The opinion was issued in the proceedings regarding the complaint submitted by BB on behalf of and with the consent of AA against the VV Health Center and Dr. GG, head of the Department for Physical Medicine and Rehabilitation, due to discrimination based on AA’s health condition. The complaint stated, among other things, that on July 18, 2018, AA came to the VV Health Center for a specialist examination by Dr. GG, who, after learning that the person was living with HIV, asked him inappropriate questions that were not of importance for his treatment, and that she improperly indicated his HIV status on the health record, which she then communicated to other persons. In the statement of the VV Health Center, among other things, it was specified that after examining AA’s medical records, it was determined that Dr. GG had written that the person in question was “HIV positive”, which was done in order to establish a diagnosis and prescribe an appropriate therapeutic procedure in accordance with the health condition of the insured person. It was pointed out that Dr. GG did not disclose information about AA’s health condition to the public, nor did she communicate it to third parties. In Dr. GG’s statement, among other things, it was specified that AA seemed impatient and agitated all the time during the examination, that he was looking at what she was writing, and that when she asked if he had any kind of surgery, he jumped off the chair and started shouting that he had never had any surgery, and that he contracted HIV through sexual intercourse. In her statement, Dr. GG disputed all the allegations in the complaint, except those related to the recording of the diagnosis of AA in the medical records. Namely, the doctor stated that “the entry of a diagnosis from the International Classification of Diseases and the status of the patient is used for the differential diagnosis of the disease, and that it is a form of communication between all participants in the process of treating the patient – health workers and associates (…)”, and that she wrote “HIV+” in the medical documentation of AA, because she was surprised by the patient’s behavior, who, according to her, shouted so much that she thought he was hallucinating, especially since she did not find any information related to his HIV status in the electronic record. She also pointed out that she acted in the above-mentioned manner because it is a patient who, due to his weak immunity, is at increased risk of contracting infections, and that because of all this, the therapists who will be working with the patient must take all the necessary protective measures. During the procedure, and based on the presented evidence, it was established that the complainant did not make it likely that Dr. GG harassed and humiliated AA because of his health condition, nor that she communicated his HIV status to third parties. When it comes to entering the diagnosis “HIV+” on AA’s medical record and therapy list, the Commissioner for the Protection of Equality stated that neither AA’s possibly inappropriate behavior in the doctor’s office, nor the absence of adequate electronic records of his medical condition, are justified reasons for his real or assumed HIV status to be recorded in the way that Dr. GG did, ignoring the regulations that prescribe that disease diagnoses be entered in the designated place in the health record, in Latin, and under a code from the current International Classification of Diseases. Also, Dr. GG had at her disposal other ways to find out if it was really a patient living with HIV. Thus, the doctor could have contacted the chosen doctor of AA, who, according to the provisions of the Law on Health Documentation and Records in the field of health, is responsible for the accuracy of the data contained in the health record. The above is confirmed by the fact, mentioned in Dr. GG’s statement, that after the conflict with AA, she called his chosen doctor and found out about the patient’s HIV status, as well as the reasons why this information was not entered in AA’s electronic record. When it comes to the allegations from the statement of Dr. GG that the second reason for which she entered the HIV status of AA, as described in the complaint, is related to the fact that this is a patient who, due to weaker immunity, is at an increased risk of contracting infections, the Commissioner pointed out the obligation of the medical staff to use protective equipment when working with each patient, which is determined by regulations in the field of occupational safety. As the complaint was also filed against the VV Health Center, during the procedure it was established that the management of this health center, although it was immediately informed about the event that took place between Dr. GG and AA, failed to take all the measures available to them in order to timely and adequately determine what exactly happened on July 18, 2018 in Dr. GG’s office, especially when it comes to the improper and stigmatizing entry of the HIV status in AA’s medical documentation. Bearing in mind the above, the Commissioner for the Protection of Equality issued the opinion that the Health Center VV and Dr. GG, by entering the HIV status of AA with the mark “HIV+” in the section provided for medical history within the health record, as well as at the top (bottom) of the therapy sheet, violated the provisions of Articles 6, 8 and 12, in connection with Article 27 of the Law on Prohibition of Discrimination. Therefore, the VV Health Center was recommended to organize education for employees about HIV/AIDS, while Dr. GG was recommended to enter the patients’ diagnosis related to their HIV status in the designated place in the health documentation and under the code from the International Classification of Diseases, to send a written apology to AA, within 15 days from the date of receipt of this opinion with recommendation, as well as to act in accordance with anti-discrimination regulations in the future, within the scope of performing tasks within her jurisdiction.
COMMISSIONER FOR THE PROTECTION OF EQUALITY