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STIGMA TOWARDS PEOPLE LIVING WITH HIV/AIDS AMONG COUNSELING OFFICERS IN SOUTH SULAWESI, INDONESIA

Background: Human Immunodeficiency Virus (HIV) / Acquired Immunodeficiency Syndrome (AIDS) has become a global problem nowadays. To reduce its spread, Voluntary Counseling and Testing (VCT) and Provider-Initiated Testing and Counseling (PITC) have been provided. However, these interventions remain ineffective to discover new cases, as the stigma among health officers may exist. Objective: To compare the stigma towards people living with HIV/AIDS between VCT and PITC officers. Methods: This was a descriptive comparative study conducted in Makassar City, Parepare City and Sidenreng Rappang Regency, South Sulawesi Province, Indonesia. There were 139 samples were selected using a convenience sampling technique, which consisted of 66 VCT counseling officers and 73 PITC officers. The questionnaire from Health Policy Project in Thailand was used to measure the HIV/AIDS related-stigma. Data were analyzed using descriptive statistics and Mann Whitney test. Results: Findings showed that there was a statistically significant difference in stigma between the group of VCT and PITC on people living with HIV/AIDS (PLWHA), which the mean of stigma in the PITC group (73.07) was higher than the mean value in the VCT group (66.61). Conclusion: There was a significant difference in stigma between VCT and PITC officers towards PLWHA. It is suggested that PITC curriculum should be evaluated, and supervision and monitoring in both VCT and PITC groups should be implemented regularly to reduce the stigma towards PLWHA.


INTRODUCTION
Currently the Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS) has spread across the world. In 2016 the World Health Organization (WHO) estimated that people living with HIV/AIDS (PLWHA) had been at the number of 36.7 million people, in both adults and children (UNAIDS, 2017). The African continent is the first rank with the highest case of 25.6 million (UNAIDS, 2017;WHO, 2016). UNAIDS reports that, in the continent of Asia and the Pacific, Indonesia has been ranked third after India and China (UNAIDS, 2017). AIDS cases in Indonesia in 2016 were at 86,780 people while HIV infections in South Sulawesi Province were 993 people with a cumulative number of 6,296 people (MOH, 2017).
The discovery of HIV/AIDS coverage in Indonesia until December 2016 has increased with a cumulative number of 232,323 people. This is still far from the estimated target for 2016 which should reach 785,621 people (MOH, 2014a(MOH, , 2017. This is certainly very worrying because the discovery of HIV/AIDS cases has not been optimal in health services as expected. HIV transmission will certainly continue to occur with the pattern of HIV/AIDS transmission which has shifted from initially focused on risky populations including women sex workers, transvestites, injecting drug users to housewives and men who have sex with other men, so the pattern of the spread of HIV/AIDS is now in the general public and no longer centered on the at-risk population, especially for housewives and there will be transmission from mother to child/baby (MOH, 2014c;Risal & Gunawan, 2018).
A study (Wagner, Girard, McShane, Margolese, & Hart, 2017) explained that one of the obstacles to the low coverage of people who would like to test and know their HIV status is that there are concerns of the stigma and discrimination from health workers so that it affects the access of PLWHA to health services. Another study (Kumar et al., 2017) explained that HIV-related stigma and discrimination are factors that drive this epidemic, despite advances in medical care and increased patient awareness of this disease. It is also explained that there is an increasing stigma as an obstacle to access in the HIV treatment series (Nyblade et al., 2017).
Stigma is a negative presumption in a group including PLWHA (Wagner, Hart, McShane, Margolese, & Girard, 2014). The stigma of PLWHA is reflected in cynicism, feelings of excessive fear and negative perceptions (Paryati, Raksanagara, & Afriandi, 2012). PLWHA reported negative experiences they received by health workers related to interaction or communication, irrelevant questions, harsh treatment, sympathy or pity, excessive precautionary measures through the use of different personal protective equipment for each patient, refusal of treatment, nonreferral health needed, delays in hospital care, inadequate psychosocial support and violations of the confidentiality of patients' HIV status (Arrey, Bilsen, Lacor & Deschepper, 2017).
Stigma and discrimination are the main factors that influence the ability of nurses to treat PLWHA patients. Nurses are well aware of the stigma and discrimination caused by HIV/AIDS so as to make adjustments in providing nursing care to reduce the manifestation of AIDS stigma. However, although it is stated that PLWHA are treated equally by applying the use of universal prevention consistently (Mill et al., 2013), many health workers are still afraid of dealing with PLWHA as one of the factors related to stigma and discrimination (Wodajo, Thupayagale-Tshweneagae, & Akpor, 2017). A previous study (Paryati et al., 2012) explained that the occurrence of stigma and discrimination to PLWHA by health workers is influenced by several things including knowledge about HIV/AIDS, perceptions of PLWHA, level of education, length of work, age, training, gender, institutional support and adherence to religion. If the stigma and discrimination among health workers is not reduced, the patients will not have the desire, fear, or delay to check HIV status.
Global HIV/AIDS control refers to three things known as three zero, namely reducing the number of new HIV cases as low as possible, reducing AIDS mortality and reducing the level of stigma and discrimination (MOH, 2014a(MOH, , 2015. One of the programs implemented by the Ministry of Health of Indonesia based on WHO recommendations to increase the scope of HIV counseling is through counseling and testing conducted by health workers / personnel trained to handle HIV/AIDS patients through both Voluntary Counseling and Testing (VCT) and Provider-Initiated Testing and Counseling (PITC) (MOH, 2014a(MOH, , 2014bWHO, 2009 VCT is the main model of HIV testing services at the patient's initiative to seek HIV screening services performed before the test, after the test, and during HIV treatment by a trained counselor (MOH, 2013;WHO, 2009). VCT counseling aims to prevent HIV transmission through assessing risk factors, reducing risk factors, changing risk behavior, improving the quality of life of patients and further counseling for PLWHA (MOH, 2014a). PITC is a counseling approach that aims to discover HIV diagnosis, early treatment and comprehensive care for PLWHA (Kennedy et al., 2013;Roura, Watson-Jones, Kahawita, Ferguson, & Ross, 2013;Topp et al., 2012). VCT has an approach strategy with patient activity and is implemented both in health care institutions and outside health services, for example in the community. While the PITC strategy carried out by health professionals including nurses is only carried out in health care institutions. VCT and PITC also help achieve self-efficacy of health workers both individually and in groups so as to increase the coverage of people doing HIV testing (Leidel, Leslie, Boldy, & Girdler, 2017).
However, as there is a lack of information about stigma and discrimination among health care officers, therefore this study aims to explore the stigma and discrimination between VCT and PITC Counseling Officers towards people living with HIV/AIDS as well as to compare the perception related stigma and discrimination between the two officer groups.

Study Design
This was a descriptive comparative study to compare the stigma towards people living with HIV/AIDS between VCT and PITC officers.

Setting
This research was conducted in Makassar City, Parepare City and Sidenreng Rappang Regency, South Sulawesi Province Indonesia.

Sample
There were 139 samples were selected using a convenience sampling technique, which consisted of 66 VCT counseling officers and 73 PITC officers. The inclusion criteria in this study were health workers (doctors, nurses or midwives) who had VCT and PITC training, being a part of continuous comprehensive services, and willing to be a respondent. Exclusion criteria were health workers who had been trained in VCT and PITC but were not active in their implementation for at least one year, the officers who were not from the health profession, for example (NGOs), and the officers who were not presented at the time of the study.

Instrument
Data were collected using a questionnaire to measure HIV-related stigma among health staff adopted from the Health Policy Project in Thailand (Health Policy Project, 2013) based on the recommendation of UNAIDS and WHO. Validity and reliability tests have been carried out with the results of Cronbach's alpha value of 0.707. The questionnaire has been translated into Indonesian language. This questionnaire is to measure stigma and discrimination. Based on the operational definition, stigma is negative connotation or labeling which can cause discrimination against PLWHA. The process that produces a stigma includes the actual stigma if there is a person or community that takes concrete actions both verbal and non-verbal causing others to be distinguished and excluded, and the potential or perceived stigma if the stigma does not occur yet, but there is a sign or feeling of discomfort so that people tend not to access health services. Internal stigma or selfstigmatization is that someone judges himself as "not entitled" and "disliked by society" (MOH, 2012). The scale used is numerical with objective criteria using the median value. A good value if it is less or equal to the median value. The highest score is 14 and the lowest score is 1.

Ethical Consideration
This research has been approved by the Research Ethics Committee of Faculty of Medicine of Hasanuddin University with number approval 427/ H4.84.5.31/PP36-Kometik/2018. The study permission was also obtained from Regional Development Planning Board in Makassar City, Parepare City and Sidenreng Rappang Regency, South Sulawesi Province as well as from the Community Health Centers for data collection. Before the research was conducted, the researchers explained the purpose of the research and asked for approval from the respondents by signing an informed consent.

Data Collection
Data were collected by the researchers assisted by three research assistants with a minimum education of Bachelor degree in nursing and also worked as a counselor in the study settings. Prior to data collection, the research assistants were trained about objective and procedures of data collection. Data collection used single blind, which the researchers did not know the respondents' data to get accurate information and prevent answers that were not in accordance with the respondents' condition. This is because the researchers were the facilitators of VCT and PITC counseling training.

Data Analysis
Data were analyzed using univariate (frequency distribution) and bivariate (Mann Whitney test) analysis. Mann Whitney test was used to examine the difference in mean rank (ordinal data) from two different independent groups and if the data distribution is not normal (Dharma, 2011). Table 1 shows that the majority of respondents was female (119%) and married (88.5%). Most of the respondents were nurses (38.8%) and midwives (33%), followed by physicians (15.1%). Majority of respondents had bachelor degree in nursing and Ners profession (33.8%) and Diploma III. Bachelor degree and Master degree in this study refer to the degree in all majors. It also shows that PITC group have joined the training about stigma and discrimination (63%) more than VCT group (45.5%).  Table 2 shows that there was a statistically significant difference in stigma between the group of VCT and PITC on people living with HIV/AIDS, which the mean of stigma in the PITC group (73.07) was higher than the mean value in the VCT group (66.61).

DISCUSSION
Findings of this study revealed there was a significant difference in mean value of stigma between VCT and PITC counseling officers towards PLWHA. The mean of stigma in the PITC group was higher than the mean value in the VCT. This result supports the previous study that majority of patients prefer VCT (66.1%) which is initiated by patients themselves compared with PITC initiated by health workers (11.6%) and independent testing (22.3%) (Van Dyk, 2013). This occurs with the reason that VCT approach prioritizes patient autonomy, no human rights violations, and keeps confidentiality of the testing results (Van Dyk, 2013). In addition, the VCT approach increases the scope of case discovery and reduces the level of HIV/AIDS stigma (Mall, Middelkoop, Mark, Wood, & Bekker, 2013). This is in line with a previous study (Misir, 2013) stated that counseling through the VCT approach is significantly correlated with a decrease in stigma.
However, the result of our study is also in contrast with another study (Ogbo et al., 2017) indicated that the PITC strategy is very acceptable and feasible, and increases the number of patients tested for HIV by 5% compared to VCT. It is also said that the utilization of HIV testing increases after PITC compared to VCT, therefore PITC must be expanded and evaluated rigorously (Kennedy et al., 2013).
On the other hand, another study (Silvestri et al., 2011) indicated that there was no significant difference VCT and PITC approaches in finding new cases. However, the others said that both VCT and PITC counseling approaches show the results of good counseling practices including the process of patient approval, confidentiality aspects, counseling processes, and referrals for follow-up care, so that both can be used to increase the coverage of HIV/AIDS cases (Wanyenze et al., 2013). But this is certainly supported by trained counseling officers in both VCT and PITC by not stigmatizing patients, especially in at-risk populations including man who have sex with man, female sex workers, drug users, transgender, etc. As a consequence, it will lead to the improvement of HIV testing coverage and help patients to get subsequent treatment interventions.
Based on the results of this study, the evaluation of the PITC implementation curriculum and training for health workers are necessary. A study stated that stigma reduction training programs carried out for health workers in Bangladesh showed a substantial decrease in stigma among health workers in men who have sex with men, young people who are active sexual or involved in immoral behavior (Geibel et al., 2017). Therefore, stigma reduction training materials can be included in the PITC training curriculum. Additionally, monitoring and supervision from professional counselors is needed to evaluate the performance of PITC officers related to stigma and discrimination.

CONCLUSION
There is a significant difference in stigma between VCT and PITC officers towards PLWHA. It is suggested that training curriculum in PITC should be evaluated and supervision in both VCT and PITC groups should be implemented regularly to reduce the stigma in PLWHA.

Declaration of Conflicting Interest
None declared.

Funding
This study is supported by Faculty of Nursing, Hasanuddin University, Makassar, Indonesia.