Discriminatory attitudes and practices by health workers toward patients with HIV/AIDS in Nigeria

"I have lost sexual interest …"-challenges of balancing personal and professional lives among nurses caring for people living with HIV and AIDS in Limpopo, South Africa

As part of a capacity-building research project, this study examined the extent to which caring for people living with HIV and AIDS (PLWHA) affects both professional and personal relationships of nurse caregivers. The data were collected using focus group interviews with 17 female nurses at two Limpopo hospitals. The PEN-3 cultural model was used as a theoretical framework for exploring how nurses balance job demands with family responsibilities. The results generated three themes: the multiple identities nurses experience within their family and professional lives; nurse attitudes related to patient gender; and stigma experienced by nurses who care for PLWHA. Caring for PLWHA influences nurses' personal and professional lives by interfering with their perceptions and emotions as they relate to spousal, parental, and gendered relationships. The findings offer insight into factors requiring consideration when designing interventions to help nurses cope with the stress associated with caring for PLWHA while simultaneously managing family responsibilities.

The impact of exposure to mass media campaigns and social support on levels and trends of HIV-related stigma and discrimination in Nigeria: tools for enhancing effective HIV prevention programmes

People living with HIV and AIDS (PLWHAs) often face stigma and discrimination, especially in developing countries. HIV-related stigma is expressed through social ostracism, personal rejection, direct and indirect discrimination, and denial from families and friends. Consequently, it is associated with reduced adoption of preventive and care behaviours, including condom use, seeking for HIV test and care-seeking behaviour subsequent to diagnosis. Ignorance about the epidemiology of the disease on modes of transmission and prevention aggravates HIV-related stigma in Nigeria. Behaviour change communication activities through mass media have been shown to be an effective approach in improving people's knowledge about the disease. This paper monitors trends in the level of accepting attitudes towards PLWHAs in Nigeria between 2003 and 2007. It also evaluates the impact of exposure to mass media and social support on the levels of accepting attitudes towards PLWHAs. A significant and positive trend was evident between 2003 and 2007 (p<0.0001). Furthermore, exposure to mass media communications on HIV and AIDS issues and social support were significantly related to the reduced stigma and discrimination against PLWHAs (p<0.0001).

Predicting intention to treat HIV-infected patients among Tanzanian and Sudanese medical and dental students using the theory of planned behaviour--a cross sectional study

Background

The HIV epidemic poses significant challenges to the low income countries in sub Saharan Africa (SSA), affecting the attrition rate among health care workers, their level of motivation, and absenteeism from work. Little is known about how to deal with deterioration of human resources in the health care systems. This study aimed to predict the intention to provide surgical treatment to HIV infected patients among medical- and dental students in Tanzania and Sudan using an extended version of the Theory of Planned Behaviour (TPB).

Methods

Four hundred and seventy five medical- and dental students at the University of Dar es Salaam (mean age, 25 yr) and 642 dental students attending 6 public and private dental faculties in Khartoum (mean age 21.7 yr) completed self-administered TPB questionnaires in 2005 and 2007, respectively.

Results

Both Tanzanian and Sudanese students demonstrated strong intentions to provide care for people with HIV and AIDS. Stepwise linear regression revealed that the TPB accounted for 51% (43% in Tanzania and Sudan) of the variance in intention across study sites. After having controlled for country and past behaviour, the TPB in terms of attitudes, subjective norms and perceived behavioural control accounted for 34% and moral norms for an additional 2,3% of the explainable variance in intention. Across both study sites, attitudes were the strongest predictor of intention followed in descending order by subjective norms, moral norms and perceived behavioural control.

Conclusion

The TPB is applicable to students' care delivery intentions in the context of HIV and AIDS across the two SSA countries investigated. It is suggested that attitudes, subjective norms, moral norms and perceived behavioural control are key factors in students' willingness to treat AIDS and HIV infected patients and should be targets of interventions aimed at improving the quality of health care delivery in this context.

Routine checks for HIV in children attending primary health care facilities in South Africa: attitudes of nurses and child caregivers

Management of HIV-infected and exposed children is challenging for health workers in primary care settings. Integrated management of childhood illness (IMCI) is a WHO/UNICEF strategy for improving morbidity and mortality in under 5 children attending first level facilities in developing countries. In high HIV-prevalence settings, IMCI includes an HIV component for identification and management of HIV-infected and exposed children, which requires health workers to ask all mothers about their HIV status and check all children for signs of HIV. Effective implementation of the HIV component depends on the ability and willingness of health workers to take every opportunity to identify HIV-infected children during routine care, and implementation in South Africa is poor. In 2006, we conducted 10 focus groups in two provinces in South Africa with IMCI-trained nurses, and with mothers attending first level facilities, to determine their attitudes towards, and experiences of, routine checks for HIV during consultations with sick children. Nurses were frequently unwilling to check for HIV in all children, believing it was unnecessary, unacceptable to mothers, and that they lack skills to implement HIV care. Nurses feared mothers would become upset or make a complaint. Mothers consistently recognised the importance of checking children for HIV and supported implementation of routine checks, although the attitude of the nurse was important in determining the acceptability of HIV-related questions. Mothers expressed fears about lack of confidentiality from nurses, and that receiving HIV-related services could lead to unintentional disclosure of their HIV status. Nurses lack the skills in HIV management and communication skills to implement the HIV component of IMCI. We identify issues relate to improved training, clear policies on record keeping, and organization of health services to respect privacy and confidentiality, to improve the willingness of health workers to provide HIV care and mothers to accept it.

Additional patient outcomes and pathways in evaluations of testing

Before medical tests are introduced into practice, they should be properly evaluated. Randomized trials and other comprehensive evaluations of tests and test strategies can best be designed based on an understanding of how tests can benefit or harm patients. Tests primarily affect patients' health by guiding clinical decision making and downstream management, such as the decision to order more tests or to start, stop, or modify treatment. In this article, the authors demonstrate that tests can have additional effects on patient outcome, which may be cognitive, emotional, social, or behavioral. They present a framework to help researchers and policy makers consider the cognitive, emotional, social, and behavioral effects of testing. These additional effects may be important themselves and may also influence the clinical outcomes of testing through different pathways. The authors provide examples from test evaluations in the literature to illustrate how these additional effects can be important in the evaluation of testing or indeed any health intervention.

Considering childbearing in the age of highly active antiretroviral therapy (HAART): Views of HIV-positive couples

OBJECTIVES

Based on a qualitative study conducted in Bulawayo, Zimbabwe, this article examines how the availability of HAART since April 2004 may impact the views and choices of HIV-positive couples on childbearing.

METHODS

In-depth interviews were conducted with 15 couples where at least one partner was HIV positive. All respondents were of reproductive age and had or were confronting reproductive and sexual decision-making.

RESULTS

HAART seems to have had a profound impact on the subject of childbearing among those who still desire to have children. Where hitherto individuals had only a desire for a child many are now, as a result of the availability of HAART, actively planning to have one. HAART has not only transformed their physical state but it has also transformed mostly what had been desire into intention. The impact, however, has not been uniform. Some respondents still desired to have a child but were not yet convinced about the efficacy of HAART in preventing vertical transmission. Some respondents felt that HAART may have a negative impact on the foetus and as such were against childbearing by HIV-positive people. No respondent indicated that their desire or intention to have a child had been extinguished by the advent of HAART.

CONCLUSION

Based on the findings of the study, HAART seems to have had a differential but nonetheless significant role in the reproductive plans of HIV-positive couples. The study also notes that there is a need to make available complete and unbiased information on HAART, mother-to-child transmission risk (MTCT) and pregnancy to HIV-positive couples so as to enable them to make informed decisions.

HIV/AIDS-related stigma and discrimination in Nigeria: review of research studies and future directions for prevention strategies

Human Immunodeficiency Virus (HIV) infection and AIDS remain a major public health crisis in Nigeria which harbors more people living with HIV than any other country in the world, except South Africa and India. A significant challenge to the success of achieving universal access to HIV prevention, treatment, care and support by 2010 is HIV-AIDS stigma and discrimination. Eight studies looking at some degree of measurement of stigma and discrimination in Nigeria were reviewed in an attempt to investigate the cultural context of stigma, health seeking behavior and the role both perceived and community stigma play in HIV prevention. Results suggest that reducing stigma does increase the individual as well as community acceptance of people living with HIV-AIDS (PLWHAs), but long term studies are needed. Some suggestions are recommended for future research on culture specific stigma studies in Nigeria.

Combating HIV stigma in health care settings: what works?

The purpose of this review paper is to provide information and guidance to those in the health care setting about why it is important to combat HIV-related stigma and how to successfully address its causes and consequences within health facilities. Research shows that stigma and discrimination in the health care setting and elsewhere contributes to keeping people, including health workers, from accessing HIV prevention, care and treatment services and adopting key preventive behaviours.

Studies from different parts of the world reveal that there are three main immediately actionable causes of HIV-related stigma in health facilities: lack of awareness among health workers of what stigma looks like and why it is damaging; fear of casual contact stemming from incomplete knowledge about HIV transmission; and the association of HIV with improper or immoral behaviour.

To combat stigma in health facilities, interventions must focus on the individual, environmental and policy levels. The paper argues that reducing stigma by working at all three levels is feasible and will likely result in long-lasting benefits for both health workers and HIV-positive patients. The existence of tested stigma-reduction tools and approaches has moved the field forward. What is needed now is the political will and resources to support and scale up stigma-reduction activities throughout health care settings globally.

HIV/AIDS knowledge, attitudes, practices and perceptions of rural nurses in South Africa

AIM

This paper is a report of a study exploring HIV/AIDS-related knowledge, attitudes, practices and perceptions of nurses in the largely black and rural Limpopo Province of South Africa.

BACKGROUND

Studies of HIV/AIDS knowledge, attitudes and practices among healthcare workers in developing countries have shown gaps in knowledge and fear of contagion, coupled with ambivalent attitudes in caring for patients with HIV/AIDS and inconsistent universal precautions adherence.

METHOD

A cross-sectional study of a random sample of primary health care (PHC) (n = 71) and hospital nurses (n = 69) was carried out in 2005, using a questionnaire, focus groups and in-depth interviews.

FINDINGS

Hospital nurses reported a higher frequency of care for patients with HIV/AIDS (P < 0.05), but less HIV/AIDS training when compared to PHC nurses (P < 0.001). HIV/AIDS knowledge was moderately adequate and associated with professional rank, frequency of care and training (P < 0.001). Attitudes towards patients with HIV/AIDS were mainly positive and were statistically significantly correlated with HIV/AIDS knowledge (P < 0.01) and training (P < 0.05). Three out of four nurses reported that they practised universal precautions (76.1%), but fear of occupational HIV transmission and lack of injection safety was found. Seven in 10 nurses reported previous needlestick injuries, but postexposure prophylaxis was not available in all healthcare facilities. Participants reported a higher workload because of HIV/AIDS, lack of training impacting negatively on their work, and stigma and shared confidentiality affecting them emotionally.

CONCLUSION

There is a need for accelerated HIV/AIDS training of rural nurses and for wider implementation of universal precautions and postexposure prophylaxis availability in public health facilities in southern Africa.

Impact of a peer-group intervention on occupation-related behaviors for urban hospital workers in Malawi

Using a pre- and posttest design with no control group, the authors evaluated the impact of a peer-group intervention on work related knowledge and behavior for health workers at an urban hospital in Malawi. The authors surveyed unmatched random samples of health workers, observed workers on the job, and interviewed clients about hospital services at baseline and at 6 months after the intervention. Universal precautions knowledge, reported hand washing, and reported client teaching were significantly higher at the final evaluation. The outcome differences remained robust in multivariate analyses with controls for demographic factors of age, gender, education, food security, and job category. Observations reported consistently greater use of universal precautions, more respectful interactions, and more client teaching at final evaluation. Patient surveys reported more discussion with health workers about HIV at the final evaluation. Peer-group interventions can prepare health workers in Malawi for HIV prevention and offer a potential model for other African countries.

Awareness and attitude of health workers at a Nigerian HIV treatment clinic toward HIV/AIDS and HAART adherence

OBJECTIVE

To assess the awareness and attitude of antiretroviral clinic workers to HIV/AIDS and highly active antiretroviral therapy (HAART).

METHODS

A descriptive cross-sectional study design using a self-administered questionnaire was used.

RESULTS

Of the 43 staff, 39 (92.5%) completed the questionnaire. Their mean age was 35.1 + 7.6 years. There were 19 (48.7%) males and 20 (51.7%) females. The majority (87.2%) had tertiary education. More than three fifths (61.5%) were married. There were 20 (51.3%) professional staff and 19 (48.7%) support staff. Only 28.2% of staff members had ever received on-the-job training in HIV/AIDS care. None of the adherence counselors had ever received any training in HIV/AIDS care and HAART adherence counseling. Despite this lack of training, this majority of the clinic staff had good knowledge about and a positive attitude to HIV/AIDS and HAART adherence.

CONCLUSION

Adherence counselors and support staff required on-the-job training for optimum job performance.

Attitude of health care workers to patients and colleagues infected with human immunodeficiency virus

Discrimination against persons living with HIV/AIDS in hospital settings has been documented. This study examined the attitude of health care workers (HCWs) to nurses, doctors and patients infected with HIV. A total of 345 respondents selected by multistage sampling techniques were surveyed, using a semi-structured questionnaire, which explored respondents' attitude to HIV-infected patients and colleagues with HIV/AIDS. HCWs were unwilling to accept that medical procedures be carried out on them by HIV-infected doctors and nurses, with almost 80% refusing surgery or assistance at surgery on them by an HIV-infected doctor or nurse. They were also significantly more unwilling to accept that medical procedures be carried out on them by an infected colleague, compared with their carrying out the same procedure on an HIV-infected patient. Thus, HCWs seemed to believe that the risk of contracting HIV was higher if an infected HCW were to perform medical procedures on them, and fear of contracting HIV seemed to be the driving force for their negative attitudes. Education on occupational risks of HIV, provision of a safe working environment with enforcement of universal precautions, as well as provision of post-exposure prophylaxis are suggested as ways to enable HCWs to change their attitudes.

The nursing implications of routine provider-initiated HIV testing and counselling in sub-Saharan Africa: a critical review of new policy guidance from WHO/UNAIDS

BACKGROUND

In 2007 WHO/UNAIDS issued new HIV testing guidelines recommending 'provider-initiated HIV testing and counselling' (PITC). In contrast to existing 'voluntary counselling and testing' guidelines (whereby individuals self refer for testing), the PITC guidance recommends that, in countries with generalised epidemics, all patients are routinely offered an HIV test during clinical encounters. In sub-Saharan Africa, PITC aims to dramatically increase HIV testing rates so that PITC becomes a vehicle to increase access to HIV prevention and care. Nurses in this region work on the frontlines of HIV testing but have been neglected in related policy development.

AIM

To provide an overview of the PITC policy guidance and to critically consider its implications for the nursing profession in sub-Saharan Africa.

METHODS

Policy documents and published and unpublished research were identified from organisational websites, electronic databases and conference proceedings.

RESULTS

PITC has generated widespread debate about whether it is the right approach in a context of HIV-related stigma and lack of human/material resources. Key concerns are whether/how informed consent, privacy and confidentiality will be upheld in overstretched health care settings, and whether appropriate post-test counselling, treatment and support can be provided. Limited available evidence suggests that health systems factors and organisational/professional culture may create obstacles to effective PITC implementation. Specific findings are that: PITC greatly increases nurses' workload and work-related stress. Nurses are generally positive about PITC, but express the need for more training and managerial support. Health system constraints (lack of staff, lack of space) mean that nurses do not always have time to provide adequate counselling. A hierarchical and didactic nursing culture affects counselling quality and the boundaries between voluntary informed consent and coercion can become rather blurred. Nurses are particularly stressed by breaking bad news and handling ethical dilemmas.

CONCLUSION

Three areas are identified in which the PITC implementation process needs to be strengthened: (i) research/audit (to explore nurse and patient experiences, to identify best practice and key obstacles), (ii) greater nurse participation in policy development, (iii) strengthening of nurse training and mentoring.

HIV/AIDS and maternity care in Kenya: how fears of stigma and discrimination affect uptake and provision of labor and delivery services

Although policies and programs exist to promote safe motherhood in sub-Saharan Africa, maternal health has not improved and may be deteriorating in some countries. Part of the explanation may be the adverse effects of HIV/AIDS on maternity care. We conducted a study in Kisumu, Kenya to explore how fears related to HIV/AIDS affect women's uptake and health workers' provision of labor and delivery services. In-depth qualitative interviews with 17 maternity workers, 14 pregnant or postpartum women, four male partners and two traditional birth attendants; as well as structured observations of 22 births; were conducted at four health facilities. Participants reported that fears of HIV testing; fears of involuntary disclosure of HIV status to others, including spouses; and HIV/AIDS stigma are among the reasons that women avoid delivering in health facilities. Maternity workers now have to take into account the HIV status of the women they serve (as well as their own fears of becoming infected and stigmatized) but do not seem to be adequately prepared to handle issues related to consent, confidentiality and disclosure. Importantly, it appeared that women of unknown HIV status during labor and delivery were likely to be targets of stigma and discriminatory practices and that these women were not receiving needed counseling services. The findings suggest that increasing infection control precautions will not be enough to address the challenges faced by maternity care providers in caring for women in high-HIV-prevalence settings. Maternity workers need enhanced culturally sensitive training regarding consent, confidentiality and disclosure. Furthermore, this study points to the necessity of paying more attention to the care of women of unknown HIV-serostatus during labor and delivery. Such interventions may improve the quality of maternity care, increase utilization and contribute to overall improvements in maternal health, while also enhancing prevention of mother-to-child-transmission and HIV care.

Stigmatization of patients with HIV/AIDS among doctors and nurses in Belize

This study, conducted from August to September 2007, utilized a population-based survey to investigate stigmatizing attitudes and acts of discrimination against HIV/AIDS patients among doctors and nurses working in public hospitals in Belize. A total of 230 subjects (81.0%) completed the survey. The mean age was 36.8 years; 75% were women; 61% were nurses; 74% were Belizean. Stigmatization was greatest for "attitudes of blame/judgment"; disclosing a patient's HIV/AIDS status to colleagues was the most frequent act of discrimination (29%). Formal HIV/AIDS training was significantly associated with less stigmatization for "attitudes towards imposed measures" (p < .01); "attitudes of blame/judgment" (p < 0.05); and testing without consent (p < 0.05). Doctors showed more stigmatization in "attitudes towards imposed measures," conducted HIV tests without consent and disclosed patient status to colleagues more frequently than nurses (p < 0.05) while nurses gave differential care to patients based on HIV status more frequently (p < 0.01) than doctors. Female and religious health care workers (HCWs) were more stigmatizing in their "attitudes of blame/judgment" than male and nonreligious HCWs (p < 0.05). Cuban HCWs were more stigmatizing in their "attitudes toward imposed measures" and were less comfortable dealing with HIV/AIDS patients than their Belizean counterparts (p < 0.01). Older age was associated with less frequent disclosure of patients' HIV status (p < 0.05). HIV/AIDS training that incorporates stigma reduction strategies tailored to the target groups identified is needed. Additionally, we recommend that the effectiveness of national HIV/AIDS policies be investigated.

Corruption and oil exploration: expert agreement about the prevention of HIV/AIDS in the Niger Delta of Nigeria

The Niger Delta, according to the Nigerian Ministry of Health, has a disproportionately high HIV infection rate, which is double the national average. The United Nations Development Program attributes the spiraling HIV infection rate in the region to poverty, migration and gender inequality. This paper examines two complementary suppositions: Is the high prevalence of HIV in the Niger Delta related to incompetent leadership and corruption? Is it related to the negative effects of oil exploration in the region? Currently, there is a dearth of research on the effectiveness of government programs or the role of the oil industry on the impact of AIDS in Nigeria. To address this gap, we conducted a survey with 27 internationally renowned experts from diverse disciplines using a three-round modified Delphi to formulate consensus about the impact of weak governance and oil corruption on AIDS in the Niger Delta. Results from the Delphi suggest that these factors and others have exacerbated the transmission of HIV in the region. To mitigate the impact of AIDS in the region, efforts to engage oil companies in implementing HIV prevention programs as part of their corporate environmental responsibility to the community are urgently needed.

Can "presumed consent" justify the duty to treat infectious diseases? An analysis

BACKGROUND

AIDS, SARS, and the recent epidemics of the avian-flu have all served to remind us the debate over the limits of the moral duty to care. It is important to first consider the question of whether or not the "duty to treat" might be subject to contextual constraints. The purpose of this study was to investigate the opinions and beliefs held by both physicians and dentists regarding the occupational risks of infectious diseases, and to analyze the argument that the notion of "presumed consent" on the part of professionals may be grounds for supporting the duty to treat.

METHODS

For this cross-sectional survey, the study population was selected from among physicians and dentists in Ankara. All of the 373 participants were given a self-administered questionnaire.

RESULTS

In total, 79.6% of the participants said that they either had some degree of knowledge about the risks when they chose their profession or that they learned of the risks later during their education and training. Of the participants, 5.2% said that they would not have chosen this profession if they had been informed of the risks. It was found that 57% of the participants believed that there is a standard level of risk, and 52% of the participants stated that certain diseases would exceed the level of acceptable risk unless specific protective measures were implemented.

CONCLUSION

If we use the presumed consent argument to establish the duty of the HCW to provide care, we are confronted with problems ranging over the difficulty of choosing a profession autonomously, the constant level of uncertainty present in the medical profession, the near-impossibility of being able to evaluate retrospectively whether every individual was informed, and the seemingly inescapable problem that this practice would legitimize, and perhaps even foster, discrimination against patients with certain diseases. Our findings suggest that another problem can be added to the list: one-fifth of the participants in this study either lacked adequate knowledge of the occupational risks when they chose the medical profession or were not sufficiently informed of these risks during their faculty education and training. Furthermore, in terms of the moral duty to provide care, it seems that most HCWs are more concerned about the availability of protective measures than about whether they had been informed of a particular risk beforehand. For all these reasons, the presumed consent argument is not persuasive enough, and cannot be used to justify the duty to provide care. It is therefore more useful to emphasize justifications other than presumed consent when defining the duty of HCWs to provide care, such as the social contract between society and the medical profession and the fact that HCWs have a greater ability to provide medical aid.

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El proceso de estigmatización asume una devaluación de la persona debido a una característica o marca que haya sido identificada socialmente y que permita que se le describa como diferente. Desde que se desató la epidemia del VIH/SIDA, vivir con la enfermedad ha sido señalado de manera social como una marca estigmatizante. Las manifestaciones de dicha estigmatización se han documentado entre profesionales de la salud. Este estigma puede afectar los servicios de salud que las personas que viven con VIH/SIDA reciben de estos profesionales. Los objetivos de esta investigación fueron explorar: 1) la percepción que tienen estudiantes y profesionales de la salud sobre su nivel de competencia para ofrecer servicios a personas que viven con VIH/SIDA, 2) las opiniones de éstos sobre el tipo de adiestramiento profesional recibido y la necesidad del mismo, y 3) la manifestación de actitudes estigmatizantes como indicadores de necesidad de adiestramiento profesional. La muestra total del estudio estuvo compuesta por 80 de diversas profesiones de la salud. Los resultados reflejan que algunos/as de los/as participantes han recibido formación en VIH pero ésta no ha sido suficiente para contrarrestar las nociones estigmatizantes. Discutimos las implicaciones de los resultados para investigaciones futuras y el desarrollo de intervenciones con vías de minimizar las nociones estigmatizantes en los escenarios de salud.

Identifying what rural health workers in Malawi need to become HIV prevention leaders

Health workers have high potential as HIV prevention leaders, but health system and individual barriers limit their impact. This descriptive qualitative study identified the HIV prevention needs of rural health workers to use as a basis for tailoring an HIV/AIDS risk-reduction intervention. Data included interviews with 9 health administrators, 22 focus groups with 200 health workers, and 12 observations of caregivers in two rural districts. Health system barriers identified included lack of essential supplies, staff shortages, overcrowded facilities, and lack of training. Individual barriers included hopelessness, stigmatizing attitudes, knowledge gaps, and risky personal behaviors. Health workers also expressed willingness to be HIV prevention leaders and role models. Most results agree with previous African studies. Personal risky behaviors and willingness to be HIV prevention leaders have not been previously reported. Results provide insights for developing effective interventions and health policies to address health workers' HIV prevention needs.

Power brokering, empowering, and educating: the role of home-based care professionals in the reduction of HIV-related stigma in Kenya

In this article the authors report on how home-based care (HBC) professionals reduce stigmatizing behavior in Kenya. This study was part of an action research project that evaluated the introduction of HBC. HBC professionals coordinate the delivery of HIV/AIDS services at a district level and educate community-based health workers in HBC. Understanding how HBC professionals reduce stigma is crucial to reduce, prevent, and treat HIV/AIDS. Fifty HBC professionals participated in 27 focus group interviews over 18 months. Stigma featured strongly when they discussed barriers to the introduction of HBC. Using sociological theory, the authors organized the data into five themes: Power broking and mobilization, Stigma as a social construction, Community and structural interventions, Educating and training people, and Historical context. The HBC professionals appear to operate at mostly individual and community levels in their efforts to challenge stigma, and in spite of the difficulties they appear to be having some impact.

Ensuring sexual and reproductive health for people living with HIV: an overview of key human rights, policy and health systems issues

Despite rhetorical attention there is little programmatic guidance as to how best to ensure that women and men living with HIV have access to sexual and reproductive health services that help them realise their reproductive goals, while ensuring their human rights. A dynamic relationship exists between the manner in which health services and programmes are delivered, and the individuals who seek these services. A review of the literature shows clear gaps and highlights areas of concern not yet sufficiently addressed. The delivery and use of health services and programmes is shaped by the underlying determinants of people's access to and use of these services, the health systems in place at community and country level, and the legal and policy environment these systems operate in. Few governments can provide the full range of services that might be required by their populations. In most places, people access health services from a variety of formal and informal providers, and health-related behaviour is influenced from many directions. The synergistic roles of health systems, law and policy and underlying social determinants in helping or hindering the development and delivery of adequate programmes and services for HIV positive people must be addressed.

Correlates of physicians' attitudes toward communication with HIV/AIDS patients in Ile-Ife, Nigeria

OBJECTIVES

The study assessed physicians' perceptions of HIV/AIDS patients and identified the determinants of physicians' attitudes toward communication with HIV/AIDS patients in Ile-Ife, Nigeria.

METHODS

A semi-structured questionnaire was used to elicit information from 110 physicians in a cross-sectional survey, while in-depth interviews were conducted with 10 people living with HIV/AIDS (PLWHA) who had been previously admitted under the care of the physicians. Univariate, bivariate and multivariate analyzes were conducted.

RESULTS

Although most physicians perceived PLWHA positively and 58% of them displayed a positive attitude toward communication with PLWHA under their care, the expectations of the patients concerning HIV/AIDS communication were not being met. Only 43% of physicians expressed any degree of comfort engaging PLWHA in lengthy discussions or communicating the diagnosis of HIV to patients. The strongest correlates of physicians' positive attitude were previous exposure to HIV/AIDS counseling, the number of HIV/AIDS patients treated per month, the number of years spent in the care of PLWHA, and the gender of the physicians (p < 0.05).

CONCLUSIONS

Physicians in Ile-Ife, Nigeria are not adequately equipped by way of training to effectively meet the expectations of their patients concerning HIV/AIDS communication. The large number of PLWHA in the country calls for urgent attention to address this important aspect of care.

Achieving gold standards in ethics and human rights in medical practice

A new study suggests that some physicians in Nigeria fall short in their ethical conduct. Benatar urges caution in interpreting the study, saying that "comparisons should be made with other countries."

The discriminatory attitudes of health workers against people living with HIV

Letamo discusses the implications of a new study suggesting that some health professionals discriminate against people with HIV.