Background
Stigma is a social and cultural phenomenon in which an individual possessing a devalued characteristic, such as HIV infection, is discredited by others [
1]. Identified by Link and Phelan, labelling, stereotyping, separation, status loss, and discrimination as various forms of stigma [
2], and are considered a violation of human rights when targeted at people living with HIV (PLHIV) [
3‐
6]. PLHIV experience the mechanisms of internalised, anticipated, and enacted HIV stigma [
7]. Internalised stigma denotes the endorsement of negative beliefs, views and feelings of oneself, whereas anticipated stigma is awareness of negative social perceptions towards HIV, and the expectation that PLHIV will experience prejudice. Enacted stigma refers to the discrimination experienced by PLHIV [
7]. This study focuses on the mechanism of enacted stigma, which refers to the discrimination experienced by PLHIV.
HIV stigma is considered a major catalyst of the HIV epidemic, and is reported all over the world in communities, work-spaces and other settings [
8,
9]. Although health care contexts should be “safe and protective” spaces, PLHIV are frequently subjected to refusal of care, irrational use of infection control measures by care providers [
10‐
12], violation of their confidentiality, unconsented testing and disclosure of HIV status, and verbal abuse [
10,
13‐
16], while seeking care. The detrimental effects of stigma on the health outcomes of PLHIV are well documented [
17], such as higher risk-taking behaviour [
18,
19], refusal to disclose the HIV status [
20], low uptake of HIV testing, care and support services [
21‐
24], and poor adherence to treatment [
25‐
27]. Stigma also undermines the mental health and quality of life PLHIV [
19,
28]. These concerns are the rationale for the increased efforts to combat the HIV stigma in general and specifically in health settings [
29].
In Yemen, one of the least developed countries [
30], HIV prevalence remains low at 4000 (2000-11,000) per 100,000), with a possible epidemic concentrated among men who have sex with men (MSM) [
31]. Estimates from programmatic data indicate a total of 30,000 PLHIV, most of whom reside in Sana’a City (35%) [
32]. HIV diagnosis and treatment services are provided in designated centres under the management of the National AIDS Control Program (NAP). The NAP relies on external funding, which has gradually declined following the global prioritization of the high HIV-prevalence areas [
33], and the need to encourage domestic funding of HIV control [
34].
The outbreak of a violent internal conflict in March, 2015 and external air strikes campaign by the Saudi-led Coalition created one of the world’s largest humanitarian social and economic crisis [
30]. The national health system has been eroded in terms of financing, human resources and infrastructure [
35]. Only 8.5% of the already underfunded humanitarian support is directed to health, mainly primary health care (PHC), and child and maternal health programs [
36]. Less than 50% of public health facilities are considered fully functional, and staff continue to work with shortages of medicines, supplies and equipment, and sporadic payment of salaries [
37].
The NAP and humanitarian agencies continue to struggle to maintain access to as many PLHIV as possible. The services are extremely inadequate, and funds have to be diverted from the preventive and support aspects to sustain the testing and treatment services [
38]. Many PLHIV have lost access to HIV care services, due to lack of personal financial resources, the closure of several NAP centres, increased transport costs, and road closures for security reasons [
39]. PLHIV usually attend public health facilities for general ailments. They tend to seek care only if necessary, but conceal their HIV status when doing so out of fear of stigma [
39]. One study reported that 56% of the health care providers in the public hospitals in Sana’a City practised HIV stigma, such as refusal of treatment and irrational use of personal protection measures [
40]. Research about HIV stigma and HIV in general is very limited in Yemen. In view of this context, a better understanding HIV stigma in the health facilities is required to reduce its prevalence and thereby provide equitable and accessible health care services for PLHIV and populations at risk [
29]. The aim of this study was to determine the prevalence and drivers of HIV stigma among the Yemeni health professionals in the teaching hospitals in Sana’a City, and its relationship to the current conflict and low-resource context of the country.
Discussion
This was a cross-sectional study that examined HIV stigma among 320 Yemeni health professionals working in departments with high body fluid exposure in four teaching hospitals in Sana’a City, Yemen. The results showed a high level of HIV stigmatizing attitudes and practices in these teaching hospitals. Irrational use of infection control measures and unconsented disclosure of the patients’ HIV status to other practitioners were almost universal among health professionals. The majority of participants felt that HIV testing should be done before surgical interventions even without prior knowledge or consent, and HIV services should be provided in separate centres. Comparatively high level of stigma were reported in urban India; almost 90% of doctors and nurses stated that they would discriminate against PLHIV in professional situations that involved high likelihood of fluid exposure [
10]. In Saudi Arabia, a study among senior dentistry students showed that 90% would use an extra pair of gloves, and 95% referred patients living with HIV to a specialist [
43]. Lower levels of stigma have been reported in other settings [
44‐
47]. For example, half of the nurses and doctors in Lao have a high level of stigma against PLHIV [
47], and among health care providers in Ghana, 35% were unwilling to treat PLHIV and 52% would use unnecessary protection covers when seeing at a patient (thought to be) living with HIV [
44]. If given the choice, about 40% of the doctors in Saudi would not work with PLHIV [
48].
HIV stigma in our study was significantly associated with the participants’ fear of infection, perceived poor HIV knowledge, and negative attitudes towards PLHIV. These findings are consistent with reports that identify fear of infection as a key driver of HIV stigma, fuelled by a perception of high risk of infection [
10‐
12,
14,
49,
50]. Similarly, poor knowledge of HIV transmission and prevention is linked to stigma [
49,
51,
52], whether directly [
53], or as a mediator of fear of infection [
54,
55]. Similar to other settings, the social component still plays a role in Yemen as indicated by the significant association between stigma and the professionals’ negative attitudes towards PLHIV [
54,
56‐
58].
Contextual factors play an important role in our study, an aspect that is inadequately addressed in HIV stigma research [
54]. Our findings corroborate the notion that HIV stigma in low-HIV prevalence and low-resource communities [
59,
60]. Funding for HIV programs is usually scarce, professionals’ contact with PLHIV is uncommon [
23,
61], and HIV knowledge is poor in these contexts [
51,
54]. HIV stigma indicators among professionals in Sana’a teaching hospitals have deteriorated following years of conflict. Between 2010 [
40] and 2017 (the current study), HIV stigma prevalence rose from 56% to almost 100%. In addition, poor HIV knowledge increased from 12 to 38%, reported PPE shortage rose from 69 to 93%, and the perception of risk of infection soared from 13% to 94% among health professionals. Moreover, the current study shows that the stigma is associated with poor HIV knowledge and fear of infection. In contrast, the professionals’ negative attitudes towards PLHIV, not HIV knowledge or fear, predicted the stigma in 2010 [
40], which suggests a shift from a social-based towards a fear-based HIV stigma. These findings call for a comprehensive multi-level strategy to address the stigma and its drivers in Sana’a hospitals, building on the growing global experience in combating HIV-related stigma [
62‐
64].
At the institutional level, antidiscrimination policies should be developed, shared with the health workers, and effectively applied. Structural adjustments are required, such as improved availability of hand-washing facilities and ensuring the availability of sharps containers and PPE. At the individual level, training is needed on HIV and universal precautions. Negative attitudes towards PLHIV should be tackled by, for example, embedding testimonials from PLHIV in the staff training workshops and ensuring PLHIV participation in the development of hospital policies.
The implementation of these interventions is challenging due to lack of funds. As previously stated, the NAP is excluded from humanitarian funding and is incapable of playing its role in controlling HIV or combating the related stigma. The UN has declared its commitment to control HIV and combat stigma during conflict as well as peace [
65]. Despite the high UN level commitment, most of the limited health funds are directed to the PHC and maternal and child health programs [
36]. The focus on the latter programs and subpopulations, although vulnerable, overlooks the needs of other vulnerable groups such as the PLHIV, and risks undermining the HIV control efforts. Therefore, funds need to be reallocated to ensure the required financial resources support the health facilities rather than certain type of services, and thereby meet the needs of a wider spectrum of the community. Joint programming should also be encouraged so as to efficiently use the limited resources e.g., mainstream the HIV knowledge and stigma education interventions in the undergraduate teaching programmes and in ongoing in-service training sessions.
There are a number of limitations that should be considered in interpreting the results. Firstly, the study was conducted in the hospital departments with high fluid exposure, which may increase the perceived risk of infection and in turn stigma. In addition, the results may not be generalizable to other levels of health care because of differences in the available resources, type of health care provided, and the health professionals’ qualification and training. There may be concern about response bias, where the providers would record what they are expected to do rather than what they practise and thereby underestimate the level of stigma, but the responses indicate the contrary. This might be explained by the fact that the data were collected confidentially, or that the professionals considered these practices acceptable. Finally, the study tool was developed for operational research purposes and we were not able to construct measurement scales or establish its measurement properties. Despite these limitations, this study was able to reveal the widespread stigma in the teaching health facilities and possible links to the context of low HIV prevalence, low resources, and conflict. Our study provides useful data to help design and evaluate HIV control interventions in hospitals.
Conclusions
There is widespread HIV stigma in the major hospitals in Yemen, consistent with previous reports of high stigma in low HIV prevalence and low-resource countries, and its association with the fear of infection, poor HIV knowledge, inadequate training, and limited allocation of funds to HIV control programmes. Notwithstanding the current financial limitations of HIV control in Yemen, stigma reduction interventions need to be mainstreamed at institutional and individual levels. In addition, anti-discrimination policies and structural adjustments should be implemented, in combination with training on HIV and universal precautions, and action taken to tackle negative attitudes towards PLHIV and key populations.
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