At the Mass General Research Institute, our community of 9,500+ investigators work diligently to publish peer-reviewed work and scientific findings to better understand disease and develop solutions to medicine’s most pressing challenges.

Footnotes in Science is a space where investigators bring you the behind-the-scenes details of their recently published work.

In this Q&A, we pick the brain of Kathryn Himmelstein, MD, MSEd, the lead author of a recent study published in Annals of Surgery, HIV and Hepatitis C Virus-Related Disparities in Undergoing Emergency General Surgical Procedures in the United States, 2016-2019

Dr. Himmelstein is a Mass General Brigham fellow in Infectious Diseases interested primarily in racial and economic justice and health intersections.

What motivated you and your team to publish this study?

In the course of our practice as infectious disease doctors and surgeons, we observed that people living with HIV and hepatitis C often experience discrimination in various domains, including accessing healthcare.

In particular, we noted anecdotally that there is often a hesitancy to perform surgery on people living with HIV or hepatitis C.

We wanted to investigate whether our observations were in fact true across the healthcare system.

What are some examples of inequities in surgical care? 

Our study shows that people living with HIV or hepatitis C are less likely to get emergency general surgical care — procedures such as appendectomies when they come to the hospital with appendicitis, or removal of their gallbladders.

This is true even when we adjust for things like the fact that people living with HIV and hepatitis C may be more likely to have other health conditions that make surgery riskier.

We know that surgery is the best treatment for most of these conditions, so the fact that people living with HIV and hepatitis C are less likely to have surgery means they’re likely receiving inferior care.

Can you expand on what stigmatizing physician attitudes mean, and their relevance to patient care? What are the implications of your findings?

Stigmatizing physician attitudes essentially mean that, instead of simply working with our patients to determine the best treatment for their illnesses, we, as doctors are making judgments about our patients that ultimately affect the care we offer or provide.

Because of racism, homophobia, transphobia, unequal access to healthcare, and criminalization of drug use, HIV and hepatitis C infection are more common among people who hold multiple marginalized identities — for example, among Black people, LGBTQ people, poor people, and people who inject drugs.

That means that people who are living with HIV and hepatitis C are likely experiencing stigma and discrimination not only based on their HIV or hepatitis C status, but also based on their other identities.

In addition, healthcare providers may erroneously believe that they are at risk for HIV or hepatitis C infection when they care for patients living with HIV or hepatitis C.

All of these factors compound such that people living with HIV or hepatitis C cannot access the healthcare they need and deserve.

What can healthcare institutions do to ensure patients living with HIV and hepatitis C have more equitable access to emergency surgery?

One important intervention is training for healthcare providers to ensure that we all understand that people living with HIV and hepatitis C have good surgical outcomes (that is, they are not more likely to have complications from surgery) and that the risk of transmission to healthcare providers is very low.

We also need providers to be aware that discrimination against people living with HIV and hepatitis C is happening in our hospitals, with real-time monitoring and feedback to ensure that we are not continuing this pattern.

An important part of this monitoring and feedback is transparency and accountability to local organizations of people living with HIV and hepatitis C.

Finally, because people living with HIV and hepatitis C often hold other marginalized identities, any policies to improve access to care for marginalized patients — such as anti-racism efforts or universal health care — will also benefit our patients living with HIV and hepatitis C.