Stigma attached health conditions have always been a great challenge to public health across the globe. HIV-related stigma among people living with HIV (PLHIV), in particular, is proven to lead to negative health consequences as well as difficulties in managing the further transmission of the infection. However, less attention is given to stigma levels among healthcare providers towards PLHIVand to discriminative behaviors during medical care. This short communication paper discusses the main manifestations of HIV-related stigma in healthcare settings within different contexts and attempts to investigate its potential causes.
It is known that with the help of advances in HIV/AIDS treatment and detection strategies the prevalence of HIV has dropped within the last few decades. This has resulted in a transformation of a death-threatening HIV diagnosis to a manageable chronic condition. However, since the introduction of antiretroviral therapy (ART) there have been numerous challenges including adherence difficulties to daily medications, cost constraints, lack of political will and inequitable access to ART in some countries.1 In addition, HIV-related stigma which reinforces the existing stigmas against some groups of people with heighted HIV risk behaviors (commercial sex and drug addiction), may result in irreversible negative consequences.2
Stigma is a complex social phenomenon and some authors claim that it is 'too cultural’, 'too context specific’ and difficult to define.3 Nevertheless, Goffman conceptualized stigma as an action of “deeply discrediting” when societies reduce someone “from a whole and usual person to a tainted, discounted one”.4 The Joint United Nations Programme on HIV/AIDS (UNAIDS) has also given a useful summary definition to HIV-related stigma describing it as a “process of devaluation” of PLHIV and even those connected to HIV infected individuals.3 Numbers of stigma attached health conditions share common attributes: a blame of a diseased one for having it; the disease is usually progressive and incurable and misinterpreted among the public; and the symptoms cannot be concealed.5 Another aspect of stigma is the fact that it can be experienced both by diseased individuals and uninfected others. This leads to determining three main domains of HIV-related stigma such as internalized stigma (negative beliefs about HIV and applied to the self), enacted stigma (experiences of stereotyping and discrimination, from others due to one's HIV status), and anticipated stigma (discrimination, stereotyping and prejudice from others in the future due to one's HIV status).7,8
Internalized stigma among PLHIV is relatively well addressed by scientific communities and has shown to reflect in self-damaging behaviors including self-hatred, self-isolation, and shame.8 However, the latest literature on HIV-related stigma mentions a need for a shift of focus from typical high risk HIV groups (men having sex with men, injection drug users and sex workers) to indigent, non-IDU substance abusers, different age groups and communities.7 It is also evident that the underestimation of perceived stigma among PLHIV may lead to poor psychological wellbeing and quality of life and most importantly, to a decreased willingness to uptake medical care.8
Enacted stigma, especially among medical workers is one of the main obstacles of an adequate HIV management as practice shows. Studies from different contexts demonstrate same patterns of discriminatory practices in healthcare settings. These include differential treatment based on HIV status, denials of providing care, unnecessary disclosure of one’s HIV status and even a verbal abuse by the healthcare staff. 9-15 One qualitative study in Ethiopia, that used key informant interviews and focus groups discussions both among healthcare staff and HIV positive patients, revealed complains of being treated as “enemies” and unwanted disclosure of one's HIV status by medical workers.12 Quantitative analyses, on the other hand, add more information on high discriminatory attitudes of all level healthcare providers and most surprisingly, insufficient basic and in-depth knowledge of HIV transmission among healthcare providers. 13, 14
Based on these consistent findings with high levels of HIV-related stigma in healthcare, it is important to investigate the roots of such behaviors, and how they differ across countries. The existing knowledge suggests three driving causes of HIV-related stigma in healthcare: lack of awareness of stigma, stigma’s manifestation and its negative impact on tackling the infection; inadequate (basic, in depth) knowledge on HIV transmission that results in fear of performing even low risk medical care to PLHIV; and having no access to Post Exposure Prophylaxis in some HIV/STI clinics. 9,15,18
Strong religious and traditional views have also been linked to higher levels of stigma in general public as well as in medical communities.18 A study conducted in Iran has demonstrated that almost half of the medical workers in the study were unwilling to provide medical service to PLHIV and among them: 70.5% reported fears of being exposed to an infection while 65.5% claimed that HIV is strictly related 'unethical behaviours’.14 Another study conducted in the Deep South (Alabama and Mississippi, USA) suggests similar findings, higher levels of HIV stigma were among White people and Protestant religious groups.17
Studies that included a domain on “shame” in assessing HIV- related stigma in healthcare (“PLHIV should be ashamed of themselves”) demonstrated increasing numbers of participants agreeing with this statement depending on their cultural and religious backgrounds.14, 18 Interestingly, studies from more developed countries seem to report lower proportions of respondents agreeing with “shame” towards PLHIV in general, but not in a family scenario. High proportions of respondents reported that they would feel ashamed if someone in their family were infected with HIV. 17
HIV-related stigma among post-Soviet countries has also been addressed; however there is little literature available from Central Asia specifically. A large scale study on a national level in Tajikistan for example, has covered the issue on many levels including medical workers.19 The findings of this study state that around the 96% of the respondents confirmed basic knowledge on HIV transmission, while only 30% of them could provide right answers on questionnaires. More than a half of medical workers in the study (62.5%) responded that they would provide basic medical service to PLHIV while 20% of medical doctors and 50% of nurses have responded otherwise. It is also worth mentioning that an adequate HIV knowledge is not strictly associated with less discriminative behaviors, since higher rates of “refused treatment”, “forced detection” and “disclosed information” were documented among those scoring high on the tests in another study.12 Nevertheless, an inclusion of all level medical workers and even non-medical staff in addressing this issue can be recommended.
Another large scale study was conducted in Central Asian countries (Kazakhstan, Kyrgyzstan and Tajikistan) by the efforts of the «Central Asian Association of People Living with HIV» and with the participation of international experts.20. Although this study assessed HIV-related stigma from the perspective ofPLHIV and mainly in the southern part of the country, this can still serve as a precursor for future comprehensive studies on the topic that
also include medical workers. According to the findings of the study, discrimination by medical workers was experienced by 6.0% -12.4% of HIV- positive respondents (Figure 1). The most refusals were in receiving dental care (17.6% of PLHIV reporting such discrimination). In addition, the violation of reproductive rights of PLHIV was on disturbing levels since only a few numbers of respondents (one in three) confirmed receiving information on healthy pregnancy and 21.3% of them were advised to not have children at all by medical workers.
HIV-related stigma in healthcare settings operates not only on individual level but also on clinic (clinic characteristics, types), and policy levels (institutional policies, support, and training).17 A lack of a strict series of HIV/AIDS-related occupational protection trainings, protective equipment seem to impact the willingness to provide medical service to PLHIV. Multivariable analysis of Dong et al's study demonstrated higher levels of “refused treatment” among primary and secondary hospitals compared to tertiary healthcare settings which can be explained by the latter being more equipped.12 Correspondingly, HIV testing in primary care in the UK was associated with high levels of anxiety; and overwhelming numbers of GPs avoiding the issue of HIV testing and recommending sexual health clinics for that task.3 On the contrary, another study conducted in the USA suggests that those working in HIV/STI clinics report higher levels of stigmatizing attitudes than the ones working in other types of clinics.17
In conclusion, according to this brief literature review, HIV- related stigma remains high among all levels of the medical care system and has not been adequately investigated from the perspective of healthcare providers themselves. The causes of such discriminative behaviors in healthcare settings seem to resemble across countries which lie on inadequate knowledge of HIV transmission, associating HIV with unethical behaviors and inadequate provision of precautionary equipment at workplaces. More in-depth literature reviews are needed however, with a particular focus on Central Asian countries including Kazakhstan. Future studies should also focus on specific causes of HIV-related stigma applying more sophisticated study designs and interventions. This in turn may help to approach an ambitious global target of the UNAIDS on capturing 95% of HIV positive patients with adequate medical care and zero HIV-related discrimination by 2030. 21 20,0
Figure 1 - Discrimination in connection with HIV status disclosure in Kazakhstan (survey results conducted among PLHIV)20
- Kazakhstan [Internet]. Unaids.org. 2018 [cited 9 November 2018]. Available from URL: http://www.unaids.org/en/regionscountries/countries/kazakhstan
- Havlir D, Gandhi M. Implementation challenges for long-acting antivirals as treatment // Current Opinion in HIV and AIDS. 2015. №10(4). Р. 282-289.
- Mahajan, A., Sayles, J., Patel, V., Remien, R., Sawires, S., Ortiz, D., Szekeres, G. and Coates, T. Stigma in the HIV/AIDS epidemic: a review of the literature and recommendations for the way forward // AIDS. 2008. №22, Suppl 2. Р. 57-65.
- [Internet]. Bibliobase.sermais.pt. 2018 [cited 9 November 2018]. Available from URL: http://bibliobase.sermais.pt:8008/BiblioNET/upload/PDF/0559.pdf
- Deacon H. Towards a sustainable theory of health-related stigma: lessons from the HIV/AIDS literature // Journal of Community & Applied Social Psychology. 2006. №16(6). Р. 418-425.
- Ruiz-Torres, Yamilette, Francheska N. Cintron-Bou, and Nelson Varas-Diaz. "AIDS-related stigma and health professionals in Puerto Rico." Revistainteramericana de psicologia // Interamerican journal of psychology. 2007. №41(1). Р. 49-56.
- Levi-Minzi M, Surratt H. HIV Stigma Among Substance Abusing People Living with HIV/AIDS: Implications for HIV Treatment // AIDS Patient Care and STDs. 2014. №28(8). Р. 442-451.
- Maman S, Abler L, Parker L, Lane T, Chirowodza A, Ntogwisangu J, Srirak N, Modiba P, Murima O, Fritz K. A comparison of HIV stigma and discrimination in five international sites: the influence of care and treatment resources in high prevalence settings // Social science & medicine. 2009. №68(12). Р. 2271-2278.
- Katz, Ingrid T., et al. "Impact of HIV-related stigma on treatment adherence: systematic review and meta-synthesis." // Journal of the International AIDS Society. 2013. №16. Р. 618-640.
- Ekstrand M, Ramakrishna J, Bharat S, Heylen E. Prevalence and drivers of HIV stigma among health providers in urban India: implications for interventions // Journal of the International AIDS Society. 2013. №16. Р. 710-717.
- Deblonde J, De Koker P, Hamers F, Fontaine J, Luchters S, Temmerman M. Barriers to HIV testing in Europe: a systematic review // The European Journal of Public Health. 2010. №20(4). Р. 422-432.
- Dong X, Yang J, Peng L, Pang M, Zhang J, Zhang Z et al. HIV-related stigma and discrimination amongst healthcare providers in Guangzhou, China // BMC Public Health. 2018. №18(1). Р. 267-278.
- Feyissa G, Abebe L, Girma E, Woldie M. Stigma and discrimination against people living with HIV by healthcare providers, Southwest Ethiopia // BMC Public Health. 2012. №12(1). Р. 316-324.
- Zarei N, Joulaei H, Darabi E, Fararouei M. Stigmatized attitude of healthcare providers: a barrier for delivering health services to HIV positive patients // International journal of community based nursing and midwifery. 2015. №3(4). Р. 292-301.
- [Internet]. Hivhealthclearinghouse.unesco.org. 2018 [cited 9 November 2018]. Available from URL: https://hivhealthclearinghouse.unesco.org/sites/default/files/resources/stigmadiscriminationrussian.pdf
- International Planned Parenthood Federation. The people living with HIV stigma index. London: IPPF, 2013. 516 р.
- Stringer KL, Turan B, McCormick L, Durojaiye M, Nyblade L, Kempf MC, Lichtenstein B, Turan JM. HIV-related stigma among healthcare providers in the deep south // AIDS and Behavior. 2016. №20(1). Р. 115-125
- Mahendra VS, Gilborn L, Bharat S, Mudoi R, Gupta I, George B, Samson L, Daly C, Pulerwitz J. Understanding and measuring AIDS-related settings: A developing country perspective // SAHARA-J: Journal of Social Aspects of HIV/AIDS. 2007. №4(2). Р. 616-625.
- National study on the stigmatization and forms of discrimination against people living with HIV | UNESCO HIV and Health Education Clearinghouse [Internet]. Hivhealthclearinghouse.unesco.org. 2018 [cited 9 November 2018]. Available from URL: https://hivhealthclearinghouse.unesco.org/library/documents/national-study-stigmatization-and-forms-discrimination-against-peopleliving-hiv
- [Internet]. Stigmaindex.org. 2018 [cited 9 November 2018]. Available from URL: http://www.stigmaindex.org/sites/default/files/reports/KAZAKHSTAN%202015%20Stigma%20Index%20report%20ENG%2017_05_ 2017.pdf [Internet]. Unaids.org. 2018 [cited 9 November 2018]. Available from URL: http://www.unaids.org/sites/default/files/media_asset/JC2686_WAD2014report_en.pdf