Male patient perceptions of HIV stigma in health care contexts

HIV and vicarious stigma in a cohort of people living with HIV in Italy: What happens when the stigma is fueled by healthcare providers?

Vicarious stigma shows how indirect stigmatizing experiences can lead people living with HIV (PLWH) to feel discriminated against. We enrolled 350 PLWH, who were administered a 17-item questionnaire to investigate a subjective experience of stigma experienced in the hospital care setting. We found that at least once 215 PLWH (61.4%) did not want the HIV exemption indicated on the prescription for a specialist medical visit, 232 PLWH (66.3%) never used their HIV-related exemption to make a specialist medical visit, 230 PLWH (65.7%) avoided undergoing a medical assessment outside the infectious disease clinics and 241 patients (68.9%) felt unwelcome during a specialist medical visit. Moreover, 241 patients (61.1%) had heard at least once stories of health workers who did not want to touch PLWH, 213 patients (60.9%) had heard stories at least once of PLWH who had been mistreated by hospital staff, 180 patients (51.4%) had at least once heard stories about PLWH being refused treatment and services and 257 patients (73.4%) had at least once heard stories about health workers talking publicly about PLWH. This is a little explored area, especially regarding the vicarious stigma faced by PLWH. Our findings indicate the importance of combating HIV-related stigma for the wellbeing of PLWH.

Provider-patient experiences and HIV care utilization among people living with HIV who inject drugs in St. Petersburg, Russia

Providers' disrespect and abuse of patients is a recognized but understudied issue affecting quality of care and likely affecting healthcare utilization. Little research has examined this issue among people living with HIV (PWH) who inject drugs, despite high stigmatization of this population. No research has examined this issue in the context of Russia. This study assesses patients' reports of disrespect and abuse from providers as a barrier to healthcare and examines the association between these reports and HIV care outcomes.We conducted a cross-sectional analysis of the associations between disrespect/abuse from health providers as a barrier to care and the following HIV care outcomes: (i) anti-retroviral treatment (ART) uptake ever, (ii) past 6-month visit to HIV provider, and (iii) CD4 count. Participants (N = 221) were people living with HIV who injected drugs and were not on ART at enrollment.Two in five participants (42%) reported a history disrespect/abuse from a healthcare provider that they cited as a barrier to care. Those reporting this concern had lower odds of ever use of ART (adjusted odds ratio 0.46 [95% CI 0.22, 0.95]); we found no significant associations for the other HIV outcomes. We additionally found higher representation of women among those reporting prevalence of disrespect/abuse from provider as a barrier to care compared to those not reporting this barrier (58.1% versus 27.3%).Almost half of this sample of PWH who inject drugs report disrespect/abuse from a provider as a barrier to healthcare, and this is associated with lower odds of receipt of ART but not with other HIV outcomes studied. There is need for improved focus on quality of respectful and dignified care from providers for PWH who inject drugs, and such focus may improve ART uptake in Russia.

HIV-related stigma among healthcare providers working within infectious diseases and gynecology and obstetrics at a large teaching hospital in Denmark

HIV-related stigma experienced in healthcare settings may be particularly detrimental to people with HIV (PWH). This study aims to examine the drivers of stigma and enacted HIV-related stigma among healthcare providers working in HIV and non-HIV care at a large teaching hospital in Denmark. In total, 162 providers working in gynecology and obstetrics, and 57 providers working in infectious diseases completed the "Measuring HIV stigma and discrimination among health facility staff" questionnaire. Compared to providers working in infectious diseases, providers working in gynecology and obstetrics had less training in infection control, HIV, and stigma, and although their level of worry and negative attitudes toward PWH was overall low, they were more like to use extra precaution measures (e.g., double gloves) when caring for PWH (20% versus 0%). Addressing HIV-related stigma in healthcare is important, as any amount of HIV-related stigma from providers has the potential to compromise the patients' engagement in care and health outcomes.

The impact of sources of stigma on health care avoidance among gay and bisexual men in Australia

Stigma has a negative impact on health and wellbeing for gay and bisexual men (GBM). There is little research which assesses whether stigma from various sources affects access to different health care services. Further, those people who pay more attention to their stigmatised condition may be more likely to avoid health services. This study aimed to assess the association between sources of stigma and health care avoidance amongst a sample of GBM, as well as the role of heightened stigma sensitivity. The sample consisted of 1116 GBM in Australia who completed an online survey. Findings illustrate that those reporting any stigma were more likely to avoid health care services, while avoiding different types of health care was related to the source of the stigma. Greater stigma sensitivity was associated with avoidance of all health care services. GBM may come to health services with complex and potentially recurrent experiences of stigma. Working on the assumption that clients have a history of negative experiences in health care will increase the ability of services to work sensitively with GBM clients and ensure that access to health care amongst this group is increased.

A Mixed Methods Study of Anticipated and Experienced Stigma in Health Care Settings Among Women Living with HIV in the United States

Among places where people living with HIV experience and anticipate HIV-related stigma, stigma in health care settings may be particularly harmful. Utilizing an exploratory sequential mixed methods approach, we conducted interviews (n = 76) and questionnaires (N = 460) with older adult women living with HIV enrolled in the Women's Interagency HIV Study in Birmingham, AL; Jackson, MS; Atlanta, GA; and San Francisco, CA. Interviews addressed facilitators and barriers to HIV treatment adherence, including HIV-related stigma. Qualitative data were coded using thematic analysis. Questionnaires assessed self-reported antiretroviral therapy (ART) adherence and experienced and anticipated HIV-related stigma from various sources (i.e., health care personnel, family, partner, and community). Covariate-adjusted logistic regression analyses examined total and mediated effects of stigma on ART adherence. Interviewees described fears and experiences of stigma in health care settings; including privacy violations, disrespect for patient autonomy, and reproductive coercion; and how these influenced their adherence to HIV treatment recommendations. Experienced and anticipated HIV-related stigma in health care settings were associated with suboptimal (or <95%) ART adherence in separate models controlling for experienced or anticipated stigma, respectively, from other sources. When entered together, only anticipated stigma in health care settings was associated with suboptimal ART adherence, controlling for anticipated and experienced stigma from other sources. The effect of anticipated stigma in health care settings on suboptimal ART adherence may work through the pathways of lower adherence self-efficacy, higher depressive symptoms, and higher coping by substance use. These findings indicate that interventions should promote cultures of acceptance within health care settings and resilience-based strategies for women to combat stigma and promote life-sustaining behaviors.

"It's Like Birth Control for HIV": Communication and Stigma for Gay Men on PrEP

This study focuses on how gay men communicate about pre-exposure prophylaxis (PrEP), focusing on how they learned about PrEP, how they discussed adoption with health care providers, and to what extent they have encountered stigma on social networks. In this qualitative study, 39 gay PrEP users were interviewed about PrEP. A majority of the participants learned about PrEP via friends and potential sex partners, and a majority of the participants experienced stigma from their health care provider and from other gay men online, mainly referring to promiscuity and risks of STIs. The authors recommend that health care providers should be trained in minimizing the expression of stigmatizing attitudes and should increase their knowledge of PrEP.

Association between Perceived Discrimination in Healthcare Settings and HIV Medication Adherence: Mediating Psychosocial Mechanisms

There is insufficient research on the impact of perceived discrimination in healthcare settings on adherence to antiretroviral therapy (ART), particularly among women living with HIV, and even less is known about psychosocial mechanisms that may mediate this association. Cross-sectional analyses were conducted in a sample of 1356 diverse women living with HIV enrolled in the Women's Interagency HIV Study (WIHS), a multi-center cohort study. Indirect effects analysis with bootstrapping was used to examine the potential mediating roles of internalized stigma and depressive symptoms in the association between perceived discrimination in healthcare settings and ART adherence. Perceived discrimination in healthcare settings was negatively associated with optimal (95% or better) ART adherence (adjusted odds ratio (AOR) = 0.81, p = 0.02, 95% confidence interval (CI) [0.68, 0.97]). Furthermore, internalization of stigma and depressive symptoms mediated the perceived discrimination-adherence association: Serial mediation analyses revealed a significant indirect effect of perceived discrimination in healthcare settings on ART adherence, first through internalized HIV stigma, and then through depressive symptoms (B = - 0.08, SE = 0.02, 95% CI [- 0.12, - 0.04]). Perceiving discrimination in healthcare settings may contribute to internalization of HIV-related stigma, which in turn may lead to depressive symptoms, with downstream adverse effects on ART adherence among women. These findings can guide the design of interventions to reduce discrimination in healthcare settings, as well as interventions targeting psychosocial mechanisms that may impact the ability of women living with HIV to adhere to ART regimens.

Arab dentists' refusal to treat HIV positive patients: a survey of recently graduated dentists from three Arab dental schools

OBJECTIVE

To assess intended refusal of recent graduates from three Arab dental schools to treat HIV + patients and factors associated with this intention.

MATERIALS AND METHODS

In 2015, convenience samples of recent dental graduates were included from Libya, Egypt and the United Arab Emirates. Participants responded to a questionnaire assessing personal background, knowledge of oral manifestations and fluids transmitting HIV, perceived adequacy of training and self-efficacy to manage blood exposures, attitude to risk of infection, moral beliefs and willingness to treat HIV + patients. Logistic regression assessed factors associated with intended refusal to treat HIV + patients.

RESULTS

The overall response rate was 552/710 (77.8%), mean age = 23.7 years with 41.8% males. The mean (SD) scores for knowledge of oral manifestations and fluids transmitting HIV were 5.5 (1.3)/8 and 4.2 (1.7)/7. The mean (SD) scores for attitude to risk of infection and moral beliefs were 2.9 (1.0)/4 and 2 (0.9)/3, respectively. One-third of respondents indicated intention to refuse treating HIV + patients. Knowledge of body fluids transmitting HIV and moral beliefs were associated with lower odds of refusing to treat HIV + patients (OR = 0.86 and 0.38) whereas attitude indicating greater concern for risk of infection was associated with higher odds (OR = 1.54).

CONCLUSIONS

One third of dentists from three Arab dental schools indicated they would refuse to treat HIV + patients. Adequate knowledge and moral beliefs reflecting professional ethics were associated with lower odds of refusal counterbalancing the association with attitude indicating increased concern for risk of infection with implications for dentist education and training.

PrEP on Twitter: Information, Barriers, and Stigma

On May 14, 2014 the Centers for Disease Control and Prevention (CDC) endorsed the drug Truvada as an HIV preventative, called pre-exposure prophylaxis (PrEP). PrEP has been shown to dramatically reduce the risk of HIV infection, but its rate of adoption has been slow, and discourse surrounding it has been marked by stigma and uncertainty. The purpose of this study was to investigate how PrEP was discussed on Twitter. Our analysis focused on barriers to PrEP adoption and stigmatization of PrEP users. We analyzed a random sample of 1,093 top tweets about PrEP posted to Twitter a year before and a year after the CDC's endorsement. Our results showed that tweets likely reinforced uncertainty about barriers to PrEP adoption and that users employed Twitter's functionality to counter stigmatizing narratives about PrEP. We suggest that our findings illuminate both the limitations and strengths of Twitter as a mechanism for health promotion.

HIV-Related Stigma Among Healthcare Providers in the Deep South

Stigma towards people living with HIV (PLWH) in healthcare settings is a barrier to optimal treatment. However, our understanding of attitudes towards PLWH from healthcare providers' perspective in the United States is limited and out-of-date. We assessed HIV-related stigma among healthcare staff in Alabama and Mississippi, using online questionnaires. Participants included 651 health workers (60 % White race; 83 % female). Multivariate regression suggests that several factors independently predict stigmatizing attitudes: Protestant compared to other religions (β = 0.129, p ≤ 0.05), White race compared to other races (β = 0.162, p ≤ 0.001), type of clinic (HIV/STI clinic: β = 0.112, p ≤ 0.01), availability of post-exposure prophylaxis (yes: β = -0.107, p ≤ 0.05), and perceptions of policy enforcement (policies not enforced: β = 0.058, p = p ≤ 0.05). These findings may assist providers wishing to improve the quality care for PLWH. Enforcement of policies prohibiting discrimination may be a useful strategy for reducing HIV-related stigma among healthcare workers.

Stigma, HIV and health: a qualitative synthesis

Background

HIV-related stigma continues to negatively impact the health and well-being of people living with HIV, with deleterious effects on their care, treatment and quality of life. A growing body of qualitative research has documented the relationship between HIV-related stigma and health. This review aims to synthesize qualitative evidence that explored the intersections of stigma and health for people with HIV.

Methods

A thematic summary was conducted that was guided by the qualitative metasummary technique developed by Sandelowski and Barraso. Literature searches yielded 8,622 references of which 55 qualitative studies were identified that illustrated HIV-related stigma in the context of health.

Results

The metasummary classified qualitative findings into three overarching categories: conceptualizing stigma which identified key dimensions of HIV-related stigma; experiencing stigma which highlighted experiences of stigma in the health context, and managing stigma which described ways in which stigma is avoided or addressed. To better illustrate these connections, the qualitative literature was summarized into the following themes: stigma within health care settings, the role of stigma in caring for one’s health, and strategies to address HIV-related stigma in the health context. A number of health care practices were identified – some rooted in institutional practices, others shaped by personal perceptions held by practitioners – that could be stigmatizing or discriminatory towards people with HIV. There existed interconnections between enacted stigma and felt stigma that influenced health care utilization, treatment adherence, and overall health and well-being of people with HIV. Intersectional stigma also emerged as instrumental in the stigma experiences of people living with HIV. A number of strategies to address stigma were identified including social support, education, self-efficacy, resilience activities, and advocacy.

Conclusion

This review of the qualitative evidence indicates that HIV-related stigma within health contexts is a broad social phenomenon that manifests within multiple social spheres, including health care environments. Findings from this review indicate that future stigma research should consider the social structures and societal practices – within and outside of health care environments – that perpetuate and reinforce stigma and discrimination towards people with HIV.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-2197-0) contains supplementary material, which is available to authorized users.

Improving hospital-based quality of care by reducing HIV-related stigma: evaluation results from Vietnam

Operations Research conducted at four hospitals in Vietnam sought to reduce HIV-related stigma and discrimination among hospital workers. The quasi-experimental study compared effects of focusing on 'fear-based' stigma (stemming from lack of knowledge) versus both fear-based and social stigma (stemming from moral judgments). Interventions included staff training (ranging from physicians to ward cleaners), hospital policy development, and supplies provision. At baseline (n = 795), reported stigma was substantial (e.g., about half of hospital workers indicated fear of casually touching PLHIV, and felt HIV was a punishment for bad behavior). By endline, stigma measures had improved significantly for both intervention groups (e.g., proportion reporting signs on beds indicating HIV status decreased from 51 to 24 % in Arm 1, and 31 to 7 % in Arm 2), with the combined intervention group showing greater effects. This study highlights successful strategies to reduce stigma, and thus, improve quality of care for PLHIV.

Patient and provider perspectives on HIV and HIV-related stigma in Dutch health care settings

Ensuring that people living with HIV (PLWH) feel accepted in health care settings is imperative. This mixed methods study explored the perspectives of PLWH and health professionals on their interactions. A total of 262 predominantly gay men of Dutch origin participated in a survey study of possible negative interactions with health professionals, and semi-structured interviews were subsequently conducted with 22 PLWH and 14 health professionals. Again, most PLWH were gay men of Dutch origin. All health professionals were Dutch. PLWH reported negative experiences with health professionals including awkward interactions, irrelevant questions, rude treatment, blame, pity, excessive or differential precautions, care refusal, unnecessary referrals, delayed treatment, poor support, and confidentiality breaches. They also reported positive experiences including equal treatment, being valued as a partner in one's health, social support provision, and confidentiality assurances. Health professionals reported having little experience with PLWH and only basic knowledge of HIV. They contended that PLWH are treated equally and that HIV is no longer stigmatized, but also reported fear of occupational infection, resulting in differential precautions. Additionally, they conveyed labeling PLWH's files to warn others, and curiosity regarding how patients acquired HIV. The findings suggest that there is a gap in perception between PLWH and health professionals regarding the extent to which negative interactions occur, and that these interactions should be improved. Implications for stigma reduction and care optimization are discussed.

The impact of pluralistic ignorance on the provision of health care for people who inject drugs

Health workers who work with people who inject drugs may believe that their colleagues hold less favorable attitudes toward health services for people who inject drugs than themselves—a phenomenon termed pluralistic ignorance. This research explores whether the presumed attitudes of their colleagues, rather than their own attitudes, predict the behavioral intentions of health workers toward people who inject drugs. A total of 57 hospital-based health workers were surveyed to assess their attitudes toward harm reduction services for people who inject drugs and their perceptions of colleagues’ attitudes. They then responded to a scenario assessing their likelihood of prescribing opiate-based medication to people who inject drugs. Data illustrate that participants support harm reduction services for people who inject drugs more than they believe their colleagues do, demonstrating pluralistic ignorance. Interestingly, participants’ prescription of opiate-based pain medication was predicted by beliefs about their colleagues’ support for services for people who inject drugs, rather than their own beliefs.

Measuring stigma among health care and social service providers: The HIV/AIDS Provider Stigma Inventory

Initial validation of the HIV/AIDS Provider Stigma Inventory (HAPSI), piloted on a sample of 174 nursing students, supported the psychometric qualities of a suite of measures capturing tendencies to stigmatize and discriminate against people living with HIV/AIDS (PLHA). Derived from social psychology and mindfulness theories, separate scales addressing awareness, acceptance, and action were designed to include notions of labeling, stereotyping, outgrouping, and discriminating. These were enhanced to capture differences associated with personal characteristics of PLHA that trigger secondary stigma (e.g., sexual orientation, injection drug use, multiple sex partners) and fears regarding instrumental and symbolic stigma. Reliabilities were strong (coefficients α for 16 of 19 resulting measures ranged from 0.80 to 0.98) and confirmatory factor analyses indicated good model fit for two multidimensional (Awareness and Acceptance) and one unidimensional (Action) measure. Evidence of convergent construct validity supported accuracy of primary constructs. Implications for training and professional socialization in health care are discussed.

HIV-related stigma and psychological distress: the harmful effects of specific stigma manifestations in various social settings

OBJECTIVES

Recent research has shown that experiences of stigmatization have an adverse impact on the psychological well being of people living with HIV/AIDS (PLWHA). Most studies investigating this relationship employ an aggregate measure of stigma. Although this approach provides useful information about the psychological implications of HIV-related stigma in general, it neglects to acknowledge the possibility that some manifestations in specific settings may be psychologically more detrimental than others. The present study examines which specific stigma experiences are most strongly related to psychological distress across a number of social settings.

METHODS

A cross-sectional survey was administered to 667 PLWHA in the Netherlands. We examined participants' experiences of 11 manifestations of HIV-related stigma in six social settings. Linear regression analyses were conducted to determine which setting-specific manifestations best predict psychological distress after controlling for marital status, education and health status.

RESULTS

Three manifestations in family settings, namely receiving advice to conceal one's status, being avoided and being treated with exaggerated kindness, and one manifestation in healthcare settings, namely awkward social interaction, best predicted psychological distress in PLWHA.

CONCLUSION

Manifestations of HIV-related stigma vary according to setting. Certain manifestations in specific social settings impact the psychological well being of PLWHA more than others. In this study, certain experiences of stigmatization with PLWHA's families and in healthcare settings were more strongly related to psychological distress than experiences occurring in other social settings. These findings suggest that stigma reduction interventions focusing on these influential settings may benefit the psychological well being of PLWHA.

Patients' perceptions of discrimination during hospitalization

OBJECTIVE

To identify sources of perceived discrimination during hospitalization and examine the relationship of perceived discrimination to patient and hospital stay characteristics, and to patient ratings of care.

BACKGROUND

Patient experiences of discrimination within the health-care system are associated with delays in care seeking, non-adherence to medical advice and poorer health status. Most research to date has focused on race and ethnicity-based discrimination, and few studies have included hospitalized patients.

METHODS

Questions about patients' experiences of discrimination were added to a regular patient opinion survey conducted at the Geneva University Hospitals. Participants were 1537 adult residents of Switzerland discharged from the hospital between 15 February and 15 March 2007.

RESULTS

A total of 171 (11.1%) respondents reported at least one source of discrimination. Most (93, 54.4%) reported a single cause of discrimination. The most frequent causes of discrimination were language, age, nationality and having a disease that is viewed negatively by others. Fifteen percentage of non-European respondents reported at least one of the following types of discrimination: language, nationality, religion and skin colour. Reporting discrimination from any cause was associated with higher Picker Patient Experience problem scores, and patients who reported discrimination were less likely to describe their care as very good or excellent and less likely to recommend the hospital to others.

CONCLUSIONS

Patient experiences of discrimination during hospitalization are relatively frequent and are associated with lower patient ratings of care. Collection of data on patient experiences of discrimination may contribute to the development of interventions aimed at ensuring respectful, quality care for all patients.

Experiences of stigma and discrimination among adults living with HIV in a low HIV-prevalence context: a qualitative analysis

Little is known about how people living with HIV in low prevalence contexts face the challenges of stigma and discrimination. Low prevalence and rural communities are unique environments in which HIV-related stigma and discrimination may be intensified due to lower tolerance of differences among people and greater fear of HIV. This study examined the experiences of 16 individuals living with HIV who reside in a predominantly rural area with low HIV prevalence. We used in-depth interviews to explore participants' experience with stigma and discrimination in social and health care settings and their behavioral and emotional responses. In their day-to-day lives, participants described feeling social rejection, being forced to follow different rules of social contact, and being treated differently. In health care settings, participants described specific instances when they felt providers were afraid of them and when they were refused or discouraged treatment or treated differently based on their HIV status. Participants experienced stigma and acts of discrimination in different settings (e.g., physician and dentist offices and hospitals) and from a range of types of providers (e.g., physicians, nurses, and dentists). Behavioral and emotional responses to perceived acts of stigma and discrimination included anger, shame, social isolation, and self-advocacy. Findings point to a need to develop tailored interventions to address stigma and discrimination for individuals, health care personnel and the community-at-large.