《瞭望东方周刊》特约撰稿张海林 | 北京报道
在此次全国两会上，全国政协委员、中国中医科学院中医药防治艾滋病研究中心常务副主任王健就解决艾滋病人手术难问题提交提案，呼吁取消“艾滋病定点医院”、将感染者纳入常规医疗体系，保障感染者就医权。
2010年7月，“感染者社区工作经验交流研讨会”召开，中国艾滋病病毒携带者联盟（CAP+）及 40 个社区组织成员计划针对艾滋病人具体手术难问题发起联合倡议，推动普通医院接受艾滋病人就诊。
“当感染者罹患其他疾病需要进行手术治疗时，常常面临求医无门的艰难处境。”CAP+秘书处协调员孟林对《瞭望东方周刊》说。
CAP+与中国人口福利基金会合作、中国人大性社会学研究所和清华大学 NGO 研究所共同起草《中国艾滋病病毒感染者/患者治疗与生存状况定性调查报告》中显示，接受调查的人员中，80%有手术需求的感染者遭到医院拒绝。
艾滋病人“地下”就诊
“患者张某（女）因患肾积水，到北京某医院专家门诊就诊，医生认为病情严重，需要立即手术。但当患者主动说明是艾滋感染者后，对方随即表示没有能力进行手术，让其转到某传染病院，而该传染病院又缺乏肾脏手术能力。”CAP+秘书处的任少鹏为本刊记者提供了诸多艾滋感染者“手术难”的具体案例，均发生在医疗机构获知患者感染事实之后，其中约八成是感染者主动向医务人员告知，约两成为医疗机构术前检查获知。
自艾滋病在我国发现以来，对感染者的治疗和管理始终被纳入传染病范畴。各地陆续指定了一批传染病专科医院作为“艾滋病定点医院”。
“传染病医院只管救治患者感染的艾滋病，不具备综合性医院的学科体系和救治能力。” 北京佑安医院传染病主治医师张可告诉本刊。CAP+等机构收集的案例中，80% 的艾滋病定点医院因能力达不到手术条件，不能为患者实施手术。
“比如脑部手术、食道癌手术等，我们就做不了。”北京地坛医院感染中心副主任护师王克荣对本刊说，有一名得了喉癌的感染者，“我们医院做不了手术，他就转到当地医院接受保守治疗，他没有跟别人说自己感染了艾滋，只做化疗和放疗，服些中药，但没有进行手术。”
“艾滋病定点医院”的存在也成为一些医疗机构推诿或拒绝为感染者提供常规医疗服务的借口。“普通医院会认为这些都归地坛、佑安医院这样的专科性医院管。”张可说。
《传染病防治法》将传染病分为甲类、乙类和丙类。艾滋病和乙肝同属于“乙类”，而乙肝感染者早已能在普通医院就诊。
“许多艾滋病感染者选择去私人诊所、不检测血液的基层医疗机构，或选择去来不及检测血液的医院急救门诊。”孟林认为，让艾滋病人在“地下”状态就诊，这反而提高了传染风险。
“在美国，85%的艾滋病人都得到了医学随访，而我国绝大多数艾滋病人找都找不到。”孟林说，我国尚未建立有效的医学随访体系，多数感染者处于隐匿状态，带来的隐患极大。
“白求恩死于手术感染”，职业暴露有多危险？
“医生拒治艾滋感染者，说是为了规避风险，这是毫无道理的。”曾担任卫生部艾滋病专家咨询委员会委员、中国性病艾滋病防治协会法律政策工作委员会主任李对本刊说，“至于职业暴露的风险，我觉得当然也会有，白求恩就是死于手术感染。但HIV手术感染的风险，国际公认的数据只有0.33%。”
手术中，一旦发生医护人员职业暴露，只要在24小时内采取紧急处理，服用4周的药物，就可以将感染的风险降到十万分之四。与传播途径相同的乙肝、丙肝、梅毒比较，HIV手术等医疗行为传染的几率更低。
“法律规定应采取普遍防范原则。给任何一个人做手术，医生都应假定会给自己带来感染。”李说。
对于职业暴露的相关处置办法，2004年卫生部曾印发关于《医务人员艾滋病病毒职业暴露防护工作指导原则（试行）》的通知。但中国目前还没有对因职业暴露而感染HIV的医务人员进行赔偿、补偿或补助的法律规定。
绝大部分医院不愿意接纳感染者就诊，亦有来自普通患者的原因。
“医院可能担心连锁反应。”张可说，如果普通医院收治艾滋病人，一时将难以消除普通患者的顾虑，“河南曾有一家医院，收治了艾滋病人，其他病人全跑掉了。”这涉及对艾滋病的社会恐惧症。
医院的压力又反过来给医生造成更多顾虑。“我要是带艾滋病人到科室去，其他医生会把我赶走，护士也不给抽血，领导肯定也不欢迎。”某三甲医院的一位医生说。
“西方国家没有专科性医院。”张可说，在美国，艾滋病感染者已经纳入常规医疗。“而我国把传染病医院和综合性医院截然分开，也源于历史原因，中国法定的传染病有30多种，都归专科性医院管。”
张可认为，最初国家将艾滋病纳入传染病医院的管理范畴，可能是为了能较好地对艾滋病人进行随访，但随访的目的没有很好地实现，反而造成很多新的问题。对此，上述《报告》建议，取消各地卫生行政部门对“艾滋病定点医院”的指定，将艾滋病治疗纳入常规医疗体系。
在法律保障方面，王健认为，《艾滋病防治条例》等对艾滋病人权益保护的条文没有问题，“但执行就是另一码事了。”
“外国的医生不敢拒治，他们的执照要求非常严，患者一旦投诉，医生就完了。”张可说，而中国医生在这方面就很随便，已存在的医疗投诉渠道多数形同虚设。
三级甲等“示范医院”构想
王健接受本刊记者采访时表示，今年两会期间，他将继续就解决艾滋病人“手术难”问题提交提案。2010年，卫生部对其上一次的提案给予答复，承认存在部分医疗机构推诿和拒绝为艾滋病人手术的问题。“同时还表示将加强对医疗机构的培训和管理，研究并制定职业暴露感染艾滋病的补偿机制，同时扩大艾滋病定点医院范围。”
CAP+工作人员表示，近年来在北京、上海、广州、哈尔滨、成都等城市，感染者手术难问题确实有所改观，部分城市还出现了为感染者提供手术服务的少数医疗机构。
“地坛医院这些年新增了好多科室，从大专科、小专科往综合性方面发展，现在能做的手术也越来越多。”王克荣说，该院做的第一例肝移植手术的病人就是艾滋病患者。
对此，李认为，专科性医院增强医治能力，属于医院自身具体规划，不能“一刀切”地要求全国所有的传染病医院都做成这样。“在县或小城的传染病医院，它总共就没有多少病人，也搞成综合的话，就会造成医疗资源浪费。”
为此，上述《报告》建议在每个省区市向社会推荐 1~3 家三级甲等的综合性医院作为 “示范医院”。
“这实际上是一个让步。按法律规定，所有的综合性医院都应该接治。”李说。但即使是这样的要求，眼下也面临难题。
资金就是头一个问题。本世纪初以来，国际国内对艾滋病防治都相当重视，李透露，中国从艾滋病防治全球基金申请到很多钱来防治艾滋病，但这些钱多用于做宣传，比如印制防艾手册和每年举办防艾大型晚会。
“如果把这些钱投入到艾滋病医疗体系的建设上，效果会实在得多。”李说。
(瞭望东方周刊)
艾滋病不治会早死，早治才康复 艾滋病不治会早死，早治才康复 艾滋病不治会早死，早治才康复 艾滋病不治会早死，早治才康复
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| 图示∶2010年12月即将出版的《中国特色医疗金鉴》登载的刘君主任及其机构 |
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AIDS "underground" treatment, funds used for publicity
At 09:11 on March 18, 2011 Xinhua Zhang Hailin
[REVIEW] Zhang patients suffering from hydronephrosis, to a hospital specialist clinic, doctors believe that a serious condition and requires immediate surgery. But that is active in patients with HIV infection, the other party can not afford the surgery went on to say, let go to a hospital for infectious diseases, and kidney disease, lack of surgical capacity, hospital
"Oriental Outlook" freelance writer Zhang Hailin | Beijing reports
In the last two sessions, the CPPCC National Committee member of China Academy of Traditional Chinese Medicine Research Center, deputy director of AIDS Jian surgery to solve the difficult problem of AIDS to submit proposals, called for the cancellation "AIDS designated hospitals", the infection into the general health care system to protect the right of HIV medical care.
July 2010, "the exchange of experience in community work infected with the" Workshop on the Chinese HIV carriers Union (CAP +) and 40 members of community organizations plan for the difficult problem of AIDS specific surgical joint initiatives to promote the general hospital for AIDS treatment.
"When the infection risk of the need for surgical treatment of other diseases when medical treatment is often faced with the plight of nowhere." CAP + Meng Lin Secretariat Coordinator of the "Oriental Outlook," said.
CAP + and the China Population Welfare Foundation, the Chinese National People's Congress of Sociology, Tsinghua University NGO Research Institute and jointly drafted the "China HIV / AIDS patients living conditions of treatment and qualitative survey report" shows that the staff surveyed, 80 % had been infected surgical needs of the hospital refused.
AIDS "underground" treatment
"Zhang patients (female) suffering from hydronephrosis, an expert in a hospital in Beijing clinic, doctors believe that a serious condition and requires immediate surgery. But that is active in patients with HIV infection, the other party that can not afford an operation immediately, so that The go to a hospital for infectious diseases, kidney and the lack of surgical capacity, hospital for infectious diseases. "CAP + secretariat Ren Shaopeng as correspondents to provide a lot of HIV infection" operation difficult "specific cases occurred in patients infected with Shi Shi informed medical institutions After about Bacheng is infected with the initiative to inform the medical personnel, medical institutions about two preoperative examination to become informed.
Since the discovery of AIDS in China has been the treatment of infections and management of infectious diseases has been included in scope. Gradually over a number of infectious disease specialist hospitals designated as "AIDS in designated hospitals."
"Just treat infectious diseases hospital infection in AIDS patients, general hospitals do not have the discipline system and treatment capacity." Zhang Beijing You'an Hospital infectious diseases physician can tell the publication. CAP + and other agencies to collect the cases, 80% of the HIV sentinel hospitals not operating conditions due to capacity, not the surgery for patients.
"For example, brain surgery, esophageal surgery, we can not do." Beijing Di Tan Hospital, nurse, deputy director of infection to the magazine, said Wang Kerong, one had carcinoma of the infection, "we can not do surgery hospital, he turned to the local hospital for conservative treatment, he did not tell people that they are infected with HIV, only chemotherapy and radiotherapy, serving some traditional Chinese medicine, but no surgery. "
"AIDS designated hospitals," the existence of a number of medical excuse or refuse to provide routine medical services infections excuse. "General Hospital would think that these are the property of the altar, so that the specialist hospital of You'an Hospital." Zhang said.
"Communicable Disease Control Act" will be divided into infectious diseases A, B and C classes. AIDS and hepatitis B with a "B", and had hepatitis B infection in general hospital.
"Many people living with HIV choose to go to private clinics do not test the blood of the primary health care institutions, or choose to go to the hospital too late to aid clinic of blood." Meng Lin believe that allowing people with AIDS in the "underground" status treatment, which only increased the risk of transmission .
"In the U.S., 85% of AIDS have been the medical follow-up, while the vast majority of our people with AIDS, looking for can not be found." Meng Lin said that China has yet to establish an effective system of medical follow-up, the majority of infected people in the hidden state, with to the risks greatly.
"Bethune died of surgical infections," occupational exposure more dangerous?
"The doctor refused to rule HIV-infected people, said that in order to avoid risks, it is unreasonable." Served as the Ministry of Health AIDS Expert Advisory Committee, the Chinese Association of STD and AIDS Prevention Working Committee of legal policy, said Lee of the magazine, "As for the professional exposure to risk, I think, of course there will be, Bethune died of surgery is infection. However, the risk of HIV infection in surgery, internationally recognized is only 0.33% of the data. "
Surgery, in the event of occupational exposure to health care, as long as 24 hours for urgent treatment, taking 4 weeks of medication, the risk of infection can be reduced to four hundred thousandths. The same with the transmission of hepatitis B, hepatitis C, syphilis comparison, HIV infection surgery and other medical behavior less likely.
"Common law should take the precautionary principle. To any one surgery, the doctor should be assumed that the infection will bring their own." Lee said.
For the disposal of the relevant occupational exposure in 2004, the Ministry of Health has issued guidance on the "medical staff working with HIV prevention guidelines for occupational exposure (Trial)" notice. But China is still not infected with HIV due to occupational exposure of medical personnel, compensation or benefits of the law.
Unwilling to accept the vast majority of infected hospital treatment, some patients from the general reason.
"Hospital may worry about the ripple effect." Zhang said, if ordinary people with AIDS admitted to hospital, sometimes patients will be difficult to eliminate common concerns, "Henan had a hospital, treated people with AIDS, other patients all got away." This involves social phobia of AIDS.
Pressure on hospitals to doctors, in turn, cause more concern. "If I go with AIDS to the department, other doctors will let me go, the nurses did not give blood, leadership certainly not welcome." A top three hospital a doctor said.
"Western countries do not have specialist hospitals." Zhang said, in the United States, AIDS has been incorporated into routine medical care. "In China, the Infectious Diseases Hospital and General Hospital completely separate, but also from historical reasons, China has 30 kinds of legal infectious diseases, are the property of the hospital management specialist."
Zhang believes that the initial state of AIDS into the areas of hospital management of infectious diseases may be better for people with AIDS can be followed up, but the purpose of follow-up is not well implemented, but caused many new problems. In this regard, the "Report" recommended that the local health administration department of the "AIDS designated hospitals," the designation of AIDS treatment into routine health care system.
Legal protection, Wang believes that "AIDS Prevention Act" and other human rights protection on the provision of AIDS is no problem, "but implementation is another matter."
"Foreign doctors can not refuse treatment, they are very strict licensing requirements, the patient once the complaint, the doctor would be finished." Zhang said the Chinese doctors in this area is very casual and has the majority of existing medical complaint channels useless.
Three A-level "model hospital" concept
Wang Jian Sinorama reporters that during the two sessions this year, he will continue to address AIDS "operation difficult" issue to the proposal. In 2010, the Ministry of Health proposal to give its reply to the last, there is some recognition of prevarication and denial of medical operations for the AIDS problem. "But also said it would strengthen the training and management of medical institutions, research and development of occupational exposure compensation mechanism of HIV infection, while expanding the scope of designated hospitals for AIDS."
CAP + staff said that in recent years in Beijing, Shanghai, Guangzhou, Harbin, Chengdu and other cities, infection is difficult, indeed, a difference operation, some cities have emerged to provide surgical services for the infection of a small number of medical institutions.
"Ditan Hospital, a lot of years, new sections, from the large specialist, small specialist to develop comprehensive, and now can do more and more surgery." Wang Kerong, said the hospital did the first liver transplant patients is AIDS.
In this regard, Lee believes that increased specialist hospital treatment capacity, specific planning is the hospital itself, not "across the board" to ask all of the country's infectious diseases hospital are made of this. "Infectious diseases in the county or town hospitals, it is no total number of patients, but also into an integrated, it would result in waste of medical resources."
To this end, the "Report" recommended that provinces and municipalities in recommending every 1 to 3 three A-level general hospital as a "Model Hospital."
"This is actually a compromise. By law, all general hospitals should have received treatment." Lee said. But even such a request, now also face problems.
Capital is first a question. Since the beginning of this century, both international and domestic AIDS prevention and control very seriously, Li said, China from the Global Fund for AIDS prevention to a lot of money to fight AIDS, but more money to advertise, such as printed brochures and annual AIDS Prevention AIDS Prevention large party.
"If these money into the construction of AIDS on the health care system, the effect will be very much." Lee said.
(Oriental Outlook Weekly)
