Medicine: Israel’s Aids Model
In Israel, it has never reached epidemic proportions, but an Israeli hospital has developed a care model for HIV/AIDS that is effectively used not only at home but also in a growing number of other countries.
Of the estimated 40,000,000 people living with HIV/AIDS globally, only 7,500 are in Israel, ranking us 109th in the world,” says Michele Bashan-Haouzi, head nurse of the Hadassah AIDS Center at the Hadassah–Hebrew University Medical Center in Jerusalem. “While the numbers are relatively small, however, we treat a very diverse population—not only those born here, but also newcomers from sub-Saharan Africa, the former Soviet Union, Latin America, the United States and Europe. With HIV/AIDS now a long-term chronic illness, successful care of patients involves far more than handing out meds.”
HIV/AIDS patients today live with their illness rather than die from it, and “living with it is intimately related to culture and social context,” explains Estelle Rubinstein, chief social worker at the AIDS center. “A homosexual with HIV/AIDS in Jerusalem’s ultra-Orthodox community, for example, has different psychosocial problems from a gay man in Tel Aviv who discovers he is HIV-positive. A woman from an African village has a different understanding of health and disease than one from a Western metropolis. Such differences have enormous impact on vital issues like compliance with therapy.”
Hadassah opened an AIDS-testing clinic in its Clinical Microbiology and Infectious Diseases Department in 1985 under Dr. Shlomo Maayan. He developed that clinic into the AIDS center, which has created a unique multidisciplinary, culture-sensitive approach to treating patients. An infectious-disease specialist and, for the past 25 years, a specialist in HIV/AIDS as well, Dr. Maayan felt strongly that this model should be used to help not only the 400 patients currently cared for at Hadassah, but should also be taken to others.
To date, those others have included children in Chimkent, Kazakhstan, following an HIV-infection outbreak in 2008; Uzbekistan, where the center ran a training program in AIDS medicine last year; Ethiopia, where it has been training physicians and nurses in AIDS medicine for over a decade; and Francophone countries in Africa—Togo, Ivory Coast, Congo—where French-born Bashan-Haouzi has taught HIV/AIDS management to health care workers and educators as well as human rights activists.
With antiretroviral therapy (ART) for HIV/AIDS more or less standard, what Hadassah has to share is its team approach to managing AIDS. “Experience has taught us that patients do better when cared for by physicians, nurses, psychologists, social workers and case managers/cultural mediators who work in concert,” says Dr. Maayan. “This is the way to ensure that patients take their meds even when they feel well. This is the way to monitor dosages and side effects, to help patients deal with social stigma…and convince them not to infect sexual partners….”
Cultural mediators are integral to the management team. “They see things from the perspective of their communities and help avoid miscommunication,” says Bashan-Haouzi. Patients from the former Soviet Union, for example, tend not to fear AIDS or feel shamed at having contracted a sexually transmitted disease; they view it as just another illness. “While there are positives to this attitude, there’s a parallel tendency to underrate the seriousness of their condition, and this impacts negatively on their drug adherence.”
A far wider cultural gulf exists between Western medicine and the traditional healing common in rural sub-Saharan African communities. “Many of Israel’s AIDS patients are of Ethiopian origin, and not all of them accept the West’s biomedical model of health and disease,” says Dr. Maayan.
When Rubinstein first worked with Ethiopian patients, she tried to establish eye contact, “having no idea that this makes Ethiopians extremely uneasy. When I found out and stopped, it made an enormous difference,” she recalls.
Bashan-Haouzi remembers an Ethiopian patient who moved to Israel 17 years ago. “She was well integrated and spoke fluent Hebrew, so we didn’t work through a cultural mediator,” she says. “The patient was instructed to take ART daily. This should have reduced the virus levels in her blood, but the levels never went down and none of the medical team could understand why. After yet another poor result, I suddenly asked her: ‘Daily? That includes Shabbat, right?’ ‘Oh no,’ she said. ‘Not Shabbat! I don’t take medicine on Shabbat.’”
The AIDS center team also brings their experience to Ethiopia, home to over two million HIV carriers. The Hadassah approach, evaluated by the United States Centers for Disease Control, was found to be particularly suited to Ethiopia. Between 2005 and 2011, the United States President’s Emergency Plan for AIDS Relief brought 11 Ethiopian physicians and nurses to Hadassah for three-week courses in AIDS medicine. The Ethiopian health care personnel saw Hadassah’s treatment model in action—from outpatient clinics to weekly team discussions. “Hadassah’s brand as a leader in AIDS medicine is known all over sub-Saharan Africa,” says Dr. Maayan. “We’ve received many requests for training from other sub-Saharan countries affected by HIV/AIDS.”
Hadassah experts also travel to Ethiopia to contribute to training in AIDS medicine for medical personnel and students. “Through our international program—the Israel Consortium on AIDS Medicine in Africa,” he says, “Israeli specialists…have made more than 20 professional visits over a six-year period.”
The Hadassah–Hebrew University Faculty of Medicine is also involved in AIDS education in Africa. An exchange program launched with Hadassah’s AIDS center in 2010 brings Ethiopian physicians to the medical school for training, while medical students spend three weeks at the Makele College of Medical Sciences in Ethiopia’s Tigray province to experience medical practice in Africa.
The center’s approach to the disease has also broadened. One direction for which the center seeks funding is combating complications that result from long-term ART use—medical conditions such as renal and neurological impairment, osteoporosis and heart disease. Another is fertility in those with HIV/AIDS.
Hadassah inaugurated its AIDS Fertility Center in April 2010. The country’s only such center, it works with HIV-positive pregnant women to prevent disease transmission to the fetus. The women are supervised throughout their pregnancy, and their viral load is monitored; if it is low enough at delivery time, they can try for a vaginal birth, otherwise a C-section is required.
For HIV-positive men, the fertility center employs a special cleansing procedure that rids the sperm of any traces of HIV and introduces the cleansed sperm to the uninfected potential mother via intrauterine insemination. Eighty-five couples have registered for the procedure in the three years since the service has been offered. Eleven healthy babies have been born in that time, and there are 19 pregnancies in progress.
“Providing a fertility solution for discordant couples [HIV-positive men and HIV-negative women], who have waited a very long time to bring children into the world,” says Dr. Karen Olshtain-Pops, fertility center director, “is a dream come true.”
For Bashan-Haouzi, her experiences working with AIDS seem unreal. “I first encountered AIDS during a Sabbatical year in Paris in 1991, working in palliative care with the dying—the only place to which AIDS led at that time,” she recalls. “When I returned to Israel, I volunteered with the AIDS task force, because there was no AIDS treatment in hospitals. Today, I am able…to help my patients live full lives, [and] I can help them bear healthy children.”