HSC 350 Principles of Health Care

Alyssa Peterson, Jordan Torgrude, Tony Lund, Shelby Dockter and Waseem Alturkistani

Department of Health Sciences, University of South Dakota

HSC 350: Principles of Healthcare

Professor Becky Wolff

July 26, 2020

Introduction

Human Immunodeficiency Virus (HIV) is a virus that weakens the body’s immune system by inhibiting cells that fight disease and infection. If not treated can lead to Acquired Immunodeficiency Syndrome (AIDS) which is the final, often fatal, stages of the HIV virus. The HIV virus is transmitted through the transfer of bodily fluids such as blood, breastmilk, vaginal and anal fluids, and semen (HIV Transmission, 2020). There is currently no cure for the virus but with an effective medicinal treatment called Antiretroviral Therapy (ART), the virus can be managed, the risk of transmitting the disease decreases dramatically with a low viral load, and the patient has the ability to live a high-quality life (Davari, Giwa, Nabizade, Taheri & Giwa, 2020).

This case study will discuss the ethical considerations that arise with a new diagnosis of HIV. There is a great deal of stigma regarding the HIV virus such as believing that only certain groups of people can contract the disease or thinking that people deserve to contract the virus based on their lifestyle choices and lack of moral judgment. Discrimination against those with the HIV virus occurs daily and has a huge impact on the emotional and physical well-being of these individuals. The case study will include a narrative of the case study, it will elaborate on all the case problems, and also outline possible outcomes and/or solutions that arise.

Overview/Narrative

This case study takes place on January 13, 2020, in Vermillion, SD. The patient in this case is a 23-year-old male who will be referred to as John Doe in order to maintain his confidentiality. John Doe was a college student looking to earn extra cash and also help others by donating plasma at Biomat USA in Vermillion, SD. He had heard of other students donating and he figured it would be worth his time. He was a little nervous that he had never donated before, but he did a little research to educate himself regarding the process and what to expect to ease his uneasiness.

On the morning of January 13, John had an appointment to donate plasma for the first time. He arrived on time and the staff seemed friendly during the check-in process. He even recognized a few of his fellow classmates working at the donation center. Prior to donating, a two-step medical screening must be passed by the donor. The first step is a comprehensive medical history and then the second includes a blood test that evaluates for transmittable diseases such as hepatitis and HIV and also checks hemoglobin and protein levels. John completed both steps and patiently waited for the results to come back so he could donate.

After waiting for what seemed to be a lengthy period of time, John was brought into a private room where two individuals were waiting. The man introduced himself as Dr. Green and the young woman stated she was a medical assistant named Amanda. John recognized Amanda from one of his classes but had never formally met her. Dr. Green apologized for the circumstances that led to their meeting and informed John that he tested positive for HIV. All at once, John’s heart sank, he became nauseous and flushed in the face. He stated that there must be some mix-up or mistake but Dr. Green assured him there was not. John did not remember much about the rest of their conversation other than that he needed to notify anyone who he may have had sexual relations with and that Dr. Green was required to notify the state government about the positive results of John’s test. John walked out of the office as quickly as he could. Many thoughts intruded on his mind such as how could this have happened to me, who gave me this, what will my family and friends think, and what in the world do I do. The thought of having to tell another person of his positive diagnosis was gut-wrenching.

Back at the Biomat office, Amanda returned to her desk reflecting on what just happened. She couldn’t believe that someone her age, let alone one of her classmates could have tested positive for HIV. She knew John as being well-liked with many friends. He seemed like a decent guy but maybe he had some undesirable qualities and obviously made some poor life choices. She simply couldn’t keep the secret and eventually told one of her friends who also worked at the donation center of John’s diagnosis. As they were conversing in a not so private area, Dr. Green happened to walk by and hear enough of their conversation to know what they were talking about John’s recent diagnosis. Soon after, Dr. Green called Amanda into his office to discuss what he had just heard and to confirm the context of the conversation she had just had with her friend. Amanda reluctantly admitted to Dr. Green that she committed a HIPPA violation and compromised patient confidentiality.

Case Problems

A case scenario of HIV testing is in South Africa. Due to high rates of HIV/AIDS, it appears good to conduct a universal test. However, this would be a violation of human rights. HIV tests should be done at one's will. People should be enlightened and given a choice of when they would be ready for the test. Forcing people could create denial and low self-esteem among other mental health problems.

A case scenario for stigmatization is when discrimination occurs due to one’s HIV status. June who has just discovered her HIV status faces discrimination at work. No one wants to be associated with her or share work equipment. Since her company wants to maintain the status, they have to terminate her contract. They do not cite incompetence as the reason for termination.

A case Scenario for transmission and prevention is about a young man Marcus. He has no idea about the risk of infection after kissing. He is cautious about having unprotected sexual intercourse and is worried about his HIV status. He needs clarity on the risks he is exposed to. He needs to be furnished with information so that he can become cautious in the future.

When it comes to confidentiality, physicians should be cautious about who they speak to. In a case where Victor, who just had his HIV results out, the physician is not sure whether to break the news in front of his family. Though they suspect he could be infected, they are curious about the results. The physician passes the test results to Victor who must decide whether he wants to disclose his status to the family. However, he decides to keep the results to himself.

Outcomes/Solutions

When AIDS first began to emerge in the 1980s, the disease was surrounded with fear, misunderstanding, and stigmas. Patients diagnosed with AIDS were given little treatment options and bleak prognosis. They faced discrimination at workplaces and from society as a whole. Fast-forward to now, HIV treatment has transformed the previously fatal disease to a manageable chronic illness (Szent-Gyorgyi et al., 2012). What Amanda did is a major violation of HIPPA, or the Health Insurance Portability and Accountability Act. According to HHS.gov, this act required the Secretary of the U.S. Department of Health and Human Services to develop regulations protecting the privacy and security of certain health information.

In this case, Amanda allowed a breach to occur. A breach is an impermissible use or disclosure of protected health information. It is presumed there has been a breach unless the covered entity or business associate can demonstrate that there is probability that the protected health information has been leaked based on the following factors: The nature and extent of the protected health information involved, including the types identifiers and the likelihood of re-identification. The unauthorized person who used the protected health information or to whom the disclosure was made. Whether the protected health information was actually acquired or viewed. The extent to which the risk to the protected health information has been mitigated (Secretary, 2013).

For this situation, the covered entities must provide notification of the breach to affected individuals, who could be John Doe. In addition to notifying individuals, covered entities must notify the Secretary of breaches (“Health Information Privacy”, 2019). At this point, the situation is covered on a case by case basis. Some providers choose to implement new training strategies and policies. It could also include termination of Amanda, something that could follow her into her career. It is not an option to not report this situation as it is a major breach of private health information.

References

Davari, M., Giwa, H., Nabizade, A., Taheri, F., & Giwa, A. (2020). Antiretroviral therapy and the risk of sexual transmission of HIV: a systematic review and meta‐analysis. HIV Medicine, 21(6), 349-357. doi: 10.1111/hiv.12841

HIV Transmission. (2020). Centers for Disease Control and Prevention. Retrieved July 20, 2020 from https://www.cdc.gov/hiv/basics/transmission.html

Hlongwa, P. (2016). Current ethical issues in HIV/AIDS research and HIV/AIDS care, (22), (51). Retrieved from https://onlinelibrary.wiley.com/doi/full/10.1111/odi.12391

Health Information Privacy. (2019, January 04). Retrieved July 16, 2020, from https://www.hhs.gov/hipaa/index.html

Szent-Gyorgyi, L. E., Desai, S., Kim, D., Sax, P. E., & Greenberg, J. O. (2012). Removing legal barriers to high-quality care for HIV-infected patients. The New England Journal of Medicine, 366(14), 1268–1270. https://doi- org.usd.idm.oclc.org/10.1056/NEJMp1114446

Secretary, H., & (OCR), O. (2013, July 26). Breach Notification Rule. Retrieved July 24, 2020, from https://www.hhs.gov/hipaa/for-professionals/breach-notification/index.html

Case Study Script:

Committee Members:

• Chairman:Alyssa Peterson

  • Reads Case Study

• Committee Member 2: Jordan Torgrude

  • Stigmatization with HIV

• Committee Member 3: Anthony Lund

  • HIPAA regulations

• Committee Member 4: Waseem Alturkistani

  • Will be recording meeting on Zoom

  • Transmission and prevention

• Committee Member 5:Shelby Docktor

  • Universal testing & patient rights with HIV

Alyssa: Welcome everyone! My name is Alyssa Peterson and I am the committee chairman for Biomat USA. Biomat USA is a plasma donation center located in Vermillion, SD. I have been with the company for almost 10 years now. Today we will be discussing a case study that occurred at the plasma donation center on January 13, 2020. Each committee member will discuss an ethical issue regarding HIV/AIDS. To begin, each committee member will introduce themselves and state what ethical issue they will be discussing.

Jordan: Hello. Thank you for having me. My name is Jordan Torgrude and I have been with the committee for five years. I am happy to be a part of today's meeting and having the opportunity to speak on such an important topic. Later today I will be discussing the stigmatization revolving around those individuals with HIV/AIDS and the importance of addressing it.

Shelby: Hello everyone, my name is Shelby Dockter. Thank you for having me today, it is a privilege to be here and be discussing this issue with you all. Today, I will be discussing universal testing and treatment of HIV.

Tony: Hello, my name is Tony Lund and I will be discussing the HIPAA violation that occurred and what the possible penalties and outcomes are pending a further investigation into the neglectful release of private information.

Waseem: Hello, my name is Waseem Alturkistani and later I will be discussing transmission and prevention around those individuals with HIV.

Alyssa: Now that all the committee members have been introduced, I will now explain the case study that occurred at our facility. The patient in this case is a 23-year-old male who will be referred to as John Doe in order to maintain his confidentiality. John Doe was a college student looking to earn extra cash and also help others by donating plasma at Biomat USA in Vermillion, SD. He had heard of other students donating and he figured it would be worth his time. He was a little nervous that he had never donated before, but he did a little research to educate himself regarding the process and had a general idea of what to expect.

On the morning of January 13, John had an appointment to donate plasma for the first time. He arrived on time and the staff seemed friendly during the check-in process. He even recognized a few of his fellow classmates working at the donation center. Prior to donating, a two-step medical screening must be passed by the donor. The first step includes a comprehensive medical history. The second step includes a blood test that evaluates for transmittable diseases such as hepatitis and HIV and also checks hemoglobin and protein levels. John completed both steps and patiently waited for the results to come back so he could donate.

Upon completion of both, John Doe’s blood work came back positive for HIV. It was then our duty to inform John of his positive test results. It is also required for our facility to inform the local and state government of the positive test result so they can accurately track the prevalence of positive cases. This is also required to hold the patient legally accountable if an issue were to arise in the future where an individual failed to inform others and can be held legally accountable for failure to inform.

After waiting for what seemed to be a lengthy period of time, John was brought into a private room where two individuals were waiting. The man introduced himself as Dr. Green and the young woman stated she was a medical assistant named Amanda. John recognized Amanda from one of his classes but had never formally met her. Dr. Green apologized for the circumstances that led to their meeting and informed John that he tested positive for HIV. All at once, John’s heart sank and he felt sick to his stomach. He was in disbelief and stated that there must be some mix-up or mistake but Dr. Green assured him there was not. John did not remember much about the rest of their conversation other than that he needed to notify anyone who he may have had sexual relations with and that he would need to seek further medical treatment. John walked out of the office as quickly as he could. Many thoughts came to mind such as how could this have happened to me, who gave me this and what will my family and friends think. The thought of having to tell another person of his positive diagnosis made him feel ashamed.

The medical assistant Amanda returned to her desk reflecting on what just happened. She couldn’t believe that someone her age, let alone one of her classmates could have tested positive for HIV. She knew John as being well-liked with many friends. He seemed like a decent guy but maybe he had some undesirable qualities and to her obviously made some poor life choices. She simply couldn’t keep the secret and eventually told one of her friends who also worked at the donation center of John’s diagnosis. As they were conversing in a not so private area, Dr. Green happened to walk by and hear enough of their conversation to know what they were talking about John’s recent diagnosis. Soon after, Dr. Green called Amanda into his office to discuss what he had just heard and to confirm the context of the conversation. Amanda reluctantly admitted to Dr. Green that she committed a HIPPA violation and compromised patient confidentiality.

A HIPPA violation has serious repercussions. Dr. Green informed the committee chairman after his conversation with Amanda about the HIPPA violation that occurred. In addition to notifying the individuals affected, Biomat USA will need to deal with the legal repercussions of a HIPPA violation that will later be explained. John’s right to patient confidentiality was breached and now he has to navigate the difficult task of dealing with a new HIV diagnosis. With a HIV diagnosis comes a great deal of discrimination and stigma. A HIV diagnosis can be both physically and emotionally demanding and with no cure for HIV, John will now be dealing with this for the rest of his life.

Jordan: Human Immunodeficiency Virus or more commonly known as, HIV, is a virus that weakens the body’s immune system by destroying cells that fight disease and infection. If not treated can lead to Acquired Immunodeficiency Syndrome, or AIDS, which is the final, often fatal, stages of the HIV virus. Many have seen, or read about what HIV can do for one's health. According to the World Health Organization, it is estimated that globally 36.7 million people were living with HIV in 2015. Within that number, 1.8 million are children living with it. These are people's siblings, spouses, friends, family, coworks. These are people everywhere.

Unfortunately, for so many of these people, there are negative ideas and stigmas that follow this disease. It is common for individuals to avoid those who have it, and even to some extent look down upon those. Many believe that people with HIV must have done drugs at one point, and got it from a needle in the past. Or even that they perform in specific sexual behaviors that resulted in the diagnosis. Some will even think that the person with HIV is irresponsible or at fault for having it. Assuming that they do this provides a discrimination factor to be placed on them, just because of their HIV status. This negative stigma largely impacts major groups within our society, such as gay men, drug addicts and the homeless. Not only are people having this stigma towards those with HIV, but many who are diagnosed with HIV also have a negative stigma towards themselves and often feel down and upset. With this negative stigma placed on themselves, many of them do not seek help from medical professionals or they even will avoid telling their sexual partners of their HIV status.

Thinking about the Case study our chairman spoke of, it is important to consider the stigmatism that the employee, Amanda, had when finding our John Doe had HIV. It is important to help protect John Doe, and many like him. The committee, community, and medical providers, should be helping break the stigmatism. Understanding HIV/AIDS and how one can contract, in a multitude of different ways, how to address the fears of those with it and protecting those with HIV with challenging those who discriminate or hurt those diagnosed. This can all help broaden the understanding of this disease. By working towards recognizing those negative stigmas within our own health care facility, it will help patients and people see what we are capable of, and helping mitigate any chance of discrimination towards someone just based on their perceived or possibly real HIV status.

Shelby: Thank you so much Jordan. Jordan introduced what HIV/AIDS is and I will be discussing treatment options and testing for HIV. While there is no cure available, there are ways in which a person with HIV can improve their health. One of the main ways to improve the health outcomes of people with HIV is to use antiretroviral treatment, otherwise known as ART. ART is a mixture of antiviral drugs that allows people with HIV to live longer lives and prevents new HIV infections. Without ART very few people infected can survive beyond ten years. Expanding ART is expected to help with the incidence rate of HIV infection, with the goal of ending the AIDS epidemic by 2030. However, ART coverage is often skewed due to other factors such as sexual networks or transmission from acutely infected people. This means that the feasibility of meeting this ambitious goal is unknown. Nonetheless, HIV/AIDS have improved dramatically since the 90s. What was once a grim prognosis has transformed into a manageable chronic disease. The future only holds positive things for those who are diagnosed with HIV, with hope that one day it will be eradicated.

Patients obviously have autonomy and are able to make decisions about their health, so unconsented universal testing is not feasible due to its unethical nature. However, physicians should support routine, universal testing. They should also make efforts to persuade reluctant patients to be screened and explain the potential benefits. Physicians should also safeguard patient information to the greatest possible extent to ensure that situations like that one that we are discussing can be avoided.

In regards to the case study, John Doe now has to receive appropriate follow-up care and counseling. His medical providers now also have to adhere to state and local guidelines regarding public health reporting and disclosure of HIV status. In this situation, his medical information was breached and the situation should be handled appropriately. The committee should continue to do research on HIV testing in our community and how it can be improved, as well as programs and initiatives to increase screening to protect vulnerable populations.

Tony: For this situation, a breach in confidential patient information was leaked and this is a violation of the Health Insurance Portability & Accountability Act. This act is to ensure that John Doe’s private information stays between those involved in his care. This includes his physician, nurse, and other essential members who manage his information.

When Amanda decided to tell someone outside of his circle of care, she broke that bond of trust. Now we do not know, nor will we likely ever know, who all this person that Amanda told will tell. John will have to live his life in fear because of the stigma that HIV has amongst people who are not educated about it, let alone having to deal with this heart-breaking diagnosis that was given to him.

According to HIPAA, this breach constitutes a Tier 3 violation because of the willful neglect of HIPAA Rules. If Dr. Green had not overheard Amanda’s conversation and confronted her about it, this would have been a Tier 4 violation. Dr. Green was aware of the situation and reached out to John to inform him of the breach. Dr. Green has met the requirement of notifying John without unreasonable delay with the given 60-day time limit. The Department of Health and Human Services’ Office for Civil Rights (OCR) sets the minimum fine at $10,000 to a maximum of $50,000 per violation. As required by law, Biomat USA will be responsible for payment of this fine. Biomat USA has the option of retaining the services of Amanda and issuing remedial HIPAA training or releasing her from employment with them.

If John wishes to pursue criminal penalties against Amanda for the unauthorized release of his private information, he may do so by contacting the South Dakota State Attorney General’s Office and filing a complaint. Due to the nature of the HIPAA violation and the severity, the case will be prosecuted by the Department of Justice. Although Amanda may have not used this information for personal gain or malicious intent, she still gave out protected private information without any authorization from John, this is a Tier 3 Criminal violation that allows a fine to be set by the judge based on the fact of the case and a maximum of 10 years in jail.

These are serious matters that Amanda is now facing. Once all of the legal actions are completed, she will still have this blemish on reputation that will be near impossible to erase.

Dr. Green could have been deemed to be criminally liable for violations of HIPAA Rules under the principle of corporate criminal liability, and if not directly liable, could be charged with aiding and abetting or conspiracy if he had known and elected to try to help keep Amanda’s neglectful act a secret and pretend that he didn’t know.

Waseem: There are misconceptions associated with HIV whereby people are afraid of associating with them. They think they can contract HIV by sharing items or living in the same family. HIV is transmitted through sexual intercourse, contact with contaminated blood, blood products, tissues and organs, contaminated needles and sharp objects and mother to child. Such contact with infected persons leads to contracting the virus. HIV transmission can be prevented by avoiding sexual contact with infected persons and avoiding contact with sharp objects that can prick the body leading to exchange of fluids.

I'm going to share a case Scenario for transmission and prevention is about a young man named Marcus. He has no idea about the risk of infection after kissing. He is cautious about having unprotected sexual intercourse and is worried about his HIV status. He needs clarity on the risks he is exposed to. He needs to be furnished with information so that he can become cautious in the future.

The committee should look into such issues. There should be adequate information on transmission and prevention. Though no treatment has been discovered, HIV patients should use antiviral drugs to curb the infection. Healthy living should be encouraged to help boost immunity.

Alyssa (Conclusion): To summarize, John, a young man was recently diagnosed with HIV and his right to patient confidentiality was breached. As we have discussed, there are many ethical dilemmas that arise with a positive HIV status. Education is key to helping these individuals effectively manage their disease and prevent transmission to others. Having a better understanding of how the disease is transmitted may reduce the number of new cases and encourage individuals to utilize prevention methods.

Education provided to the community will help reduce the stigma and discrimination that occurs within this patient population. Knowing that it can happen to anyone and is not limited to IV drug users or gay men, may reduce the stigma associated with HIV. Antiretroviral therapy (ART), has proven to be an effective treatment for HIV. By drastically reducing the patient’s viral load, it decreases their chance of transmission to others. If their viral load is below a certain point their risk of transmitting the virus is extremely low. While some cases prove to be more difficult to manage than others, many people have success with ART and are able to live a high quality of life. I hope this case study provides insight regarding HIV and a patients legal right to patient confidentiality. Thank you all for participating in this meeting today.