Reluctance to care for patients with HIV or hepatitis B / C in Japan

This study examined factors associated with a reluctance to care for hypothetical
patients infected with HIV or HBV / HCV among Japanese nurses. As such, it represents
one of the first studies of prejudicial attitudes toward patients infected with HIV
and HBV / HCV in this country. Our findings suggest that anxiety regarding the perceived
risk of infection and having a prejudicial attitude might affect the acceptance of
infected patients, while personal confidence in universal precautions probably mitigates
this attitude. It is worth noting however, that the prevalence of HIV remains quite
low in Japan, and therefore this issue is unlikely to become a higher priority without
targeted awareness raising.

Previous research has shown that a certain proportion of healthcare workers are reluctant
to care for specific patient groups 22]–24] including some early studies of reluctance to care for HIV patients in the US, and
elsewhere 25], 26]. In the current study, we found that more nurses reported an unwillingness to care
for hypothetical patients infected with HIV (41 %), than for patients infected with
HBV / HCV (18 %). In comparison, there are few recent studies which have investigated
this issue in developed countries 22], although there have been various investigations undertaken in developing countries
or countries with high HIV prevalence rates 23], 24], 27], 28]. It may be that in developed countries, expressing any discriminatory attitude towards
infected people is prohibited, as the standard precaution is a fixed protocol for
infection control. However, in real life situations, some healthcare workers (regardless
of location) may still harbor concerns regarding infected patients. In a study conducted
in urban India, for example, 88 % of nurses with a high risk of body fluid exposure
and 44 % with a low risk of body fluid exposure reported that they discriminate against
people living with HIV in professional situations with a high risk of exposure 29]. Future research is therefore necessary to investigate health care workers’ attitudes
towards infected persons in order to develop more effective interventions for reducing
of discrimination of this nature.

There is no doubt that nurses may be at risk of HIV or HBV / HCV infection through
needlestick injury or fluid exposure during their daily work tasks 5]. However, positive safety climate and confidence in their own skills probably helps
improve their acceptance of patients infected with blood-borne infections. In the
current study, we found that nurses who had no prior experience caring for patients
with HBV / HCV, reported less acceptance of this patient group if on duty. Around
two-thirds of respondents described previous experience in caring for patients infected
with HBV / HCV, while only 11 % of nurses reported prior clinical experience with
HIV-positive patients. However, appropriate training to prevent fluid exposure and
needlestick injuries can certainly help minimize negative perceptions and bias against
infected patients, as demonstrated by other studies 19], 30], 31].

Negative attitudes towards patients infected with HBV and HCV also negatively affected
nurses’ perception of their duty, with 13 % reporting that they would be reluctant
to care for patients with HBV / HCV. The most likely route of HCV infection is by
large or repeated percutaneous exposure to infected blood, such as during transfusion
or injecting drug use 32]. In Japan, HCV transmission by fibrinogen concentrate historically represented one
of the major sources of infection 33]. However, in Japanese healthcare settings, nurses may also encounter patients who
have been infected with HCV and HIV due to drug use 12]. Caring for drug users (especially IV drug users), poses a challenging moral dilemma
in Japan, meaning that some nurses may be reluctant to care for these patients when
on duty 34]. A similar phenomenon might also apply for homosexual men, as the majority of Japanese
HIV infections are reported to be among this demographic 35]. At a broader level, the acceptance of sexual minorities in Japan is still in its
early stages 36], 37], and some nurses may therefore experience difficulty in communicating with homosexual
people and being confronted with the issues faced by HIV infected patients 38].

It is important to note that older Japanese nurses have probably lived through a more
severe era of HIV panic, when compared to their younger counterparts. Until the late
1990s when antiretroviral therapy was developed, for example, HIV was recognized as
a progressive illness with an invariably fatal outcome. As a result, many Japanese
nurses were particularly afraid of HIV infection via needlestick injury or fluid exposure
39]. In addition, previous research suggests that older people may harbor greater prejudice
toward others living with HIV 18], 40]; a finding consistent with our current study. Japanese citizens were also affected
by the so-called “AIDS panic” characterized by highly sensational media reports in
1986 and 1987, after the first and second cases of Japanese HIV infection were identified
41], 42]. Since that time, however, improvements in antiretroviral therapy have changed HIV
infection more towards a chronic, manageable disease; while the relatively low prevalence
of the disease in Japan means that younger nurses tend to have less discriminatory
attitudes 40]. Even so, this situation clearly highlights the need for healthcare workers in managerial
positions (who are usually senior) to implement appropriate educational opportunities
aimed at eliminating discrimination toward patients infected with HIV and other infectious
diseases.

There are certain limitations that may have affected the current study, namely that
it was cross-sectional in design and therefore, causal relationships could not be
inferred. In addition, as the study was conducted as an internet based survey, the
results may not be generalizable to all nurses in Japan. However, as participation
was online and anonymous, concerns regarding their free expression of bias should
have been minimized. A further limitation is that we only asked the nurses’ perception
towards hypothetical patients with HIV, HBV, or HCV, rather than their actual experience
of refusing to care for them in clinical practice. Additionally, the questionnaires
for reluctance care and other variables were not validated, as there is no existing
tool currently available in Japanese. This, in itself, represents an ideal opportunity
for future research in the field. It is also worth noting that our survey tool only
obtained limited demographic information on the participants. Additional studies should
take these points into account.