2011.

Results and discussion

The students’ expectations and perceptions were observed and three main categories emerged: “Expectations concerning assistance at the HIV/AIDS clinic”, “The fear of being infected”, and “Behavioral change”.

During the participant observation, it was possible to verify the students’ anxiety regarding the patient and his/her physical appearance. This expectation concerning the new situation revealed manifestations of fear. When they were preparing themselves to the first assistance, one of the students put a protection on the nails because he had cut them and commented that he had “a little exposure”. One female student reported that she had already had the opportunity of assisting a patient and that she was surprised when he said that “he’s an AIDS patient because he’s a strong person”. In addition, it was possible to notice a male student’s resistance regarding the assistance. At the end of the clinical activity, another female student mentioned that she was admired to witness the patients’ motivation to live.

It was also noticed that a pair of students used a surgical cloth and surgical gowns to extract a child’s deciduous tooth. In the Child Clinic of the seventh semester, an identical procedure performed in children of the same age is not conducted with this apparatus, which revealed a different attitude of the students when the patient is known to be infected. The protocol for the extraction of deciduous teeth in the Child Clinic and also in the assistance provided for children with HIV/AIDS does not include the use of surgical cloths, as it generates fear and anxiety in the children. Standard biosafety norms are utilized.

Therefore, it can be considered excess of zeal, as the procedure consisted of the extraction of a deciduous anterior tooth with mobility, which could be performed in a very quick and safe way using standard procedures. In view of the apparatus, what would be a quick procedure became a lengthy one, as the child became scared and fearful, disappearing under the surgical cloth The professors had to intervene, removing the surgical cloth and tranquilizing the child; only after the intervention could the deciduous tooth be extracted.

In relation to the interviews, when the researcher initiated them by asking each student about the meaning of AIDS, she expected answers loaded with feelings; however, the students described it using scientific terms, as can be confirmed by the examples of the discourses of E3, E4 and E8, as they probably reproduced the knowledge they had acquired about “Etiopathology of the HIV infection”, which had been discussed during the moments of theoretical classes in the Integrated Clinic IV - HIV/AIDS, which happen before the practical activities.

Expectations concerning assistance at the HIV/AIDS clinic

Although the students know the difference between HIV and AIDS, as they had theoretical classes about “Cross-infection control” and “Etiopathogenesis of HIV infection”, it can be noticed that all of them idealized an image about the disease concerning the future patients. Through the answers, it is possible to notice that they believed that they would assist low-income male homosexual youths, and they would be pale and thin, downcast, depressed.

A study carried out with a population of migrants from the cities of Fortaleza and Teresina (Northeastern Brazil) showed that there is a direct connection between AIDS and physical appearance, that is, the belief that a beautiful body is healthy and impenetrable to the HIV¹⁰.

At different historical moments and in different societies, HIV infection presented similar cultural characterizations in the collectivity, such as prejudice, discrimination and stigma related to the individual affected by the epidemics¹¹. The disease has presented four preexistent sources of stigmatization: sexuality; gender; race; poverty¹².

Papers published in the 1980s approached young homosexual men who were inexplicably contracting rare diseases for people of their age group, diseases that debilitated them; they were dying due to some diseases that would normally not kill healthy people¹³. A study conducted with adolescents has shown that they still believe that dangerous situations occur when the female partner is recognizably a high-risk partner, an unknown person or prostitute, and in male homosexual relations¹⁴.

It can be seen in E7’s discourse that the media has a strong influence on the formulation of an image. The notions that most of laypeople have are not provided by scientific production, but by the narratives broadcast by the media, which reproduces scientific discourse in a simplified way¹³. The media has strengthened the initial characterization of AIDS, configured by death, contagion and sex. This characterization holds emotional components that are deeply rooted in culture, causing an impact on the symbolic level¹⁵. When individuals interpret organic phenomena, they are supported by concepts, symbols and structures of references internalized according to the social and cultural groups in which they are included¹⁶.

Before proposing strategies, it is necessary to know the aspects related to health beliefs, myths and stereotypes, and to the knowledge of each one, among other aspects¹⁷; after all, the phenomena concerning health, disease and care are not isolated events restricted to the organic and physical dimension: they tend to express other dimensions of the social and cultural life¹⁸.

Being surprised by the HIV-seropositive patient

Antiretroviral therapy, mainly after 1996, with the Highly Active Antiretroviral Therapy – HAART, has enabled to transform a syndrome that used to be culturally perceived as synonymous with death¹¹. For this reason, the patients’ healthy appearance and good psychological status surprised the students and this fact emerges in the interviewees’ discourse.

At the beginning of the semester, during the group discussion that preceded the clinical assistance, the students answered the professors’ questions based on the papers they had previously read. To one of the students, the HIV patient should be assisted at the end of the day. This attitude revealed lack of ethics and of knowledge regarding the difference between HIV-seropositive and the person’s appearance. How will they know who has been and who has not been infected?

HIV/AIDS infection produces numerous responses concerning human behavior, and it is necessary to offer a discipline to stimulate, in the students, this knowledge about human nature¹⁹.

The fear of being infected

Emotions are the result of the emotional representations of the disease that have occurred historically, but which, to this day, still circulate in the scientific environment, in the means of mass communication and in popular thinking.

In the assistance provided by the dental clinic of Unimontes, it is possible to observe a difference in the students’ attitudes: greater care regarding biosafety. When they were interviewed, some of them revealed that they feel afraid:

Others commented that they do not have fear, but this feeling is veiled, as shown by E1’s sentence: “It’s not that you work with fear, it’s not that, but you wear gowns”, and by E9’s sentence: “… when you get to know that the patient is HIV-infected, you watch your movements more closely”.

Fear of contagion is the main source of anxiety concerning HIV-infected patients^4,20,21. The meaning that the disease has no cure and that it generates prejudice seems to interfere in the assistance practice. Although the risk of transmission is low, the consequences can be serious and stressful²⁰. After all, although the dentist has scientific knowledge, s/he also has personal conflicts and human limitations⁴.

Culture provides the individual with the limits within which the interpretations related to corporal phenomena are operated, especially disease and its symptoms. People are supported by concepts, symbols and structures of references which are internalized according to the social and cultural groups in which they are included¹⁶. Before scientific research provided grounds, “theories” were developed based on data related to carriers and vectors²². Strange social objects produce fear because they threaten people’s sense of order²³.

Biosafety

With the emergence of AIDS, the dental team’s concern about biosafety has increased. With the adoption of universal biosafety norms, it has become possible to prevent the transmission of all the infectious agents inside the clinical environment, including HIV, which, in fact, has a very low infectivity and does not represent a high risk to the professional³. Scientific evidences have shown that the risk of HIV transmission is 0.2 (0.5%) in accidental percutaneous injuries, lower than the risk of infection for hepatitis B (HBV), which is 5 (40%), and for hepatitis C (HCV), which is 3 (10%)^4,20,21. Despite the reports about fear, the discourses mentioned that there is safety to perform the dental procedures. The fact that they say they are safe only shows a reproduction of scientific evidence, but their attitudes show that they overprotect themselves in relation to biosafety:

An ambiguity of feelings can be observed and this is clear both in the discourses reproduced above and in E7’s and E3’s reports, in which fear makes them be more rigorous in relation to biosafety when they know that the patient is seropositive. E7’s discourse also shows that, up to that moment, they had had a stereotyped image.

A research carried out at the city of Natal (Northeastern Brazil) has revealed that some dentists would not assist AIDS patients because they do not feel prepared and the reasons were: lack of information on this subject, lack of psychological conditions, and lack of biosafety conditions at the workplace. In addition, they stated that the seropositive patient must be assisted at a specialized place, and their prejudice concerning the patient was revealed. Among those who said that they would assist seropositive patients, the majority answered that they would use special procedures in the treatment²⁴.

The dentist, instead of being afraid of AIDS, must adopt the universal biosafety norms and consider that every patient is a potential carrier of some infectious disease²⁵. However, it is very difficult to change prejudices, stigmas and beliefs. The feelings go beyond knowledge and science, because human weaknesses and moral conflicts are reflected on the professional as an individual⁴.

One of the concerns refers to needlesticks, and needles are the objects that cause most of the accidents²⁶. Percutaneous injuries occur when the professional is recapping the needle²⁷. For this reason, the students revealed fear of handling needlesticks:

Behavioral change

To understand the importance of biosafety, the theory learned in previous semesters was not enough. It was perceived that the scientific evidence did not guarantee a safe assistance. Staliano and Coêlho²⁸ have reported that knowledge alone does not make people have favorable attitudes.

Knowledge does not necessarily imply change, for between knowing and doing there is a series of factors that influence behavior. Based on this principle, it has become relevant to develop skills that act directly on a change in attitudes²⁸.

Therefore, the importance of clinical practice with seropositive individuals was observed in order to lose “that image of the HIV patient” (E7), for them to give “importance, the need to protect yourself” (E1), that is, to verify that the biosafety protocol is “extremely necessary” (E2).

In fact, it is not that more norms were transmitted to the students; rather, they were reinforced, as they are in every semester, before the clinical practice starts. What was observed was that the students paid more attention to them due to the fear of being contaminated, as it is a clinic for HIV/AIDS-seropositive individuals.

Due to the transmissibility characteristics of AIDS, changes in the infection control procedures happened quickly, which years of education had not been able to achieve⁴. The paradigmatic rupture occurs when there is a concrete space where teachers and students move, creating a learning context that contradicts the essential presuppositions of the old paradigm.

It is important to offer a discipline that aids the students “[...] in the articulation of feelings and beliefs, in their self-perception process, in the perception of the world’s alterity, in the perception of different human behaviors and potentialities […]”¹⁹ (p.30) so as to educate individuals “[…] who are humanized, sensitive, prepared to deal with themselves and with their patients, a task that demands working with diverse values inserted in complex historical, cultural and social contexts” ¹⁹ (p.30).

Final remarks

Students have stereotyped representations regarding their future HIV/AIDS patients. The characterizations still are social stereotypes like thin bodies, male homosexuals, people with a depressed appearance. When they came into contact with the HIV/AIDS patients, their image of seropositive individuals changed. As the disease has no cure and generates prejudice, the clinical practice emphasized biosafety issues. Fear was observed through the tendency to overestimate the risks of HIV transmission, both in the students’ attitudes and in their discourses, as they were more careful when they assisted patients who were known to be infected – in the other clinics, the protocol was not followed in excess as it happened at the Integrated Clinic IV - HIV/AIDS.

Holding a discussion before clinical assistance, so that the students can expound aspects related to each one’s beliefs, myths and knowledge, seems to be a strategy that will help to break stereotypes.

Ethnography as a methodological path to study the perceptions of the Dentistry students of Unimontes during the clinic with HIV/AIDS individuals has shown that it is important to offer a space, in the assistance provided to this population during the undergraduate program, to break paradigms and ratify that the biosafety norms must be the same with all patients.

It is fundamental to educate professionals who have initiative, creativity and critical sense, and who are also ethical, humanized and have an amplified view of the world, so that they can understand it and act to transform it into a better society.

References

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