Combating HIV stigma in low‐ and middle‐income healthcare settings: a scoping review

Abstract

Introduction Nearly 40 years into the HIV epidemic, the persistence of HIV stigma is a matter of grave urgency. Discrimination (i.e. enacted stigma) in healthcare settings is particularly problematic as it deprives people of critical healthcare services while also discouraging preventive care seeking by confirming fears of anticipated stigma. We review existing research on the effectiveness of stigma interventions in healthcare settings of low‐ and middle‐income countries (LMIC), where stigma control efforts are often further complicated by heavy HIV burdens, less developed healthcare systems, and the layering of HIV stigma with discrimination towards other marginalized identities. This review describes progress in this field to date and identifies research gaps to guide future directions for research. Methods We conducted a scoping review of HIV reduction interventions in LMIC healthcare settings using Embase, Ovid MEDLINE, PsycINFO and Scopus (through March 5, 2020). Information regarding study design, stigma measurement techniques, intervention features and study findings were extracted. We also assessed methodological rigor using the Joanna Briggs Institute checklist for systematic reviews. Results and discussion Our search identified 8766 studies, of which 19 were included in the final analysis. All but one study reported reductions in stigma following the intervention. The studies demonstrated broad regional distribution across LMIC and many employed designs that made use of a control condition. However, these strengths masked key shortcomings including a dearth of research from the lowest income category of LMIC and a lack of interventions to address institutional or structural determinants of stigma. Lastly, despite the fact that most stigma measures were based on existing instruments, only three studies described steps taken to validate or adapt the stigma measures to local settings. Conclusions Combating healthcare stigma in LMIC demands interventions that can simultaneously address resource constraints, high HIV burden and more severe stigma. Our findings suggest that this will require more objective, reliable and culturally adaptable stigma measures to facilitate meaningful programme evaluation and comparison across studies. All but one study concluded that their interventions were effective in reducing healthcare stigma. Though encouraging, the fact that most studies measured impact using self‐reported measures suggests that social desirability may bias results upwards. Homogeneity of study results also hindered our ability to draw substantive conclusions about potential best practices to guide the design of future stigma reduction programmes.

HIV–AIDS Stigma in Burundi: A Qualitative Descriptive Study

“…At the institutional level, strategies typically focus on reducing HIV stigma at healthcare settings [27,28]. An example of a community level intervention was carried out in five churches in a high HIV prevalence area of Los Angeles County, including strategies such as HIV education, pastor-delivered sermons on HIV, and HIV testing events [29].…”

Nurses' experience of caring for people living with HIV: a focused ethnography

“…Several factors contributed to this perceived risk, including the fear of self‐contamination during care provision and fear of possible consequences of being infected. Feelings of fear and worries are common among healthcare providers during care provision to patients with HIV, mainly because they are apprehensive about the risk of self‐contamination (Athley, Binder & Mangrio 2018; Smith et al 2020). This fear results in healthcare providers' hesitance to be involved in providing care to HIV ‐affected persons or may even refrain from care provision (Garus‐Pakowska & Górajski 2019).…”

“…It is estimated that 59 000 people are living with HIV in Iran, of whom only 25 000 are on antiretroviral therapy (UNAIDS 2019). Although HIV has been around for a long time and significant advancements have been made in its treatment in the last decade, some studies have shown that there is still a significant stigma towards people living with HIV (PLWH), and the knowledge of the society of HIV infection is low, particularly in low‐ and middle‐income countries (Pudpong et al 2014; Smith et al 2020). This can adversely impact the affected people's help‐seeking behaviours and the quality of care they receive (Athley et al, 2018; Duby et al, 2018).…”

“…They are often well aware of the contamination risk when handling HIV‐infected needles, sharps, cutting objects and the patients' body fluids (Bouya et al 2020; Hasak, Novak, Patterson & Mackinnon 2018). Awareness of the risk may affect nurses' willingness to provide caring services to PLWH (Smith et al 2020). Nurses report negative experiences, such as stress, fear, fatigue and burnout, when providing care for PLWH (Wagner, McShane, Hart, & Margolese 2016).…”

“…Nurses report negative experiences, such as stress, fear, fatigue and burnout, when providing care for PLWH (Wagner, McShane, Hart, & Margolese 2016). Some studies from low‐income countries suggest that nurses feel fear and worry about becoming infected with HIV when providing care to patients (Athley, Binder & Mangrio 2018; Smith et al 2020). In this regard, Lui et al (2014) found fear of injury with infected needles and accidental exposure to a patient's blood and body fluids among nurses.…”