Abstract

Introduction

Healthcare for people living with HIV/AIDS (PLWHA) is a source of physical and emotional stress for the health providers involved, considering that this occupation exposes them to various complex demands, such as accidents involving biological material¹1 Tong H, Li X, Qiao S, Zhou Y, Shen Z, Yang X, et al. Sources and impact of work-related stress among HIV/AIDS health care providers in Guangxi, China: a qualitative research. Workplace Health Saf. 2020; 68(2):81-91.

2 Kim MH, Mazenga AC, Yu X, Simon K, Nyasulu P, Kazembe PN, et al. Factors associated with burnout amongst healthcare workers providing HIV care in Malawi. PLoS One. 2019; 14(9):e0222638.^-33 Pan C, Wang H, Chen M, Cai Y, Li P, Xiao C, et al. Stress and coping in nurses taking care of people living with HIV in Hunan, China: a descriptive qualitative study. Neuropsychiatr Dis Treat. 2022; 18:303-15. .

According to statistics from the International Labor Organization (ILO), 313 million workers suffer non-fatal occupational injuries every year, i.e. 860,000 people are injured at work every day around the world⁴4 Organização Internacional do Trabalho. Segurança e saúde no trabalho [Internet]. Lisboa: Organização Internacional do Trabalho; 2023 [citado 28 Abr 2023]. Disponível em: https://www.ilo.org/lisbon/temas/WCMS_650864/lang--pt/index.htm
https://www.ilo.org/lisbon/temas/WCMS_65... . According to the latest Statistical Yearbook of Accidents at Work from the Ministry of Social Security, when the reason for the record corresponds to contact with/and exposure to communicable diseases, represented by code Z20 of the International Classification of Diseases (ICD-10), 15,961 accidents at work involving exposure to potentially contaminated biological material were recorded in Brazil in 2021, 8,983 of which were in the southeast region alone⁵5 Brasil. Ministério da Previdência Social. Anuário Estatístico de Acidentes do Trabalho – AEAT 2021 [Internet]. Brasília: Ministério da Previdência Social; 2021 [citado 16 Mar 2023]. Disponível em: https://www.gov.br/previdencia/pt-br/assuntos/previdencia-social/saude-e-seguranca-do-trabalhador/acidente_trabalho_incapacidade/arquivos/copy_of_AEAT_2021/aeat-2021
https://www.gov.br/previdencia/pt-br/ass... .

When an accident occurs at work involving biological material, risking HIV infection, there are recommendations in the Clinical Protocol and Therapeutic Guidelines for Post-Exposure Prophylaxis at Risk of HIV Infection, STIs and Viral Hepatitis, known by the acronym PCDT-PEP⁶6 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis. Protocolo clínico e diretrizes terapêuticas para profilaxia Pós-Exposição (PEP) de risco à infecção pelo HIV, IST e hepatites virais. Brasília: Ministério da Saúde; 2021.. However, the focus of these recommendations is on objective and biomedical actions, and little attention is paid to the emotional aspects of this situation.

Both in the national and international literature there are several references to accidents at work involving biological material⁷7 Fernandes AT, Nery AA, Matos Filho AS, Morais RLGL, Oliveira JS, Oliveira YNS. Sentimentos vivenciados por trabalhadores de saúde na ocorrência de acidentes com material biológico. Rev Paul Enferm. 2018; 29(1-3):56-67.

8 Pleśniak R, Kocór S, Kuźniar K, Oboz-Adaś A, Ziojła K. Assessment of the state of knowledge of bloodborne infections, occupational exposure and post-exposure prophylaxis and study of exposure to potentially infectious materials among students of selected medical faculties in Poland. Eur J Clin Experimental Med. 2021; 19(2):153-61.^-99 Eyong EM, Ngwe NY, Nfuksai CN, Niba LL, Jane-Francis A. Prevalence of occupational exposure to HIV and factors associated with compliance with post-exposure prophylaxis among health workers of the Biyem-Assi, Buea, and Limbe Health Districts of Cameroon Maternal and Child Health and AIDS. Int J MCH AIDS. 2022; 11(1):e557., but there is a lack of studies that examine how health professionals who work specifically in these specialized HIV/AIDS services experience these events.

One of the relevant aspects of evaluating health services is that professionals are not prepared to deal with the subjective dimensions that surround their health practice. Faced with this issue, the National Health Humanization Policy (PNH), also known as HumanizaSUS, through its guiding principles, advocates the evaluation of subjective and social dimensions in all health actions of the Brazilian National Health System (SUS), thereby reinforcing the commitment to the human rights of the population¹⁰10 Nascimento JAS, Costa RS, Almeida RSM, Abadessa RS. Compreendendo a política nacional de humanização em saúde. Rev Multidiscip Saude. 2021; 2(4):102..

For these reasons, and the need to seek theoretical reflections that could contribute to understanding the complexities of the phenomena studied in this research, Ayres’ conceptions of Care were used¹¹11 Ayres JR. Vulnerabilidade, cuidado e integralidade: reconstruções conceituais e desafios atuais para as políticas e práticas de cuidado em HIV/Aids. Saude Debate. 2023; 46 Spec No 7:196-206.. For this author, the Care concept - coined with a capital letter - allows the studied issue to be approached beyond the technical or biomedical aspects in order to obtain comprehensive healthcare, the subjectivity of those involved must also be taken into account. In other words, for Ayres¹¹11 Ayres JR. Vulnerabilidade, cuidado e integralidade: reconstruções conceituais e desafios atuais para as políticas e práticas de cuidado em HIV/Aids. Saude Debate. 2023; 46 Spec No 7:196-206., care is more than just constructing an object and intervening in it. Faced with the changes in the modern world, health professionals must think critically, possess skills in ethical and civic commitment, autonomy, problem-solving, reflection and transformation of their practice, because technical skills alone will not be enough for humanity¹¹11 Ayres JR. Vulnerabilidade, cuidado e integralidade: reconstruções conceituais e desafios atuais para as políticas e práticas de cuidado em HIV/Aids. Saude Debate. 2023; 46 Spec No 7:196-206..

Aiming to deal with this issue, Permanent Education in Health¹²12 Carvalho MS, Merhy EE, Sousa MF. Repensando as políticas de Saúde no Brasil: Educação Permanente em Saúde centrada no encontro e no saber da experiência. Interface (Botucatu). 2019; 23:e190211. doi: 10.1590/Interface.190211.
https://doi.org/10.1590/Interface.190211... is an excellent tool. Initially recommended by the Pan American Health Organization (PAHO) in 1980 and becoming a public policy of the SUS in 2003, it was born as a proposal for teaching-health integration and reflective education of health actors. In Brazil, despite the emergence of some isolated movements to weaken it, it has held its ground, because there is evidence that it leads to positive changes in health practices, which translates into an improvement in the production of care¹²12 Carvalho MS, Merhy EE, Sousa MF. Repensando as políticas de Saúde no Brasil: Educação Permanente em Saúde centrada no encontro e no saber da experiência. Interface (Botucatu). 2019; 23:e190211. doi: 10.1590/Interface.190211.
https://doi.org/10.1590/Interface.190211... . In this respect, Permanent Education in Health emerges as a reference in this study because it is based on dialogues and listening among health professionals to solve problems, favoring the expansion of the notion of Care and counting on local creativity for possible rearrangements in these spaces¹²12 Carvalho MS, Merhy EE, Sousa MF. Repensando as políticas de Saúde no Brasil: Educação Permanente em Saúde centrada no encontro e no saber da experiência. Interface (Botucatu). 2019; 23:e190211. doi: 10.1590/Interface.190211.
https://doi.org/10.1590/Interface.190211... .

Research into accidents at work aims to provide input for planning strategies that can prevent and deal with injuries and illnesses. Evaluation at this juncture offers people a new understanding of these accidents, by identifying the risks beforehand and making the necessary changes⁷7 Fernandes AT, Nery AA, Matos Filho AS, Morais RLGL, Oliveira JS, Oliveira YNS. Sentimentos vivenciados por trabalhadores de saúde na ocorrência de acidentes com material biológico. Rev Paul Enferm. 2018; 29(1-3):56-67..

Likewise, according to Ayres¹¹11 Ayres JR. Vulnerabilidade, cuidado e integralidade: reconstruções conceituais e desafios atuais para as políticas e práticas de cuidado em HIV/Aids. Saude Debate. 2023; 46 Spec No 7:196-206., in the context of HIV, while risk integrates an individual’s (or group’s) chances of becoming ill, the concept of vulnerability brings more abstract elements to the processes of becoming ill. Thus, it is necessary to speak of “vulnerabilities” (individual, programmatic or social), in the plural, where exposure to the HIV virus is considered to be linked to a range of outcomes, not just individual, but collective and contextual¹¹11 Ayres JR. Vulnerabilidade, cuidado e integralidade: reconstruções conceituais e desafios atuais para as políticas e práticas de cuidado em HIV/Aids. Saude Debate. 2023; 46 Spec No 7:196-206..

It should also be noted that after the personal experience of an accident at work involving biological material with the main researcher (first author) - a dental surgeon at a service specializing in HIV/Aids - the need for a better understanding of this experience was triggered, which led him to propose this research.

Against this backdrop, although any accident involving biological material can lead to worry and suffering, it is plausible to assume that an accident involving a health professional who specifically cares for PLWHA can be a more distressing experience, increasing the chances of negative repercussions in the life of the person affected. The aim of this study was therefore to understand the post-accident experiences of health professionals working in a specialized HIV/AIDS service.

Method

This research was based on the main author’s PhD thesis¹³13 Parola GB. Um homem também chora: vivências pós-acidente com material biológico de profissionais de saúde que trabalham em um serviço especializado em HIV/Aids de Santos - São Paulo [tese]. Santos (SP): Universidade Federal de São Paulo; 2023., developed in the Interdisciplinary Program in Health Sciences at the Federal University of São Paulo. A qualitative approach was used to access the experiences of the participants because, according to Minayo et al.¹⁴14 Minayo MCS, Costa AP. Técnicas que fazem uso da Palavra, do Olhar e da Empatia: pesquisa qualitativa em ação. Aveiro: Ludomedia; 2019., this type of strategy allows to assign values to the universe of meanings, motives, aspirations, beliefs, values, and attitudes, which corresponds to deeper relationships, processes and phenomena that cannot be reduced to the operationalization of variables.

The research was carried out at the Coordination for the Control of Infectious Diseases (CCDI), a specialized HIV/AIDS service that has been operating since 1989 in the city of Santos - SP. This service currently has around 3,500 registered PLWHA, who are assisted by a multi-professional health team made up of seventy professionals¹⁵15 Prefeitura Municipal de Santos. Atendimento a doenças infectocontagiosas ganha nova sede em Santos [Internet]. Santos: Prefeitura de Santos; 2020 [citado 22 Maio 2021]. Disponível em: https://www.santos.sp.gov.br/?q=noticia/atendimento-a-doencas-infectocontagiosas-ganha-nova-sede-em-santos
https://www.santos.sp.gov.br/?q=noticia/... .

A survey was conducted through personal contact, in which each member of the team (seventy professionals) was asked if she/he had suffered any accidents involving biological material. Through this process, seven health professionals were identified. It should be noted that, in accordance with the aim of the research, only health professionals who worked in this service during the period of data collection (between June and September 2020) and who suffered accidents with biological material between 2000 and 2019 were considered. This time frame was necessary because, before the 2000s, HIV Post-Exposure Prophylaxis (PEP) protocols were in a primary and structuring phase⁶6 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis. Protocolo clínico e diretrizes terapêuticas para profilaxia Pós-Exposição (PEP) de risco à infecção pelo HIV, IST e hepatites virais. Brasília: Ministério da Saúde; 2021.. Another exclusion criterion, due to the characteristics of the research itself, was an accident involving the main researcher (first author).

After this stage of identifying and accepting the health professionals who met the recommended criteria, semi-structured interviews¹⁶16 Guazi TS. Diretrizes para o uso de entrevistas semiestruturadas em investigações científicas. Rev Educ Pesqui Inclusao. 2021; 2:1-20. were carried out, recorded with their permission, using a thematic script of questions drawn up by the researchers (all the authors), based on the aim of the research and the conceptions of Care proposed by Ayres¹¹11 Ayres JR. Vulnerabilidade, cuidado e integralidade: reconstruções conceituais e desafios atuais para as políticas e práticas de cuidado em HIV/Aids. Saude Debate. 2023; 46 Spec No 7:196-206.. To this end, seven meetings were held, one with each participant, lasting around 40 minutes each, in a private room at the service during working hours. The interviews were carried out only by the main researcher (first author) and were transcribed by him, with the names of the participants preserved, using the acronym “P” and a reference number to ensure confidentiality. The transcriptions of the speeches were made in the literal form of language, so that they could expose the veracity of the emotions, thoughts, characteristics, and personalities of the research subjects. After this dynamic, the speeches were analyzed and categorized by the researchers (all the authors) using the thematic content analysis method¹⁷17 Bardin L. Análise de conteúdo. Lisboa: Edições 70; 2016.. For this purpose, the transcribed reports were subject to free-floating reading, highlighting the meaning cores, the most frequent thematic nuclei and the relevant and singular themes, to allow the construction of thematic categories representative of the content of the speeches, moving from the most specific aspects to the most general and abstract aspects, which increased the complexity of the categories.

All participants signed an Informed Consent Form in accordance with National Health Council Resolutions 466/12 and 510/16. The research project was approved by the Santos City Council and by the Federal University of São Paulo’s Research Ethics Committee under CAAE number 28823620.6.0000.5505 and final ruling number 3.853.456.

Results and discussion

Owing to the fact that research’s participants came from a healthcare facility with a small number of providers, their characterization is presented in a broad and general way, to guarantee their privacy. Here is some information: the age of the participants ranged from 30 to 59, with five people declaring themselves white, one black and one brown. One person who identifies as male/heterosexual and six people who identify as female/heterosexual took part. All declared themselves to be cisgender. The professions identified in this study were nursing (nursing assistant and technician) and dentistry (oral health assistant and dental surgeon). It is also important to note that all the participants are statutory employees of the Santos municipality, working in the Infectious Disease Control Coordination (CCDI) during the period of data collection. Finally, none of the participants had been infected with HIV or any other illnesses resulting from their respective accidents at work with biological material.

After collecting and transcribing the data, three categories of analysis were constructed using the thematic content analysis technique¹⁷17 Bardin L. Análise de conteúdo. Lisboa: Edições 70; 2016.: 1) Immediate experiences after of the work accident involving biological material; 2) Experiences after a work accident involving biological material; 3) Experiences of discrimination, prejudice and/or stigmatization in relation to the work accident involving biological material.

Immediate experiences of the work accident involving biological material

The participants’ first reaction reported in the survey was fear, a fact which corroborates studies on work accidents involving biological material with a risk of HIV infection, where they pointed out that fear of becoming infected was prevalent among the health professionals involved in such a situation¹⁸18 Mabwe P, Kessy AT, Semali I. Understanding the magnitude of occupational exposure to human immunodeficiency virus (HIV) and uptake of HIV post-exposure prophylaxis among healthcare workers in a rural district in Tanzania. J Hosp Infect. 2017; 96(3):276-80.^,1919 Rasweswe MM, Peu MD. Occupational exposure to blood and body fluids and use of human immunodeficiency virus post-exposure prophylaxis amongst nurses in a Gauteng province hospital. Health SA. 2020; 25:1252., as indicated by the following speeches:

Through P1’s speech below there is the knowledge that it was an accident with a PLWHA who was not adherent to treatment, which made the risk of infection more significant, where the concern became more aggravated when the user in question died:

Currently, treatment with antiretrovirals can be seen as a way of preventing transmission of the virus, which is known in the field as “treatment as prevention”²⁰20 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis. Protocolo clínico e diretrizes terapêuticas para Profilaxia Pré-exposição (PREP) de risco à infecção pelo HIV. Brasília: Ministério da Saúde; 2022.. In view of this, P1 - aware that the user in question did not take the necessary precautions for his own treatment - is faced with an increased risk of becoming infected. In this sense, Rasweswe et al.¹⁹19 Rasweswe MM, Peu MD. Occupational exposure to blood and body fluids and use of human immunodeficiency virus post-exposure prophylaxis amongst nurses in a Gauteng province hospital. Health SA. 2020; 25:1252. point out that this fear of testing positive is so great in some health professionals who suffer this type of accident that it can lead them not to report what happened, which could cause them great harm.

During P1’s reception, the doctor seemed to be trying to make a “joke”, but the clinical situation of the patient involved in the accident - non-adherent to treatment - made her even more anxious:

Baffour²¹21 Baffour PK. Of fear and hope. A reflexive ethnography of uncertainty following a needle stick injury. J HIV AIDS Infect Dis. 2019; 5:1-7., in an ethnographic study on sharps accidents, also mentions attempts by co-workers to relativize what happened, which also had no positive effect on the injured person’s emotional state.

P5’s account also shows the impact of the accident, which occurred during home care for a service user. At first, she took a course of action that is not recommended by the PCDT-PEP⁶6 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis. Protocolo clínico e diretrizes terapêuticas para profilaxia Pós-Exposição (PEP) de risco à infecção pelo HIV, IST e hepatites virais. Brasília: Ministério da Saúde; 2021. - the act of “squeezing her finger” - as well as expressing her deep sense of fear:

However, on the other hand, her speech also shows a deep concern for the other person, as she reported that, although terrified, she tried to “disguise” her suffering in front of the patient, leaving while crying:

In relation to the initial reception, Baffour²¹21 Baffour PK. Of fear and hope. A reflexive ethnography of uncertainty following a needle stick injury. J HIV AIDS Infect Dis. 2019; 5:1-7. reports in his study a certain feeling of helplessness in post-accident care. Similarly, a striking aspect of the reports in this study was that, in the immediate aftermath of the accident, some participants said they were not sufficiently welcomed at the service. They reported disorganized care, which contributed to the torment they experienced. P1 reported that at that moment nobody seemed to know what to do and it was up to her to fill in the “paperwork” for her own accident:

P3 also reported some shortcomings in the process of welcoming patients and handling the information they needed to continue with their follow-up:

P3 felt that there was a lack of structured care and more support from the health team. She noticed that people seemed confused and unprepared. She points out that she was “given” some antiretroviral (ARV) without further explanation or guidance. Because of this, in her view, there was a lack of appropriate training, something worth noting, considering that this is a specialized service.

The PCDT-PEP recommends that the initial reception be carried out in a suitable place, guaranteeing the privacy of the injured professional, which is also recommended by the PNH⁶6 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis. Protocolo clínico e diretrizes terapêuticas para profilaxia Pós-Exposição (PEP) de risco à infecção pelo HIV, IST e hepatites virais. Brasília: Ministério da Saúde; 2021.^,1010 Nascimento JAS, Costa RS, Almeida RSM, Abadessa RS. Compreendendo a política nacional de humanização em saúde. Rev Multidiscip Saude. 2021; 2(4):102.. However, given the reports, it is legitimate to consider that this guidance seems insufficient. In this sense, it is necessary that, in addition to adopting protocol actions, there is a look that supports attention to the emotional aspects of injured professionals working in HIV/AIDS services, taking as a guiding point the construction of comprehensive and humanized care, as evidenced by the contributions of Ayres¹¹11 Ayres JR. Vulnerabilidade, cuidado e integralidade: reconstruções conceituais e desafios atuais para as políticas e práticas de cuidado em HIV/Aids. Saude Debate. 2023; 46 Spec No 7:196-206.. Of course, the practical organization of the services is fundamental, but there is a need to take a firm and explicit stance that guarantees the emotional care of these professionals, in order to minimize possible emotional damage from the impact of this experience. In this way, both the welcoming practices and the PCDT-PEP itself can be widely worked on in Permanent Education in Health processes in the services, fostering reflection on Care.

Experiences after a work accident involving biological material

As a general matter, the participants’ speeches revealed that the experience of the accident with biological material was remarkable and that different feelings and attitudes interfered in the way each one reacted afterwards. Fears (of becoming infected, of infecting the sexual partner, among others), feelings that paralyze the professional, continued to be the predominant aspects of their experiences, in line with the literature¹⁸18 Mabwe P, Kessy AT, Semali I. Understanding the magnitude of occupational exposure to human immunodeficiency virus (HIV) and uptake of HIV post-exposure prophylaxis among healthcare workers in a rural district in Tanzania. J Hosp Infect. 2017; 96(3):276-80.^,1919 Rasweswe MM, Peu MD. Occupational exposure to blood and body fluids and use of human immunodeficiency virus post-exposure prophylaxis amongst nurses in a Gauteng province hospital. Health SA. 2020; 25:1252..

In this way, the fear of HIV infection was intense, especially when they returned for clinical laboratory monitoring:

One striking point was that, after the initial shock, P5 reported having adopted a stance of deep rationalization as a coping mechanism, in other words, she tried to trust the medical advice and PEP⁶6 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis. Protocolo clínico e diretrizes terapêuticas para profilaxia Pós-Exposição (PEP) de risco à infecção pelo HIV, IST e hepatites virais. Brasília: Ministério da Saúde; 2021.. However, from a subjective point of view, she adopted the position of “not thinking about it anymore”. We can therefore see an internal contradiction within the subject, since on the one hand he objectively adopts the necessary procedures to avoid infection, while on the other hand he adopts a posture of denial as a way of coping with his apprehension:

This account shows how important it is for people who have these experiences to be cared for from an emotional point of view²¹21 Baffour PK. Of fear and hope. A reflexive ethnography of uncertainty following a needle stick injury. J HIV AIDS Infect Dis. 2019; 5:1-7.^,2222 Aigbodion SJ, Motara F, Laher AE. Occupational blood and body fluid exposures and human immunodeficiency virus post-exposure prophylaxis amongst intern doctors. South Afr J HIV Med. 2019; 20(1):958., since their concerns are not always conscious or evident in their daily behavior, but they interfere with their ability to deal with life in a healthy way.

P6’s speech highlighted another aspect: that the experience of the accident is “stored” in the memory and that the subject “creates” explanations and justifications to deal with the suffering. However, this suffering resurfaces when something from the objective experience happens. In this sense, P6 said that she felt afraid after the accident only when there was a “routine” test at the service, but that she tried to reassure herself by saying that “the time of contamination would have passed”:

The above excerpt from P6 reveals that, even though she was a professional with knowledge of the area, she tried to come up with an explanation so as not to come into contact with the agony generated by the experience of the accident, because there is no sense in the idea that the “time of contamination has passed”, because after the actual infection, regardless of the time, the person becomes HIV positive even if they don’t know it⁶6 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis. Protocolo clínico e diretrizes terapêuticas para profilaxia Pós-Exposição (PEP) de risco à infecção pelo HIV, IST e hepatites virais. Brasília: Ministério da Saúde; 2021..

In this sense, Mabwe et al.¹²12 Carvalho MS, Merhy EE, Sousa MF. Repensando as políticas de Saúde no Brasil: Educação Permanente em Saúde centrada no encontro e no saber da experiência. Interface (Botucatu). 2019; 23:e190211. doi: 10.1590/Interface.190211.
https://doi.org/10.1590/Interface.190211... also point out that this fear of testing positive may be associated with the fear of a pre-existing HIV infection. Thus, this participant’s report once again highlights the need for Ayres’ Care¹¹11 Ayres JR. Vulnerabilidade, cuidado e integralidade: reconstruções conceituais e desafios atuais para as políticas e práticas de cuidado em HIV/Aids. Saude Debate. 2023; 46 Spec No 7:196-206. and emotional support²¹21 Baffour PK. Of fear and hope. A reflexive ethnography of uncertainty following a needle stick injury. J HIV AIDS Infect Dis. 2019; 5:1-7.^,2222 Aigbodion SJ, Motara F, Laher AE. Occupational blood and body fluid exposures and human immunodeficiency virus post-exposure prophylaxis amongst intern doctors. South Afr J HIV Med. 2019; 20(1):958. over time, so that these professionals can work through their afflictions without adopting substitutive symptomatic behaviors or defense mechanisms that could interfere with self-care.

This was also evident in P1’s reports, where she said that, in order to deal with her pain, she adopted compensatory behaviors or defense mechanisms such as “taking it out on food” and “not exercising”. Once again, it is striking that even though she is a professional in the field, she assumes a logic of her own to justify this withdrawal from physical activities, as she said she was afraid of infecting others with her bodily fluids, which is clearly not the case:

Another aspect revealed by the research was that the protocol was not followed in full, specifically in prophylaxis with the use of ARVs. In these cases, the literature points out that failure to comply with this step of the protocol may be linked not only to the adverse effects of ARVs, but also to fear of these effects²³23 Degavi G, Adola SG, Panari H, Pawar S, Dereso CW. Prevalence of occupational exposure to HIV and utilization of HIV post-exposure prophylaxis among health staff at Bule Hora General Hospital, Bule Hora, Ethiopia. Pan Afr Med J. 2020; 37:333.^,2424 Tarimo EA, Mashoto KO. A qualitative study of perceived risk of occupational exposure to HIV and use of post exposure prophylaxis services among health-care workers in Tanzania. East Afr Health Res J. 2019; 3(2):96-104.:

These experiences in the post-accident period are extremely important points that highlight the need for specialized emotional support, and can also be dealt with in Permanent Education in Health processes, as they allow professionals to reflect on the issue promptly and consequently improve their practices.

Experiences of discrimination, prejudice and/or stigmatization in relation to work accidents involving biological material

Fear of stigma was present in most of the participants’ narratives. This aspect is also highlighted in studies dealing with accidents at work involving biological material with a risk of HIV infection and post-exposure prophylaxis²⁵25 Mushambi F, Timire C, Harries AD, Tweya H, Goverwa-Sibanda TP, Mungofa S, et al. High post-exposure prophylaxis uptake but low completion rates and HIV testing follow-up in health workers, Harare, Zimbabwe. J Infect Dev Ctries. 2021; 15(4):559-65.^,2626 Njemanze U. Factors Impacting HIV post exposure prophylaxis among healthcare workers [tese]. Minneapolis: Walden University; 2017..

From this perspective, P1 reported intense concern about exposing herself socially, manifested by fear of judgment and blame:

Although P2 felt supported by her spouse, her account pointed to fear of prejudice, as she decided to only tell her circle of friends about the accident after she was sure she hadn’t been infected, which shows that she was silenced for a while as a form of self-protection:

P3’s report also indicates fear of prejudice, as she said she had only told one family member about what had happened, but the latter advised her to hide the situation, justifying that this would be necessary to spare the other:

Mushambi et al.²⁵25 Mushambi F, Timire C, Harries AD, Tweya H, Goverwa-Sibanda TP, Mungofa S, et al. High post-exposure prophylaxis uptake but low completion rates and HIV testing follow-up in health workers, Harare, Zimbabwe. J Infect Dev Ctries. 2021; 15(4):559-65. refer to the fear of health professionals who experience this situation in relation to the possibility of a lack of confidentiality, stigma and discrimination in the workplace. Njemanze²⁶26 Njemanze U. Factors Impacting HIV post exposure prophylaxis among healthcare workers [tese]. Minneapolis: Walden University; 2017. also points out that this fear of stigma and prejudice after an accident involving biological material with a risk of HIV infection can also interfere with the practice of PEP by the injured professional.

In the meantime, although P4 doesn’t bring up any narratives of conflicts in the workplace, she does demarcate a “distancing” when she reports that she didn’t want to tell her coworkers about what happened for fear of being the target of prejudice from her own colleagues:

Through these ways, discrimination, prejudice and stigmatization, in relation to the context of HIV/Aids in general, can and should be worked on with professionals in Permanent Education in Health environments, in order to complexify their conceptions on the subject.

Final considerations

The threat of becoming ill brings us into direct contact with the condition of human finitude. In this way, when health professionals have an accident with biological material in HIV/AIDS services, they need not only the objective/technical care available to prevent possible infection, but also subjective and emotional care. Although each participant reacted according to their own values and ways of being - through the singularities of each one - they all emphasized that the experience of the accident with biological material was remarkable and affected them in various aspects: family, social and professional.

In a scenario where most of the biomedical aspects involved in the treatment of HIV/Aids are known and mastered, it is necessary to recognize that the human factor has brought about the need to deepen reflections on the conceptions of an idealized model of the human being, that is, the SUS has offered universal and free treatment, but does not always offer a logic of health care that really makes sense and meets people’s complex demands²⁷27 Zihlmann KF, Moreira FA. Desafios atuais da prevenção do HIV/Aids e o olhar da Psicanálise diante das estratégias de prevenção combinada. In: Quayle J, organizadora. O adoecer. São Paulo: Editora dos editores; 2019. p. 61-84..

Within this context, the participants’ speeches showed that sometimes the health professional does not immediately perceive or recognize the repercussions of the accident experienced. Thus, the person may have a subjective demand for care and this may not appear in their initial speech, but it may appear later in their behavior or in other symptoms (physical, psychosomatic). This is why there is a need for a specialized professional assessment, as highlighted by Baffour²¹21 Baffour PK. Of fear and hope. A reflexive ethnography of uncertainty following a needle stick injury. J HIV AIDS Infect Dis. 2019; 5:1-7. and Aigbodion et al.²²22 Aigbodion SJ, Motara F, Laher AE. Occupational blood and body fluid exposures and human immunodeficiency virus post-exposure prophylaxis amongst intern doctors. South Afr J HIV Med. 2019; 20(1):958., who highlighted the need for psychological and emotional support for health professionals who have been exposed to biological material with a risk of HIV infection.

With regard to aspects prior to the accident, it is worth reflecting on the different dimensions of vulnerability proposed by Ayres¹¹11 Ayres JR. Vulnerabilidade, cuidado e integralidade: reconstruções conceituais e desafios atuais para as políticas e práticas de cuidado em HIV/Aids. Saude Debate. 2023; 46 Spec No 7:196-206.. In the study, it was possible to detect individual vulnerabilities, as not all participants had an exact understanding of the behavior that led to the accident. At this point, it should be noted that individual issues, such as stressful psychosocial situations, psycho-organizational situations, among others, could be addressed in Permanent Education in Health spaces as accident prevention factors.

Programmatic vulnerability, on the other hand, was expressed in the context of public policies, since the PCDT-PEP⁶6 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Doenças de Condições Crônicas e Infecções Sexualmente Transmissíveis. Protocolo clínico e diretrizes terapêuticas para profilaxia Pós-Exposição (PEP) de risco à infecção pelo HIV, IST e hepatites virais. Brasília: Ministério da Saúde; 2021. proposal as an institutional standard, although it brings unequivocal benefits, does not include sufficient determination regarding initial reception and emotional care. In this sense, the discrepancies between the propositions expressed in manuals and the actual contexts of care for those concerned lead to important gaps that need to be highlighted.

Finally, social vulnerability was shown through HIV/AIDS stigma, when reactions and behaviors of avoidance and isolation on the part of some professionals were identified. Fear of prejudice interfered not only in professional relationships, but also in silencing the experience of the accident in the eyes of family members and those close to them. This is a demand that could be addressed beforehand in Permanent Education in Health, including possible discrimination due to the fact that they work with people living with HIV/Aids.

Despite the study’s limitations, especially with regard to the qualitative aspects and its often-restricted sample characteristics, the research has the potential to indicate the need for training health professionals in specialized HIV/AIDS services to broaden their concepts on this subject. In this way, traditional training, strongly focused on technical aspects, is unable to cover the complex needs involved in this context. In order to guarantee a truly engaging, reflective training process that makes sense to people, in addition to traditional educational processes, Permanent Education in Health is a demand that needs to be highlighted in the services, due to the possibility of bringing about positive changes by making it possible to rethink accidents involving biological material and the PCDT-PEP itself in a collective way.

It should also be noted that, although the small number of participants may seem to be a limitation of the research, it should be considered that the population studied has key characteristics, since they are health providers who work in the field of HIV/Aids, have technical information and access to health services. But even so, their experiences were painful, which allows us to reflect on the impact of this type of accident among lay people.

Finally, taking into account the need to give these people a voice, it is hoped that this research will help to rethink protocols and care processes for these professionals. To this end, it is necessary to take on Permanent Education in Health actions in specialized HIV/AIDS services, as a policy that guarantees a more sensitive approach to “caring for those who care”, considering not only the biomedical aspects of exposure, but also the experiences of this moving and exceptional experience. A proposal that goes beyond the objectivity of Care, because in practice, according to Ayres¹¹11 Ayres JR. Vulnerabilidade, cuidado e integralidade: reconstruções conceituais e desafios atuais para as políticas e práticas de cuidado em HIV/Aids. Saude Debate. 2023; 46 Spec No 7:196-206., subjective interference in these processes is beyond the scope of current guidelines.

Acknowledgments

To the health professionals from the Infectious Diseases Control Coordination of the Santos municipality, who took part in the research, for their contribution in sharing their experiences of accidents involving biological material in the context studied.

References

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