Aleksandar (name changed), from North Macedonia, who is living with HIV and has an undetectable viral load due to antiretroviral therapy (ART), was referred to a gastroenterohepatology clinic because of long-standing gastritis problems.
During the initial consultation, the gastroenterologist took Aleksandar’s medical history and determined that a colonoscopy was necessary to investigate his gastritis issues further. However, when Aleksandar informed the doctor about his ART regimen and undetectable viral load, the doctor reconsidered and decided to prescribe oral medication instead. The doctor suggested that it would be better to attempt to resolve the problem with tablets first. He advised Aleksandar that if the tablet therapy did not help within a month, then a colonoscopy would be required. The doctor pointed out that a colonoscopy could not be performed at their clinic because of Aleksandar’s HIV status. Instead, he recommended that the procedure should be done at the Infectious Disease Clinic, citing that such interventions had been performed there in the past.
After a month of tablet therapy, Aleksandar’s symptoms persisted. He was informed that the Infectious Disease Clinic no longer performed colonoscopies. Faced with this situation, Aleksandar decided to undergo a colonoscopy at a private health facility without disclosing his HIV status.
A person living with HIV who takes antiretroviral medications can work. In North Macedonia the Law on Labor Relations and the Law on the Prevention and Protection from Discriminationboth prohibit discrimination based on health status, which includes HIV. However, in this case, an attempt was made to prohibit a person living with HIV from continuing to work at his place of employment, a city hospital in one Macedonian town.
“Don’t come to work.”
In August 2023, the person underwent an HIV test at the hospital where he works as auxiliary medical staff. When the test came back positive, the information was shared with all of his colleagues. That same day, he received a call from a doctor informing him that he should not report to work the following day. At the same time, the individual had other health issues, so he sought medical assistance at the same hospital where he had worked for almost 35 years. The same doctor who informed the individual that he should not report to work declined to examine him. The individual left to seek medical assistance in another place. In the meantime, the person started taking antiretroviral medicines.
After the visit to the hospital, the person took medical leave due to additional health conditions that necessitated bed rest. After his health issues were resolved, he wanted to return to work. However, his family doctor and the medical commission, which is in charge of awarding medical leave, continued to extend his medical leave without his consent and any specific reason, citing the fact that he is a person living with HIV. Soon after, he was directed to a doctor, who specialized in labor medicine, to evaluate his ability to work. According to the relevant legislation, if a person living with HIV is on medical leave for 10 months or less, he or she must have an assessment to determine his or her ability to work.
REAction and outcome
A REActor met with the individual and suggested he obtain a report from his doctor at the Clinic for Infectious Diseases and Febrile Conditions, stating that he is well and has no reason not to work. After receiving the report, the Association Stronger Together from Skopje filed two complaints: one with the director of the hospital where the individual works and one with the state Health Insurance Fund. The letter to the director described the violations committed by the staff, such as the denial of healthcare, the disclosure of medical data, and insults directed at the employee, and demanded that the hospital should initiate an investigation and punish the perpetrators, while also undertaking measures to stop the harassment of the employee. The Hospital was also notified that Stronger Together and other civil society organizations would be ready to provide legal support to the person with HIV should he decide to take the matter to court. The letter to the Health Insurance Fund indicated that the family doctor and the medical commission are providing medical leave to those who don’t need it and by default, spending the Fund’s money without justification; additionally, the letter enunciated that the extension of the medical leave was without the patient’s consent. Following the complaints, there was a reaction by the Hospital, which allowed the person to return to work and he has not reported any other breaches of his rights afterward.
In North Macedonia, significant strides have been made in addressing cases of discrimination and promoting HIV awareness. This update highlights some noteworthy developments in this regard.
Resolution of Discriminatory Practices
One notable case from the previous year involved the mandatory HIV testing of foreign students by a public university in the Republic of North Macedonia. The Association «Stronger Together» took proactive steps by submitting a petition to the Commission for Prevention of and Protection against Discrimination, citing violations of the Anti-Discrimination Law. This case has been successfully resolved in a positive manner: the university responded by revising its discriminatory requirements for foreign students, ensuring fair and equal treatment.
Collaboration with the Clinic for Plastic and Reconstructive Surgery
Further progress was achieved through collaboration. On June 6th, the Association «Stronger Together» conducted its inaugural workshop in partnership with the Clinic for Plastic and Reconstructive Surgery. The workshop aimed to educate medical professionals about HIV prevention and patients’ rights. This initiative was made possible due to the positive resolution of a previous case and the signing of a Memorandum of Understanding between «Stronger Together» and the Clinic.
These developments signify North Macedonia’s commitment to combating discrimination and enhancing awareness about HIV within the country. Such collaborative efforts and the resolution of discriminatory cases serve as important steps towards a more inclusive and informed society.
As North Macedonia continues its journey towards promoting equality and public health, it is evident that positive changes are taking place, thanks to the collective efforts of organizations like the Association «Stronger Together» and their partners.
Several laws in the Republic of North Macedonia govern the right to privacy of patient’s medical records and information, which are given special consideration in data protection laws. However, in some cases, patients’ HIV status is disclosed, which can have a significant impact on their social lives and violate their right to privacy and family life.
Scarlet Letter: “HIV+”
In November 2022, the patient, a person living with HIV, visited the Clinic for Plastic and Reconstructive Surgery, where he was scheduled to undergo surgical intervention for the third time in six years. During the consultations, the patient informed the anesthesiologist and the surgeon that he had been diagnosed with HIV a year ago, that he was taking antiretroviral medications, and that his virus level was undetectable. Such information did not prevent the surgeon from performing the surgery, and he was scheduled for surgery the following month. There were 15 people in the operating room on the day of the surgery, and the anesthesiologist told the patient that he was supposed to notify them about his HIV status, which he had previously done.
During his stay at the Clinic, the patient was subjected to stigmatizing and unprofessional behavior from medical professionals, particularly medical nurses. “HIV+” was written in bold and red letters on his patient documents, including his medical history and temperature list. This was not standard practice, and as a result, all of the other six patients in the same room learned about his HIV – status. Additionally, the nurses warned the young doctors to be “extra careful” with the patient and to “not touch” him.
REAction and outcome
The patient agreed for the Association «Stronger Together»to send a letter to the Clinic’s director outlining the facts of the situation and the legal provisions that had been broken. Following the delivery of the letter, representatives of the Association met with the Director and several Clinic employees, who stated that they required more information about the patient because they did not recall a patient living with HIV being admitted to the Clinic. Following the sharing of such information, another meeting was held at which the employees acknowledged the accuracy of the patient’s claims and apologized to the Association and the patient. The head nurse told the representatives of an internal meeting, where she informed the personnel of their responsibilities as physicians. The Association and the Clinic agreed to work together to educate young doctors about HIV and the social implications of an HIV diagnosis on patients, by signing a Memorandum of Understanding. The first workshop resulting from the Memorandum was held in early June of this year.
The rights of people living with HIV, particularly their health rights, are routinely violated in the Republic of North Macedonia. An analysis of reported cases to NGOs working in this field reveals that approximately 90% of human rights violations of people living with HIV are related to their health rights, and the perpetrators are medical professionals. The health rights of people living with HIV are being violated either by disclosing their HIV status or, in this particular case, by refusing to provide them with health care.
Not here!
During an examination at the Clinic for Infectious Diseases and Febrile Conditions – Skopje, the patient was advised to go to the University Clinic for Dermatology. Certain serious skin changes (pyoderma) indicated that the person needed to be admitted to the Clinic for Dermatology right away, at which point a specialized doctor was contacted by the Clinic for Infectious Diseases and Febrile Conditions, and an appointment was scheduled. In the presence of the patient, the doctor was starting the administrative procedure for patient admission at the Clinic’s reception desk, and he reminded the nurse that the patient has an immunodeficiency. The department nurse reacted angrily, questioning why the patient had not been admitted to the Clinic for Infectious Diseases instead, how he would stay with the other patients at the Dermatology Clinic, and how she would inform the other patients that one of the hospitalized patients has AIDS. The doctor informed the nurse that the patient has a dermatological condition and must be admitted to the Clinic for Dermatology. Furthermore, he stated that other patients cannot and are not permitted to know about his HIV status. Meanwhile, the patient needed to use the Clinic’s restroom. After exiting the toilet, he was met with a slew of inconveniences by the medical staff, such as remarks that others would now be unable to enter after him, that the toilet needed to be disinfected, and so on.
Even though the patient was aware that he should be admitted to the Dermatology Clinic, the doctor arrived after a long wait, informing the patient that he would still have to be admitted to the Clinic Infectious Diseases and that for “some” reason he could not be admitted to them. The patient believes that, despite the doctor’s good intentions and recognizing that he had a dermatological problem, the refusal to hospitalize him came from the nurse.
REAction and outcome
Because the patient chose not to pursue the violation in court, the Association for the Support of People Living with HIV “Stronger Together,” Skopje, decided to address the infringement of rights by writing to the director of the Clinic for Dermatology. The letter outlined the case while enumerating all domestic legislative rules concerning discrimination and patient rights. The Association demanded that measures be taken by the Clinic to sanction the violating behavior of the Clinic’s staff and prevent similar situations in the future. It also offered support in providing sensitization training to doctors and nurses, to prevent any future incidents of human rights violations in the Clinic. After a few days, the director of the Clinic for Dermatology called the Association’s executive director to inform them that they were aware of the situation before the Association sent a letter and that the nurse would be sanctioned. The Association has yet to receive written confirmation of any sanctions imposed on the nurse, and it intends to inquire whether the Clinic for Dermatology imposed any sanctions.
Relevant legal provisions
According to Article 5 paragraph 2 and Article 32 paragraph 4 of the Law on Protection of Rights of Patients, medical professionals are prohibited to discriminate against anyone based on their health condition. Such prohibition is also regulated in the Law on the Protection from and Preventing Discrimination.
Nowadays, North Macedonia is a country with low prevalence and concentrated epidemic of HIV. However, the number of cases is increasing, the percentage of people, living with HIV who are aware of their status, is around 60 %, which is way below the goal set by the United Nations. There is still no research on stigma index, but if one is to evaluate the media reporting on the matter of HIV, we can conclude that there is a high level of stigma and discrimination as well. What to do if your status has been revealed and should you react or face it alone in silence?
Tittle-tattle with a social impact
A person employed in one of the university clinics in the country did an HIV test in the laboratory, where he got a positive result. The test result of the HIV test must be confirmed and assessed by a doctor, however very shortly after that, he realized that the information about his HIV status has been shared with most of his colleagues. It was spread around the clinic as a gossip and violated his right to privacy. What’s more, positive results from viral markers had already been entered into the medical system, although, according to Protocol until confirmatory tests were done at the University Clinic for Infectious Diseases and Febrile Conditions/Institute of Public Health, the results cannot be considered confirmed and no diagnosis must be entered in the patient’s medical record.
Flagrant violation of privacy
Some of his colleagues immediately changed their attitude towards him, openly letting him know that they no longer wanted to work with him, because they were afraid that he would transmit the virus to them somehow and that he was a danger. He faced rejection from certain colleagues, humiliation and avoidance. He was extremely surprised that as medical staff, his colleagues were not aware of the way of the HIV transmission. He immediately spoke openly with some of them and tried to explain that there is absolutely no way that it can be transmitted through air, touch, use on the same toilet, cutlery, equipment, etc. And that there really is no potential danger of them getting HIV just because they work in the same workplace, nor that there is any danger in relation to patients receiving health services from his side. His efforts were unsuccessful and certain colleagues continued to behave rudely and humiliatingly with the intention of forcing him to quit his job.
The patient’s rights were also violated in relation to the release of a professional secret, that is, even though he was an employee, he, as a patient, requested a health service: HIV testing within the Clinic, which violated his rights to health care and he faced discrimination as well. In his case, the results of the HIV test were shared with almost all of his colleagues, which is a flagrant violation of privacy and the duty of professional secrecy by the doctor who processed his HIV test data. And all this, because it is about the HIV (a type of health condition about which his colleagues apparently have no knowledge, only prejudices) they assumed that once he was HIV positive, he must be a homosexual as well.
Immediate REAction and positive outcome
The Association for the support of People Living with HIV “Stronger Together”, Skopje, heard about this case and decided to take a control on it. Its representatives prepared a letter, that was sent to the Director of the clinic, who was understanding and very professional. After, some of the colleagues were called to a meeting with him, where they were informed about all the aspects mentioned in the letter (rights of workers, the obligation of non-discrimination in the workspace and the modern aspects of the HIV, including the undetectability = untransmittable).
As a result of the letter and the director’s actions, after one month of returning to the work environment, the person reported no stigma and unequal treatment from colleagues and employers. The client still works in the university clinic.
Lawyer’s comments
1. Is a disclosure of status a crime in the North Macedonia? What punishment would people receive if the victim would go to the court?
– The Criminal Code does not contain a specific provision that would constitute disclosing an HIV-status a crime. However, depending on the person who have disclosed the status, that person can be charged for Abuse of personal data, pursuant to Article 149 of the Criminal Code, or Unauthorized disclosure of professional secret, pursuant to Article 150 of the Criminal Code. Depending on the circumstances and the crime, the punishment is either monetary,a prison sentence of one year or three years. The disclosure of personal data, specifically medical data, is also prohibited with the Law on protection of rights of patients.
2. What are restriction for people with HIV regarding professions regarding the North Macedonia legislation? Would this person be able to continue working in laboratory?
– There are no restrictions for people with HIV regarding professions in the Republic of North Macedonia. As a matter of fact, the Law on Labor Relations and the Law on Preventing and the Protection from Discrimination prohibits discrimination based on a person’s health condition. However, all candidates for work positions and employees must disclose health conditions that might prevent them or limit them in completing their work tasks. Although there are no cases so far regarding this provision and employees who are living with HIV, this provision might be misused by employers with respect to HIV-status of employees or potential employees. Notwithstanding that, it would be unproportioned invasion of privacy, and by default unlawful, for employers to use this provision and ask employees or future employees to disclose their status. Speaking about the continuation of work – yes, the client can continue working in the laboratory and still is.
