HIV Attitudes and Practices
Among Professors in a Brazilian Dental School
Ana V. Pagliari, D.S.; Cléa A.S. Garbin, Ph.D.; Artênio J.I.
HIV, dentistry, professional ethics, dental education,
prejudice, dentist-patient relations
Submitted for publication 03/25/04;
Although there is considerable published research on Acquired
Immunodeficiency Syndrome (AIDS), individual biases
persist because of lack of information regarding HIV
virus transmission. As a result, both infected
patients and health care professionals suffer. The
objective of this study was to determine if there is
prejudice among university professors at the School of Dentistry
at Araçatuba’s São Paulo State University (FOA-UNESP)
concerning HIV-positive patients or HIV-positive
health care professionals. Out of the seventy-seven professors
who responded to the questionnaire, 62.3 percent
(forty-eight) stated that they advise their students
not to refuse to treat a patient with HIV. Although
96.2 percent (fifty-two) of the fifty-four professors
who treat patients have reported that they treat
patients who are HIV-positive, only 65.3 percent of
them were aware of infection control precautions, and only
32.7 percent reported that they would treat an
HIV-positive patient like any other patient. There is
also prejudice regarding HIV-positive professionals
because only 48.1 percent (thirty-seven) of the
professors responded that they would be willing to be
treated by an infected professional. It can be concluded that
there is prejudice among some of the FOA-UNESP university
professors regarding individuals who are
of Acquired Immunodeficiency Syndrome (AIDS) epidemics
in the 1980s generated discrimination and prejudice
towards HIV-infected individuals1
and increased the concern among health professionals
about the danger of transmission of infectious agents
from their patients.2
Ignorance of the risk of HIV transmission during
dental procedures led many dentists to refuse to treat
HIV-positive individuals. In addition, infected dental
professionals have sometimes been prevented from
There are reports of
dentists refusing to treat HIV-positive patients.3–7
verified that 74 percent of the dentists interviewed
by him in California preferred to direct HIV-positive
individuals to specialized centers, despite 70
percent of them believed they had a responsibility to treat
these patients. Increased knowledge of issues concerning
HIV has led to dental professionals’ increased
willingness to treat HIV-positive patients.2,8,9
The survey carried out by Solomon et al.10
in the United States revealed that 62 percent of the
undergraduates were willing to treat HIV-positive patients.
In Brazil, Garbin et al.9
reported that 91 percent of the undergraduates were
willing to treat HIV-positive patients, although 43 percent
answered that they did not believe that infection control
procedures are sufficient to avoid the transmission
of the HIV virus. However, if proper barrier
precautions are followed, the risk to contract the
virus as a result of occupational exposure is very low.2 According to the Centers for Disease Control and
Prevention (CDC) of the U.S. Public Health Service,11
HIV transmission risk for health care professionals
after percutaneous exposure to HIV-contaminated blood
was estimated to be between 0.2 and 0.5 percent and
following exposure to mucous to be approximately 0.1
percent. In contrast, for HBV virus, the transmission risk
after accidental exposure is between 6 and 30 percent. In
1992, Ciesielski et al.12
reported HIV transmission by a Florida dentist to his
patients during invasive procedures. It contributed to
increased discrimination against HIV-positive health care
According to the Brazilian
Code of Dentistry Ethics,13
Article 6, IV,
"There is an ethical infringement if a patient is abandoned,
except for a justifiable reason." However, specific
legislation has not yet been enacted to provide
treatment for an HIV-positive patient or for an
HIV-positive health care professional’s right to keep
on practicing dentistry in Brazil.14
The U.S. judicial system usually tends to defend the
infected patient’s right to treatment because it
realizes that infection control precautions can
protect workers against infection.15,16
As for HIV-positive professionals, in 2001, the U.S.
Court of Appeals for the 11th Circuit
ruled that an infected hygienist represented a
"direct threat" to patients and colleagues, individuals who
may not be able to protect themselves,15
and authorized his employer to prohibit him from
providing dental hygiene services. Although other
courts of appeals may not follow this decision, it
has the potential to affect many health care workers.
Ministry of Health17
asserts that health care professionals must be able
to treat contagious disease-carrying individuals. As
for infected dental surgeons, "they can practice
dentistry, with no danger to their own health or that of their
patients, as long as they employ infection control rules
and procedures recommended by the Ministry of
Health." The purpose of this research was to evaluate
whether there is prejudice among university
professors in a dental school regarding treatment of
HIV-positive patients and how they felt about HIV-positive
health care professionals practicing dentistry.
According to Discacciati and Pordeus,2
one of the ways to assess a dentist’s "willingness
index" to treat HIV-positive patients is to obtain
pertinent information from the professionals
themselves. In this study, dental professors at Araçatuba’s
São Paulo State University (FOA-UNESP) responded to a
written multiple choice survey (Appendix 1) on dental
treatment for HIV-positive patients and infected
professionals’ dental practice.
After the questionnaire was
approved by FOA-UNESP’s Ethics Committee, it was
tested with six postgraduate students of the
FOA-UNESP’s Preventive and Social Dentistry postgraduate
program for validation. After the appropriate
modifications, the questionnaire was sent to all
professors in the dental school. The results were
processed and analyzed with the aid of the Epi-Info
Program, version 6.04.
During this study, there were eighty-two professors at
Araçatuba’s São Paulo State University, School of
Dentistry. Seventy-nine professors consented to
participate in the study. The responses to the
questionnaire from two individuals were considered invalid
because they chose more than one alternative on questions
5, 6, and 7 when just one answer was allowed. This
resulted in a final total of seventy-seven responses
(93.9 percent of the professors).
Twenty-six (33.8 percent) of
the professors were female. Six (7.8 percent) had
graduated from dental school less than ten years ago,
thirty-eight (49.4 percent) between ten and twenty
years ago, and thirty-three (42.9 percent) over twenty years
Fifty-four (70.1 percent) of
the professors treated patients at the faculty clinic
or at private clinics, whereas twenty-three (29.9
percent) did not have a clinical practice. In the questionnaire,
the latter obviously did not respond to the questions
related to clinical practice.
Of the seventy-seven
professors interviewed, 62.3 percent (forty-eight)
stated that they advise their students not to refuse any type
of service for HIV-positive patients and 26 percent
(twenty) reported that they advise their students not
to refuse emergency service, but to refer patients to
another professional in case of nonemergency
treatment (Figure 1).
Eight (10.4 percent) of the professors were of the
opinion that they teach that treatment must be
carried out only if the professional feels able to do
it and if the working conditions are favorable. No professor
stated advising students not to treat HIV-positive
Figure 1. Percentage distribution of the professors’
responses related to guidelines given to students
It was not possible to confirm if gender or time of graduation
affected the responses in a significant way. It is only
possible to report that 57.7 percent of the female
professors and 66.7 percent of the male professors
said that they teach their students not to refuse to
treat HIV-positive patients and that 26.9 percent of
the female professionals and 25.5 percent of the male
professionals teach their students not to refuse
urgent treatment. As for the time of graduation,
among professors who graduated ten years ago, between
ten and twenty years ago, and more than twenty years
ago, 57.1 percent, 64.1 percent, and 64.5 percent respectively
answered that they taught their students not to refuse to
treat HIV-positive patients; 14.4 percent, 25.6
percent, and 29 percent taught their students not to
refuse urgent treatment only.
When asked if they would be
willing to be treated by an HIV-positive health care
professional, 48.1 percent (thirty-seven) of the
seventy-seven professors answered that they would accept any
appropriate treatment, and 38.9 percent (thirty) replied
that they would accept only non-invasive treatments
Out of the 13 percent (ten) that would not accept any
kind of treatment provided by an HIV-positive
professional, 50 percent (five) asserted that the
fear of being contaminated was the reason for their
decision; 30 percent (three) gave reasons such as
"precaution," "fear of being one more way to spread the virus,"
and "possibility of accidents during procedures"—all of
which suggest a "fear of contamination." Ten percent (one)
pointed to contamination scare and fear of losing
clients, and 10 percent (one) alleged contamination
scare and fear of prejudice.
Figure 2. Percentage distribution of professors that
would accept to be treated by HIV-positive health care
shows that, of the fifty-four professors providing
clinical service, 54.7 percent (twenty-nine) reported that they
treat HIV-positive patients after taking proper infection
control precautions; 32.1 percent (seventeen) stated
that they treat HIV-positive patients like any other
patient; 9.4 percent (five) said that they attend to
these patients on a special schedule; and 3.8 percent
(two) answered that they do not treat HIV-positive
patients and refer them to an appropriate clinic.
Figure 3. Percentage distribution of the professors’
willingness to treat HIV-positive patients
If the professors found out they themselves were infected by
the HIV virus, 50.9 percent (twenty-seven) of the
clinicians said they would normally continue their
didactic and clinical activities; 28.3 percent
(fifteen) said they would continue with didactic and
clinical activities, except for invasive procedures;
18.9 percent (ten) would give up their clinical activities;
and 1.9 percent (one) did not know what they would do.
Likewise, if they found out
they were HIV-positive, 54.7 percent (twenty-nine) of
the clinicians said they would inform their patients
about it; 43.4 percent (twenty-three) said they would
not inform their patients; and 1.9 percent (one) did not know
what they would do (Figure 4).
Among those professors who would continue their
didactic and clinical activities, 54.8 percent said
they would inform their patients about their HIV status,
and 45.2 percent would not. Of the professors who answered
that they would stop doing only invasive procedures,
60 percent would inform their patients of their HIV
status, and 40 percent would not. Among the
professors who would not inform others about their
HIV status, 69.5 percent (sixteen) would be worried about
patients’, students’, and coworkers’ bias, and
30.5 percent (seven) for other reasons such as "there is
no need to make the fact known," "irrelevant," and "it
does not interfere with treatment."
Figure 4. Percentage frequency of the clinicians who
would inform their patients in case they contracted HIV
Although there is considerable research on AIDS, uncertainty
towards HIV-positive patients and refusal to treat these
patients still persists along with the fear and
possibility that an HIV-positive professional might
be prevented from practicing dentistry.3,4,6–8 Increased knowledge of issues concerning HIV has led to
increased willingness by dentists to treat
HIV-positive patients.2,8,9 In this regard, the responsibility of health care
professionals is high and even higher for university
professors in the area of health care because they
are responsible for educating their students and
When we consider that
prejudice is "the opinion or preconceived feeling
without sufficient knowledge" and that discrimination
means "distinguishing, separating, mistreating someone,"18
it is interesting that, among the fifty-two FOA-UNESP
professors who reported treating HIV-positive
patients, 55.7 percent responded that they treat
their patients after taking appropriate infection
control precautions, and 9.6 percent had a special appointment
schedule because they needed time to carefully prepare the
dental office. Only 32.7 percent of the FOA-UNESP
professors reported that they treat HIV-positive
patients like any other patient.
Brazil’s Ministry of Health
asserts that all patients should be treated with the
same infection control procedures that should be
routinely applied in every dental treatment (sterilized
instruments, noncontaminated operative field,
professionals wearing gloves, masks, caps, glasses),17,19,20
especially because some HIV-positive individuals do
not inform their health care professional about their
serological condition for fear of being refused
This refusal is often rationalized by technical
arguments such as lack of specialty training or by charging
Our results show that 10.4 percent of the professors
reported that they advise their students to treat HIV-positive
patients as long as they feel they are competent to do so,
by taking appropriate infection control precautions
and making sure that the operatory is adequately
prepared for treatment.
According to Smith and
Pinheiro, it is not a justifiable reason to refuse to
treat an HIV-positive patient because of lack of
specialty training or lack of appropriate equipment because
it is the professional’s responsibility to stay abreast
of advances in his or her field in order to treat all
patients.21,22 However, according to the Brazilian Code of Dentistry
Ethics, professionals have the right to refuse to
work in a public or private office that is lacking in
healthy working conditions.23 As dentists have the obligation to provide safe treatment
for all patients, including HIV-positive individuals,
the decision to treat or not treat a patient whose
general status can be fragile depends on good
judgment and prudence.
In this study, the
professors also exhibited preconceived ideas
regarding HIV-positive health care professionals because when
asked if they would be willing to be treated by an
HIV-positive professional, only 48.7 percent
(thirty-seven) of the professors responded that they
would accept treatment, whereas 38.9 percent (thirty)
responded that they would not be willing to be treated
by an HIV-positive professional. After analyzing their
responses, it was apparent that all the professors
who would not be willing to be treated by an
HIV-positive professional were afraid of becoming
infected because of "contamination."
Similarly, if the
professionals found out they were themselves infected
by the virus, 43.4 percent (twenty-three) responded
that they would not inform their patients about it. Of these
professionals, 69.5 percent (sixteen) said that they would
be worried about their patients’, students’, and
coworkers’ biases. When it comes to informing others
about their serological condition, dental surgeons
behave like any other person: they are afraid of
prejudice, judgment, and discrimination.20
As such, there is no legal obligation for
HIV-positive dental health professionals to inform
others about their serological status.24 Nevertheless, these professionals must strictly employ
infection control procedures.17
Therefore, although they report that they teach their
students not to act in a discriminatory manner towards
HIV-positive patients, the professors themselves exhibited
prejudice towards infected patients and
professionals. Consequently, this topic must be
further explored and debated in the academic milieu.
In conclusion, while a few FOA-UNESP university professors were
not willing to treat HIV-positive patients, most of them
expressed the need for special infection control
precautions, and a few professors asserted that they
would treat HIV-positive patients like any other
patient. Prejudice towards infected health care
professionals was also evident among the professors who
responded to the questionnaire because some of them
would not be willing to be treated by an HIV-positive
professional and several professors said that they
would be willing to be treated only if treatment did
not involve invasive procedures.
The concern regarding a
misinformed society’s prejudice appears to be still
high among health care professionals because
participants in this study said they would not be willing to
inform their patients about their serological status if
they found out they were infected because they were
concerned about colleagues’, patients’, and students’
biases. Therefore, it is evident that there is a need
for better dissemination of knowledge regarding HIV
transmission in the academic milieu as well as in the
UNESP, São Paulo State University, Dentistry School,
Campus at Araçatuba
Preventive and Social
Dentistry Postgraduate Program Area of Bioethics
Dear Professor, please
answer the following questions:
1. Gender: A ( ) male B ( )
2. Time of graduation: A ( )
less than 10 years ago.
B ( ) between 10 and 20
years ago. C ( ) more than 20 years ago.
3. Graduation: ( ) Dentistry
( ) others:____________________
Answer the questions
below even if you are not graduated from Dentistry
4. What is your professional
occupation? (more than one answer possible)
a) ( ) professor of
theoretical subject matters
b) ( ) professor in
c) ( ) professor in
d) ( ) dental clinic/office
5. What kind of orientation
do you give your students related to treating
a) ( ) They must not refuse
to provide any kind of treatment to HIV-positive
b) ( ) They must not refuse
to provide urgent treatment to HIV-positive patients,
but they can direct them to another clinic if treatment
is not urgent.
c) ( ) They can refuse to
provide any kind of treatment to HIV-positive
d) ( ) Another
6. Would you accept to
receive health treatment (dental, medical, nursing
care) if you knew that the professional responsible
for your treatment is infected by the HIV virus?
a) ( ) Yes, I would accept
any kind of treatment.
b) ( ) Yes, I would, except
for invasive treatment.
c) ( ) Yes, I would, but
only for an appointment.
d) ( ) No.
In case of negative answer,
why? (more than one answer possible)
a) ( ) fear of contamination
b) ( ) fear of losing your
own clients, in case they get to know about it.
c) ( ) fear of prejudice
from workmates, students, or family members in case
they get to know about the situation.
d) ( ) another
7. Would you allow any
family member (e.g., child, father) to be treated by
an HIV-positive professional?
a) ( ) Yes, for any kind of
b) ( ) Yes, I would, but
except for invasive procedure.
c) ( ) Yes, I would, but
just in case of appointment.
d) ( ) No, I would not.
Answer the questions
below in case you carry out clinical activities,
having direct contact with patients, at the dental office and/or
8. What is your criterion to
treat HIV-positive patients?
a) ( ) I treat them by
taking proper infection control steps.
b) ( ) I treat them like any
c) ( ) I do not treat them,
I prefer to direct them to a specialized service.
d) ( ) I treat them with a
special appointment schedule. Why?
9. If you found out you were
infected by HIV, would you keep on carrying out your
a) ( ) Yes, I would keep on
carrying out my didactic and clinical activities as
b) ( ) Yes, I would keep on
carrying out my didactic and clinical activities,
except for procedures with bleeding.
c) ( ) I would keep on
carrying out my didactic activities, but I would give
up my clinical activities.
d) ( ) I would give up
carrying out my didactic and clinical activities.
10. In case you found out
you were infected by HIV, would you tell your
patients about it?
( ) Yes, I would.
( ) No, I would not.
If your answer is negative,
why? (it is possible to check more than one answer)
a) ( ) worried about
prejudice from patients.
b) ( ) worried about
prejudice from workmates and students.
c) ( ) worried about
possibility of losing clients.
d) ( ) another reason
The authors would like to thank the professors of the School
of Dentistry at Araçatuba’s São Paulo State
University (FOA-UNESP) who kindly agreed to participate in this
Dr. Pagliari is a Postgraduate Student, Preventive and Social
Dentistry Postgraduate Program; Dr. Cléa Garbin is
Assistant Professor, Preventive and Social Dentistry
Postgraduate Program; and Dr. Artênio Garbin is
Assistant Professor, Children and Social Dentistry
Department—all at São Paulo State University-UNESP.
Direct correspondence and requests for reprints to
Dr. Cléa Adas Saliba Garbin, R. José Bonifácio, 1193
Vila Mendonça, Araçatuba-SP, Brazil 16015-150;
18-3636-3249 phone; 18-3636-3332 fax;
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