An Investigation on People Living with HIV and AIDS Rejected by Medical Staff in China

Background: A cross-sectional survey was conducted from the two perspectives of the incidence, type, help-seeking situation of PLWHA (cid:0) People living with HIV and AIDS (cid:0) rejected by medical staff and the willingness of medical staff to diagnose and treat PLWHA to analyze the realistic problem of PLWHA and AIDS rejected by medical staff under the current Chinese cultural background. Methods: 1500 people were selected from PLWHA users in the WeChat work account of a Center for Disease Control and Prevention(CDC), and 1000 medical staff were selected from a third-class hospital in Guangxi, China. The self-compiled general information questionnaire and PLWHA medical rejection questionnaire were used to conduct a one-to-one WeChat online survey on PLWHA. A questionnaire on HIV/AIDS clinical knowledge, a questionnaire on HIV/AIDS attitude, and a questionnaire on the willingness to diagnose and treat PLWHA with clinical surgery were used to conduct a face-to-face survey on the selected medical staff. Results: 1146 valid PLWHA samples and 890 medical staff samples were obtained. 30.2% (346/1146) of HIV-infected/AIDS patients had experienced refusal from medical staff when visiting a hospital for non-HIV/AIDS-related diseases since the diagnosis of HIV+; 17.1% (196/1146) of HIV-infected/AIDS patients had been rejected by medical staff in the hospital due to other diseases in the past 12 months and 10.8% (124/1146) had been rejected in clinical surgeries; after receiving a refusal, 58.2% (114/196) of the HIV-infected/AIDS patients never asked for help, while only 37.8% (74/196) of the refused patients were resolved accordingly. Only 38.7% of medical staff clearly expressed their willingness to provide surgical treatment or post-operative nursing services for HIV-infected/AIDS patients. After controlling other factors, the answer accuracy of HIV/AIDS-related knowledge [odds ratio (OR)=2.41, 95% condence interval (CI): 1.31, 4.43] and the attitudes towards HIV/AIDS (OR=6.74, 95%CI: 3.59, 12.66)


Background
It has been nearly 40 years since the rst case of AIDS was recorded in 1981. The world has suffered greatly due to AIDS and its pathogen; HIV (Human Immunode ciency Virus). Although much progress has been made in the prevention and treatment of HIV/AIDS over the past decade, the HIV pandemic remains the most serious challenge facing the global public health eld [1] . According to data from National Center for AIDS/STD Control and Prevention (NCAIDS), China CDC, a total of 849,602 cases of PLWHA were reported nationwide as of September 30, 2018; including 497,231 HIV-infected patients and 352,371 AIDS patients [2] . However, the discrimination and stigmatization of PLWHA has inevitably produced a culture of discrimination. In China, most people still regard HIV/AIDS as only the consequence of homosexuality, commercial sex, and drug abuse [3] [ 4][5] [6] . In fact, most HIV infections in China occur in rural areas [7] [8] .In October 2012, Xiaofeng, an HIV-infected person, was admitted to Tianjin Cancer Hospital for lung cancer but was forced to leave the hospital on the eve of the operation because of HIV. Afterwards, Xiaofeng had to modify the HIV test report privately and obtain an operation in another hospital in Tianjin. Later, Li Hu, the former head of the Tianjin Haihe Star AIDS Working Group, disclosed the incident through Sina Weibo; which caused huge controversy throughout China. On November 21st, 2012, Chinese Premier Li Keqiang immediately called the head of the Ministry of Public Health after seeing relevant news reports; asking the health department to take practical measures to protect the rights of AIDS patients to receive medical treatment without discrimination and to protect the safety of medical staff. The next day, the Ministry of Public Health issued the "Notice on Strengthening Medical Services for HIV-Infected/AIDS Patients". After investigation, the Tianjin Health Bureau stated that Tianjin Cancer Hospital had prevaricated AIDS patients. It revealed the serious discrimination against HIV-infected/AIDS patients seeking medical care in Chinese medical and health service institutions, and also highlighted an important issue: refusal of treatment by medical staff is a common phenomenon during the treatment of HIV-infected/AIDS patients in China due to misunderstandings and discrimination against the PLWHA; many medical workers are less willing to diagnose and treat PLWHA.
Being rejected by medical staff in this study refers to the fact that medical institutions prevaricate or refuse to treat patients with HIV-infected/AIDS [9] . Their willingness to diagnose and treat patients refers to the attitude of health service providers to provide emotional, material and technical support to PLWHA [10] .
Since the 1990s, PLWHA's health status has improved with the use and promotion of Highly Active Anti-Retroviral Therapy(HARRT); this includes reduced morbidity and mortality, longer survival time and improved quality of life [11] [12] . Although there is no cure for HIV/AIDS, signi cant progress has been made in recent years, especially in the development of HARRT; which has effectively extended the lifespan of many PLWHA and reduced opportunistic infections [13] [14] . Therefore, the accessibility of long-term PLWHA in medical and health services has become the primary concern of PLWHA [15] . However, China has a higher PLWHA mortality rate due to the di culty in accessing comprehensive disease-related prevention, treatment and care services [16] compared with developed countries. There are still many medical ethics disputes over the rejection of PLWHA in many countries. In Germany, 28% of health service workers are unwilling to provide medical services to PLWHA to protect themselves and their families [17] . The research results of Cai [18] and Oyeyemi [19] also proved that most nurses are reluctant to provide nursing services for PLWHA. This study conducts a cross-sectional survey from the two perspectives of the incidence, type, help-seeking situation of PLWHA(People living with HIV and AIDS)rejected by medical staff and the willingness of medical staff to diagnose and treat PLWHA to analyze the realistic problem of PLWHA and AIDS rejected by medical staff under the current Chinese cultural background.

Participants
The objects of this study consider two aspects: PLWHA and the medical staff.
PLWHA belongs to the inaccessible population. According to the pilot survey, it is di cult to guarantee the privacy of the investigation and the personal privacy of PLWHA during the eld investigation at the CDC and the outpatient department of Infectious Disease Hospital. The PLWHA's cooperation degree is quite low and the investigation is di cult to proceed. In consideration of the current development and popularization of WeChat media, this study took the PLWHA users on the WeChat public account established by the XX City CDC as the research object. The WeChat platform was established in July 2014 to provide the PLWHA and people affected by HIV/AIDS with popular scienti c knowledge concerning AIDS, psychological counseling, and medication guidance. The platform has about 74000 online fans and accumulated more than 140000 followers; 90% of whom are HIV-infected, others are family members, volunteers, AIDS specialists in grassroots CDC and designated hospitals, others are AIDS-phobic people and numerous people interested in HIV/AIDS. For PLWHA with further consultation needs on the WeChat platform, we will provide a dedicated WeChat ID for further communication. As of September 1st 2018, there are 9,987 PLWHA in the 3 WeChat accounts of the CDC. Based on the sample size standards for sentinel surveillance of high-risk groups of sexually transmitted infections (usually in 250 ~ 400) recommended by the World Health Organization and the CDC [20] and the convenience of contacting samples of "we media" and the objective conditions limiting the di culty of investigation on sensitive issues such as HIV/AIDS, the minimum sample size of PLWHA has been determined to be 1,500 people. In this study, simple random sampling was used to select samples. Firstly, we established a sampling frame containing 9,987 PLWHA and then selected one infected person from the top 10 of the list as a random starting point. Next, we sequentially selected the remaining sample units; 1 person was selected every 6 people until 1,500 people were drawn. The researchers contacted participants using the WeChat ID and conducted a one-to-one questionnaire survey via the WeChat line.
The medical staff in this study are doctors and nurses from a third-class hospital in Guangxi. The hospital, directly under the Health Commission of Guangxi Zhuang Autonomous Region, is a class A, grade III general hospital integrating medical treatment, teaching, scienti c research, prevention, health care, rehabilitation and other functions. It currently has more than 1,200 hospital beds and 1,900 employees. Approved by the hospital's ethics committee and based on the hospital's staff roster, we randomly selected 400 clinicians and 600 nurses in the hospital. The investigators contacted the selected doctors and nurses to conduct a one-to-one questionnaire survey with them. The failure of the respondent to cooperate with the investigator on three visits was deemed as a refusal of the investigation. Questionnaires The questionnaire consists of two parts: rstly, the general information section which includes social demographic characteristics, namely gender, age, nationality, education, marital status, and average monthly income. PLWHA should be inquired about the route of HIV infection and medical staff should be asked about employment years, title and department, etc. Secondly, the PLWHA medical rejection section which includes the following 5 items: since the diagnosis of HIV+, has there been a refusal from medical staff when visiting a hospital, whether there has been a refusal from medical staff when visiting a hospital in the last 12 months. For PLWHA who have been rejected in the past 12 months, we need to further ask about the types of rejection: non-surgical disease outpatient service, clinical surgery, clinical postoperative care, non-postoperative care, psychological outpatient service, other hospital treatments, etc. Fourthly, the patients seeking help after a refusal and nally if the refusal has been properly resolved after the patients sought help. In addition, a self-compiled questionnaire on HIV/AIDS clinical knowledge among medical staff, with 24 items has been issued. To ensure the quality of the survey, we rstly conducted a pre-survey with 40 medical staff before adjusting, improving and modifying the structure and content of the questionnaire based on the results. The nal questionnaire has good reliability and validity, as well as the Cronbach has α coe cient > 0.7. The questionnaire on HIV/AIDS attitude has 24 items; which are derived from the AIDS Attitude Scale (AAS) compiled by Froman [21] and a related questionnaire by Aeree [22] as well as the self-compiled questionnaire of medical staff's willingness to diagnose and treat PLWHA has a total of 11 items. The questionnaire includes emotional, material, and technical support. It has good reliability and validity as well as a Cronbach reading of α coe cient > 0.7. Quality control All PLWHA samples were investigated by investigators for WeChat one-to-one online interviews, while medical staff samples were investigated by investigators for one-on-one on-site questionnaires. The investigators were uniformly trained and each online investigation was conducted in a quiet, undisturbed environment. Every questionnaire must be veri ed on-site and the items that were not answered in time or clearly by the respondent were questioned and con rmed based on ensuring compliance with ethical principles. Statistical method EpiData 3.1 was used to establish a database and SPSS 20.0 was used for statistical analysis. The test level (α) was taken as 0.05 and the positive rate of different groups was compared by the χ2 test (Pearson Chi-Square Test). The t-test was used to compare the measurement indexes between different groups, and the Ordinal rank regression analysis was used for multivariate analysis.

Results
A questionnaire survey of 1500 PLWHA was conducted from September 1, 2018 to March 1, 2019. Among them, 101 people could not be contacted because their WeChat ID was no longer used and 220 people refused to cooperate with the survey. 13 people interrupted the online investigation due to private affairs during the investigation. The number of PLWHA who nally completed the survey was 1166 and the response rate was 77.27%. After excluding 20 invalid questionnaires with serious logical confusion, 1146 valid PLWHA samples were ultimately obtained. As shown in Table 1, the oldest age was 66 years old, the youngest was 17 years old, and the mean age was (31 ± 8) years old. 96.1% (1101/1146) of the respondents were male, 93.6% (1073/1146) were Han nationality, 53.0% (608/1146) had a bachelor's, master's degree or above, 72.1% (826/1146) were unmarried, 58.5% (670/1146) were from cities, 43.5% (498/1146) were the only children, and 10.6% (121/1146) were students.  The incidence, type, help-seeking situation of PLWHA rejected by medical staff test results showed that there was no signi cant difference in the incidence, type and help-seek data of rejection in between men who have sex with men and those infected by other means.  (2,3,5,6,8,9,13,14,15,17,19,21,22). Among them, the correct answer rate of 6 questions in the doctor group (2,3,5,15,19,22) was higher than that of the nurse group; while the answer rate of 7 questions in the nurse's group (6,8,9,13,14,17,21)    3.52 *** * .P 0.05; ** .P 0.01; *** .P 0.001 The χ2 test results displayed that there was a statistically signi cant difference in the answers between the doctors and nurses on 11 items (2,3,4,7,12,13,16,17,18,22,23). After reversing the scores of 12 reverse scoring items (8,9,11,13,14,16,17,19,20,21,23,24) in the HIV/AIDS attitude questionnaire, adds the scores of other items to obtain the total score of each sample. The total score is between 24 and 120 points. The higher the score, the more negative the attitude towards HIV/AIDS. The scores of 890 respondents ranged from 30 to 87, with an average of 62.18 ± 9.75. As shown in Table 5, the t-test results show that there were statistically signi cant differences in 15 items (1,3,4,5,7,12,13,15,16,17,18,23,24) and total scores between the doctors and nurses groups. After controlling for age, marital status, educational, professional title, employment years and other factors, the difference between the two groups was still statistically signi cant (OR = 1.55, 95%CI: 1.01, 2.38), and the doctor group's attitude towards HIV/AIDS was more negative. After controlling for these factors, HIV/AIDS knowledge is the in uencing factor of the medical staff's attitude towards PLWHA (OR = 1.57, 95%CI: 1.06), 2.31).
Medical staff's willingness to diagnosis and treat HIV-infected /AIDS patients In this study, 11 items in Table 6 were used to evaluate the willingness of all samples for the surgical treatment of PLWHA. Reverse entries 1, 3, 7, 8, 9 are scored as 1 point for answers "disagree" and "totally disagree", 0 points for responses "agree" and "totally agree"; and forward entries 2, 4, 5, 6, 10, 11 are scored as 1 point for answers "agree" and "totally agree", 0 points for responses "disagree" and "totally disagree". The scores of 11 items are added together. The higher the score, the stronger the willingness to treat PLWHA.The scores of 890 respondents ranged from 1 to 9, with an average of 5  [23] . At present, AIDS has been regarded as a preventable and controllable chronic disease. If HIV-infected persons receive timely and appropriate antiretroviral treatment, functional treatment can be successfully achieved and life expectancy can almost not be affected [24]. Nearly half of the participants do not understand this; even nearly 40% of medical staff don't know what cocktail therapy is. Only around 40% of medical staff understand that "after exposure to HIV, drug blocking can be performed within 72 hours" whilst nearly 40% of medical staff believe that "as long as they come into contact with the blood, semen, vaginal secretions, and exudates from severely ulcerated wounds from an HIV/AIDS infected person, they will be infected". Therefore, we believe that it is still necessary for doctors and nurses to learn and train HIV/ AIDS-related clinical knowledge to improve the medical staff's willingness to treat PLWHA. Then, why do our Chinese medical staff behave so differently when facing patients with different infectious diseases? At this time we can't help but ask questions about the reasons for this. The intentions that cause Chinese medical staff to reject PLWHA are thought-provoking.
At present, the Chinese medical treatment of PLWHA is mainly carried out through the vertical medical management model of the CDC-Infectious Disease Hospitals. However, the surgical systems of infectious disease hospitals in various regions are not perfect and it is di cult to carry out large-scale surgical operations. Most general hospitals in China will conduct routine HIV antibody testing before surgery. Once a patient is found to be HIV-positive, doctors often tactfully refuse surgery, which makes it di cult for the PLWHA to obtain corresponding medical treatment [25] and due to this, the problems of PLWHA seeking medical treatment and surgery are becoming increasingly prominent. Discrimination against PLWHA among medical workers is widespread [26] [27] and their willingness to provide medical services to PLWHA is low. This discriminatory attitude directly affects the tendency of HIV-infected people to seek medical treatment and causes high-risk groups of HIV to conceal their infection status and be unwilling to undergo HIV voluntary counseling and testing. It also makes them unwilling to learn knowledge and information to protect themselves and others [28] . PLWHA has become an uncontrolled source of infection and objectively promotes the spread of AIDS [29] [30] . In fact, after successful antiviral treatment, the viral load of HIV-infected people is lower than the detection limit (20copies/ml), which is no different from ordinary people and it is not infectious [31]. However, according to the survey results of this study, only nearly 40% of medical staff clearly expressed their willingness to provide diagnosis and treatment services for PLWHA; which shows the rejection of HIV-infected patients.
Chinese "AIDS Prevention and Control Regulations" clearly states that medical institutions must not shu e or refuse treatment because the patients they see are PLWHA. The Ministry of Health issued a notice on November 23, 2012, requiring all localities to do a good job in PLWHA antiviral treatment and other medical services, implement the rst-diagnosis responsibility system, and strictly prohibit shu e or refusal of diagnosis and treatment. Whether medical staff are willing to provide medical services for PLWHA is directly related to their lives and health. How can the current Chinese medical staff's refusal behaviors for PLWHA be resolved? We think there are two ways out: the reason for the low willingness of medical staff in diagnosis and treatment and the di culty of PLWHA surgery is the lack of system, which has nothing to do with medical ethics. System construction should be improved to protect the legal rights and interests of medical staff, solve the problems that may cause damage to their lives and health due to occupational exposure, and mobilize the enthusiasm of the medical staff. The second is "public welfare compensation"; further improving the risk compensation and incentive mechanism for the hospitals and medical staff to receive PLWHA and avoid the worries of doctors so that medical staff will not refuse to treat them.
This study also has certain limitations; for example, we only investigated the PLWHA of a certain CDC WeChat account. Among the 1146 valid samples, men who had sex with men accounted for 86.6% (992/1146). We believe this is related to the higher education level of men who have sex with men and the daily interaction of friends who rely more on Blued, WeChat, Weibo and other new media. The situation of men who have sex with men is also unique. Our results cannot be generalized to the entire PLWHA group because of sample bias. Due to the di culty of the actual survey in the PLWHA special population, for the 220 (14.67%) survey subjects who did not cooperate with the investigation, we did not record their basic information such as age, gender and infection route. Therefore, we cannot give a speci c explanation as to whether there is a difference between the situation of the persons who do not cooperate with the investigation and the persons who cooperate, and whether it will affect the results of this research. In addition, we conducted the investigation through the WeChat connection. There are still some differences between WeChat's connection and a face-to-face survey. For example, during the WeChat online survey, it was di cult for us to comprehend the environment of the survey; other details such as the participants' body language were also di cult to observe. Finally, this survey is only a crosssectional survey; the respondents' recall bias or reporting bias on some issues is still out of control. For example, some PLWHA cannot recall the previous situation well. In the case of sensitive problems, some respondents may be unwilling to give correct answers and cause reporting bias. A standardized form of verbal informed consent was obtained in this study, which included counseling on the risks, bene ts and anonymities. Informed consent was obtained from all the samples and was documented on a standardized form that was included in samples' paper study record. The institutional review boards and ethics committees that obtained the verbal informed consent reviewed this study.

Consent to publish
Not applicable.

Availability of date and materials
The datasets used and analysed during the current study are available from the corresponding author on reasonable request.