Private practitioners' communications with patients around HIV testing in Pune, India
1Maharashtra Association of Anthropological Sciences, Pune, India and 2London School of Hygiene and Tropical Medicine, UK
Correspondence: Vinita Datye, Maharashtra Association of Anthropological Sciences, Centre for Health Research and Development, 64/5 Anand Park, Aundh, Pune 411 007, India. Tel: 91 20 2588 4150; Fax: 91 20 2588 9919; E-mail: maaschrd{at}vsnl.net or vinitadatye{at}rediffmail.com.
Unlike any other disease so far, the ‘exceptional’ nature of HIV/AIDS has prompted debate about the necessity, but also the challenges, of regulating practitioner–patient communication around HIV testing. In India, the National AIDS Control Organization (NACO) has adopted the guidelines of the World Health Organization with regard to HIV testing and counselling, yet the extent to which these guidelines are fully understood or followed by the vast private medical sector is unknown. This paper examines the gaps between policy and practice in communications around HIV testing in the private sector and aims to inform a bottom-up approach to policy development that is grounded in actual processes of health care provision. Drawing on 27 in-depth interviews conducted with private medical practitioners managing HIV patients in the city of Pune, we looked specifically at practitioners’ reported communications with patients prior to an HIV test, during and following disclosure of the test result. Among these practitioners, informed consent is rare and pre-test communication is prescriptive rather than shared. Confidentiality of the patient is often breached during disclosure, as family members are drawn into the process without consulting the patient. While non-adherence to guidelines is a matter of concern, practitioners’ communication practices in this setting must be understood in the given social and legal context of the patient–practitioner relationship in India. Communication with their patients is strongly influenced by practitioners’ perceptions of their own roles and relationships with patients, perceived characteristics of the patient population, limitations in knowledge and skills, moral values as well as perceptions of legal guidelines and patient rights. We suggest that policy guidelines around patient–practitioner communication need to take sufficient cognizance of existing practices, cultures and the realities of care provision in the private sector. Patients themselves need to be empowered in order to grasp the importance and implications of HIV testing and counselling.
Key Words: communication, private practitioner, guidelines, HIV testing, informed consent, counselling, confidentiality, HIV/AIDS policy, India
1Effective communication between practitioners and their patients is linked to such benefits as better identification of patient problems, patient satisfaction and increased adherence to medical advice and treatment (Maguire and Pitceathly 2002).
2Concordance is most frequently used to refer to a process of prescribing and medicine-taking based on partnership, where ‘... patient and health care professional participate as partners to reach an agreement, drawing on the expertise of the health care professional, as well as the experiences, beliefs and wishes of the patient to decide when, how and why to use medicines’ (Cox et al. 2004).
3Despite existing legislation like the Consumer Protection Act (COPRA) of 1986, Indian Medical Council Act, Criminal Law and Civil Law etc., the private medical sector in India remains largely unregulated due to weak implementation and enforcement of rules and regulation, and lack of a common policy framework for the country. COPRA allows clients to prosecute doctors through a fast-track system of consumer courts and has been hailed as a tool for medical regulation and client empowerment. It is the only act that is applicable all over India (Bhat 1999). However, its effective implementation has faced constraints (Bhat 1996).
4The private medical sector covers 82% of outpatient care. It comprises practitioners from different systems of medicine (western biomedicine, homeopathy and Indian systems including Ayurveda, Unani and Siddha medicine) working in a spectrum of institutional organization ranging from individual practices to state-of-the-art hospitals (Baru 1998). ‘Mixed’ or ‘cross-system’ practice is common, whereby medicines from one system are used in conjunction with those of another (Uplekar and Rangan 1993).
5State governments are responsible for implementing NACO guidelines, making way for different, sometimes contradictory, interpretations across states. For example, in 2002, the states of Goa and Andhra Pradesh announced their decision to make premarital HIV testing compulsory. In contrast, the state of Maharashtra openly condemned this stance as it was seen to violate principles of human rights and personal freedom (Chatterjee 2002; Times News Network 2002).
6The study area is equipped with two charitable hospitals, two public hospitals, a public AIDS clinic and VCT, and numerous municipal dispensaries. There are close to 50 private diagnostic labs, nearly 100 private pharmacies and approximately 500 private practitioners practicing in the area.
7In the course of the first phase of the project, all private medical practitioners advertising with a signboard within the 25 km2 of the study area were mapped and listed (n = 479). 289 met the operational definition of a private medical practitioner, and of these, 215 practitioners agreed to respond to the survey on management practices based on a recall period of 1 year from the time of data collection.
8The practitioners were approached by visits to their clinics (a maximum of three visits to the clinics at different times of the day) and a telephone call, if listed in the public directory.
9Marathi is the local language spoken in the state of Maharashtra.
10In the larger survey, 72% of the private practitioners studied were male (n = 154/215) and non-allopathic practitioners comprised 57% of the total population (122/215).
11The practitioner is trained in allopathy and has been practicing for the last 15 years with an average daily patient load of 50.
12The majority of the cases narrated by the practitioners were male, HIV-positive patients.
13A leading government teaching hospital in Pune.
14The family in India continues to be a source of strength and support for most people, especially during sickness and death (Sinha 1988), despite the weakening of familistic orientations and sentiment (Ramu 1988) and growing individuation.
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