HIV-related S&D, especially occurred within health facilities, is a recognized barrier to HIV detection, disclosure of sero-status, access to care and adherence to anti-retroviral treatment (ART) [15, 24-26]. Researches also confirmed that the quality of care is compromised for PLWH because of stigma and the quality of life of PLWH is undermined [12, 15, 27]. Effective and large-scale S&D intervention delivery is still impeded by critical challenges and it is believed that relevant and consistent scaling of S&D is the key to address the issue [28]. Hence, this study aims to explore the factors attributable to S&D of PLWH in 18 Shenzhen hospitals. It is envisaged that the findings from this study may inform the intervention of reducing HIV-related S&D in health care settings.
Worry of being infected
It’s been established that worry of being infected and biased opinions are the essential drivers behind S&D behavior against PLWH[3, 8, 20, 24, 28, 29]. Like other studies, findings from this study demonstrate that drivers of S&D are still prevalent among health facilities resulting in staff working in hospitals themselves becoming active participants in S&D targeting PLWH [11].
The proportion of health staff expressing worry about being infected when caring PLWH is higher than these reported by Shah et al [18], Nyblade et al [16] and Kriengkrai et al [17] who were using the same measurement tool with their studies among healthcare workers. More specifically, findings from our study confirmed the hypothesis that health care staff are most worried when it’s likely to contact PLWH’s body fluids. Such wide spread of fear is quite anxious when China’s relatively low prevalence of HIV infection is taken into account, and the fact that most respondents agree there are adequate supplies and standardized protocols in health facility to reduce risk of becoming infected with HIV (Table 2. B). This extensive worry in patient care might be associated with the generally higher baseline of anxiety among medical staff in China as they are facing higher workload and challenging doctor-patient relationship. These factors may overlap with or aggregate the worry caused by infection exposure risk.
On the other hand, a research in China [30] demonstrates that stigma toward PLWH is associated with HIV prevalence. They illustrated that less HIV stigma is reported in countries with relatively higher HIV prevalence and suggested more resources (e.g., funds) in promotion of laws and policies as well as education against HIV stigma were implemented in these countries. Another similar studies also found that high levels of fear of contagion among health workers is related to a lack of understanding about HIV and HIV transmission, and how to protect oneself in the workplace through universal precautions [20, 31-34]. Therefore, future intervention programs addressing HIV stigma drivers should focus on educating people about HIV and HIV transmission, especially among countries or regions with low HIV prevalence.
Risk factors of fearing HIV infection
Results from the logistical regression suggests that nurses are more concerned of occupation infection risk than doctors. This finding is also confirmed in Samir Shah’s study[18]. It can be partially explained that nurses usually spend more time with patients and have more hands-on practice in terms of patient care compared to other medical professions. From another perspective, since doctors in our survey have higher education than nurses, doctors may be better equipped with the knowledge about HIV infection control than nurses which in turn result in less fear. For instance, a study from Italy indicated among nurses with good knowledge about HIV, only 2% refused to care for patients based on their HIV status[35]. Oppositely, a study in Jordan found that 84% of nurses with less understanding of HIV refused to provide care to PLWH[36]. Thus more attention should be directed to addressing the worry or fear among nurses in S&D reduction program via knowledge building and training concerning HIV infection control.
Analysis of influencing factors showed that receiving training in reducing S&D is less anxious than these untrained. This further indicates that there is a large room for improvement in reducing discrimination in the following train-based interventions. Since public health interventions are often complex and this makes intervention challenging, stigma reduction activities in hospitals, mainly based on the training on HIV-related knowledge and behavior [15, 19, 20]. Research in Nyblade’s had improved significantly effect to reduce HIV-related S&D among hospital workers through the intervention of staff training on HIV transmission, prevention, and appropriate infection control. Especially combined fear-based and enacted stigma, they reported more reductions than fear-based stigma alone in intervention groups [3, 20]. Another two studies conducted in China [37, 38] also demonstrated that staff training will significantly decrease HIV-related stigma.
It's interesting to know that working in private hospital are also protective factors against worrying being infected with HIV. The possible reason is speculated to be as follows: firstly, in order to compete with public hospitals, private hospitals pay more attention to patient care; Secondly, due to relatively limited medical and human resources, private hospitals have less opportunities to contact HIV-positive people and worry of being infected HIV in actual operation is relatively rare. Quite few studies can be found in this domain and further investigations are needed to shed light on this discrepancy between public and private hospitals.
Biased opinions against PLWH
Among the biased opinions against PLWH, health staff are less likely to stigmatize PLWH morally but more likely to be biased against them from a professional perspective [3, 39, 40]. PLWH is usually associated with the MSM, IDU and sexual workers, thus the general held the deep-rooted prejudice that HIV/AIDS is a punishment for their bad behavior [4, 7]. A qualitative study conducted by Kriengkrai among Thai general population found that 38.2% would be ashamed of having a PLWH family member and 69.2% agreed that PLWH lose respect or standing [21]. Nevertheless, health workers would be pay more attentions to the HIV prevention [3, 18, 20]. In this study we found only a small percentage label HIV infection as irresponsible or shameful, while 75.2% respondents believed that PLWH should seek care exclusively from specialized hospitals for Infectious diseases. Fear of being infected and misconceptions about HIV is the primary reason to delay or avoid provide services to PLWH among health staff [20, 30, 41]. Undoubtedly, these specialized hospitals are more qualified in treating HIV and its coinfections. However, besides AIDS, the PLWH also need other basic medical services such as maternal health care.
Therefore, improving the awareness of treating PLWH equally would be fundamentally eliminated S&D among health facilities. No matter what are the roots of such high level of biased opinions against PLWH (Figure 2), the finding highlights the urgency of action-taking.
Enacted stigma
Despite the prevalent worry of being infected, not all infection concern of health staff is translated into enacted stigma since the percentage of taking extra precautions during patient care is less than that of being worried. Despite the fact that general physical contact does not spread HIV, more than half of the staff still wore double gloves or used other special protection when providing care or services for PLWH (Table 3.A). These indicate that excessive or inappropriate protection is still common among medical staff. Such typical intentional distancing with PLWH will only deepen PLWH’s sense of inferiority and make them afraid of seeing doctors [3, 20]. Fear of acquiring HIV and misconceptions about HIV transmission when caring for PLWH leads healthcare workers to take unnecessary, often stigmatizing actions. Also it may be accounted for by the policy made by health facility managers for preventing hospital infection. A hospital’s excessive emphasis on avoiding hospital infection leads staff in hospital to take unnecessary measures. It's easy to develop an overprotective subconscious when 85.9% received HIV related occupational exposure risk while much less people have trained on S&D reduction within our study. Therefore, besides providing health workers with complete information about how HIV is and is not transmitted and how practicing universal precautions to relieve their fears, we should also seek a balance between preventing infection and reducing S&D [3, 20, 34].
S&D challenging EMTCT
The responses from maternal health workers are quite alarming as it mirrors the deeply rooted stigma against women of child-bearing age infected with HIV. A large proportion of maternal health workers support neither the reproductive rights nor the privacy of pregnant women living with HIV. As vertical transmission of HIV from mother to baby is another main transmission route following sex behavior, S&D against pregnancy complicated with HIV infection will cause significant barrier to equal and adequate access to maternal care, furthering aggravating the mother-baby transmission[19, 23, 42]. The detrimental effect of S&D will even manifest itself in the offspring’s mental health as suggested by previous studies. Evidences from the survey highlight the importance of training tailored to maternal health staff as a way of intervention.
Limitations of this study
Since the study population is from the Shenzhen city, a young and wealthy Special Economic Zone in china, it may not be representative of the underdeveloped regions in China. The relatively larger percentage of young and well-educated respondents with adequate training in the study population may also eunderestimate the percentage of enacted S&D toward PLWH. Another potential limitation of the study is the questionnaire items on training which are inadequate. More information regarding training such as the frequency and how the training is delivered should be surveyed to better illustrate its role in S&D reduction.