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Healthcare Workers Attitude and Stigma among People living with HIV/AIDS (PLHA): A Literature Review

Background: The concept of stigma and discrimination discussed in literature illuminate patient's experiences in the hands of health care providers. The review aims to assess the existing literature published in internet databases focusing on the personal perception of stigma and discrimination of health care workers as well as the patient's perception of their attitudes that may be stigmatizing and discriminatory. Methodology: A web-based search was done in the three (3) databases including EBSCOhost, Google Scholar, and PubMed. The search utilized five keywords: 'Stigma'; 'Discrimination', 'Perception', HIV/AIDS,' and 'Nurses.' Inclusion criteria includes full-text, peer-reviewed, academic journal in the English language, and published between the years 2013-2018. The studies were screened according to their relevance to the objectives of the study. The quantitative and qualitative checklist of the Standard Quality Assessment Criteria for Evaluating Primary Research Papers and Joanna Briggs Institute data extraction protocols were utilized by two interrater in the analysis of the literature. The extracted data were synthesized using a table highlighting the key findings of the studies. Results: A total of fourteen (14) titles were included in the review after evaluating its relevance to the objective and appraising its high quality. Content analysis was done and resulted in the formulation of four themes which include: (1) General Characteristics of the Literature (2) HIV/AIDS Stigma and Discrimination as perceived by health care providers; (3) Perception of health providers' attitude among HIV infected persons; and, (4) the consequences of HIV/AIDS stigma.

Statistically, the majority of HIV infections are from low prevalence settings which are considered as key populations -people who inject drugs, transgender, prisoners, gay men, and men who have sex with men (MSM). It appears that gay men and other MSM accounted for 12% of new infections in 2015, followed by sex workers (5%), and drug users (8%) (UNAIDS, 2017a). Over the last decade, tangible signs of progress were reflected in global statistics on HIV/AIDS. The global trend shows a dramatic 48% decline in AIDS-related between 2005(UNAIDS, 2017a. This was achieved because of the higher treatment coverage and the client's better adherence to antiretroviral therapy. With early detection and referral for early treatment and management, HIV can be managed as a chronic disease with good chances of living longer comfortable lives (Nakagawa et al., 2012).
While there have been notable improvements in the epidemiological aspect of HIV, issues on stigma, and discrimination (S&D) remained. Various literature has suggested the detrimental consequence of S&D to the overall improvement of the quality of life among persons living with HIV/AIDS (PLHA). Discouragement to disclose and seek medical attention, fear of getting tested for infection, refusal to get counseling and care services, and poor health outcomes are a few of the negative impacts of stigma to a person who may have issues on having HIV (Turan et al., 2017;UNAIDS, 2017b). The repercussion of this lack of education is the uncontrolled multiplication of infected individuals who may predispose the entire population to the risks of acquiring HIV.
The concept of stigma and discrimination discussed in the literature illuminates patients' experiences in the hands of health care workers. The social and cultural environments where people T Introduction interact and associate are precursors to the conceptualization of stigma and discrimination, making it an insidious and persistent issue to date. This suggests that how one person perceives the concept of HIV/AIDS, maybe conveyed either positively or negatively to another. The exchange of interaction may create possible prejudices between and among individuals compromising the fundamental role of health workers as patient advocates.

Aims of the Study
This study aimed to review the existing literature published in internet databases focusing on the concept of perception and attitudes towards HIV/AIDS between the care provides and care recipients. Specifically, this review intends to identify the health care providers' perception of stigma on HIV/AIDS as well as PLHA patient's perception of the health care providers' attitudes that may be stigmatizing and discriminatory.

Eligibility Criteria
The following are the inclusion and exclusion criteria applied to screen for applicable articles: Inclusion criteria: (1) in full-text (2) Peer-reviewed (3) Published between the year 2013-2018 (4) Academic journal (5) in the English language (6) within major heading: 'attitude of health personnel' Exclusion criteria: (1) not full-text (2) not peer-reviewed (3) published earlier than 2013 (4) non-academic literature (5) not in English

Information Sources and Search strategy
A literature review is appropriate for the diverse range of literature published on the concept of stigma and discrimination among health care personnel caring for PLHA. The review consisted of a comprehensive search in the three (3) research databases including EBSCOhost, Google Scholar, and PubMed. The search utilized five keywords: 'Stigma'; 'Discrimination', 'Perception', 'HIV/AIDS,' and 'Nurses.' We used these keywords and the Boolean term "AND" in search of relevant studies. The review was done on July 15, 2018.

Methodology Selection Process
The initial search resulted in 14,400 hits. Two reviewers screened the retrieved reports for their appropriateness in this review. Deliberation was done on which literature is to be retained or excluded. The decision to retain was made only if both reviewers agree to such. The researchers limited the search within the last 5 years (2013)(2014)(2015)(2016)(2017)(2018) to ensure that he included articles are timely and relevant in the current time. Using the inclusion and exclusion criteria, we were able to get relevant studies by reading through the abstracts. The search further reduced to twenty-three after instituting the other inclusion and exclusion criteria. Relevant studies were saved in a folder that was later read and analyzed. Excluded literature were those not peer-reviewed, reports, irrelevant to the objective of the research, and inaccessible. The authors contacted the authors of these inaccessible papers but later decided to exclude the same due to lack of follow-through. Finally, there were fourteen retained articles included in this review. The process followed for this review is shown in Figure 1.

Data Collection Process
The researcher utilized a quantitative and qualitative checklist of the Standard Quality Assessment Criteria for Evaluating Primary Research Papers (Kmet et al., 2004) to assess the quality Records were identified through an online research database (EBSCOhost, Google Scholar, and PubMed of the article retrieved. The checklist was helpful in our evaluation of the quality of the relevant studies that were retained in our search. The studies were appraised by at least two inter-rater agreement based on the purpose of the study, appropriateness of the research design, methodological rigors, and sufficient reporting. There were fourteen quantitative and ten qualitative criteria to consider for each article. After evaluating the reports and ensuring their high quality (80%-100% scores), data extraction was done following the Joanna Briggs Institute data extraction protocols (Munn et al., 2014).

Synthesis Method
After screening the retained articles, we found that the studies are incomparable because of their differences, such as the methods, analysis, measurements, presentation of results used, among others. Due to this limitation, the researchers used content analysis centered on the key findings by reading through the text and extracting relevant information pertinent to this review. The data was organized and synthesized using a tabular form noting the names of authors, year of publication, the purpose of the study, research design, participants of the study, and the stigma related key findings (Table 1). Reading and re-reading process was done on the extracted data which resulted in the formation of the four themes namely: (1) general characteristics of literature; (2) the HIV/AIDS stigma and discrimination as perceived by health care providers; (3) Perception of health providers' attitude among HIV infected persons, and, (4) The consequences of HIV/AIDS Stigma. A summary of the key findings is presented in Table 2.

General Characteristics of the literature
Meticulous selection and evaluation of articles were made on the remaining literature after screening. There were a total of eight (8) qualitative; four (4) quantitative; and one (1) mixed-method, and one (1) systematic review for a total of 14 relevant research articles included in this review. No literature was found to examine HIV/AIDS stigma and discrimination exclusively among nurses. All studies involved a variety of participants across all members of the health care team. It included doctors, nurses, laboratory technicians, health aides, and the like. All literature included in this review observed ethical standards. All studies discussed how ethical clearance was secured before the conduct of their research. One Study utilized a mixed-method approach combining cross-sectional and thematic analysis. Among the qualitative literature gathered, samples range between 5-25 participants gathered purposively. The method of data gathering employed were in-depth interviews among key informants and focused group discussions. Thematic analysis and grounded theory analysis were the most commonly used method.
On the other hand, the quantitative literature was mostly cross-sectional studies except for one experimental design. Study samples range from 88 to more than 1700 respondents of whom were selected using systematic sampling techniques. Data gathering employed the use of questionnaires and the conduct of face-to-face interviews. • Acts as a barrier to seek for treatment among PLHA Sison et al., 2013;Bofill et al., 2014

HIV/AIDS Stigma and Discrimination as perceived by health care providers
Stigma among people living with HIV/AIDS may result from different sources which include lack of knowledge, discordant personal relationships with their partners or family, friends, judgmental workplace and members of the community, and even among care providers (Servin et al., 2014;Valencia-Garcia et al., 2017;Wagner et al., 2016). Among vulnerable groups, it appears that most stigmatized are the men having sex with men (MSM) and sex workers (SW) (Rogers et al., 2014;Scorgie et al., 2013). Furthermore, there is an association between religious belief and stigmatized attitude, society stigmatized attitude, and knowledge of transmission mode (Zarei et al., 2015).
Most care workers feel that caring for patients with HIV has become comparatively normalized and is no longer a big issue and considers the stigma attached to this as obsolete and nonexistent (Stutterheim et al., 2014;Leidel et al., 2015). Literature suggests that health providers understand the gravity of stigma that their patients feel as HIV carriers especially when they present for care in clinics fearing shame and discrimination when disclosing their seropositive status (Servin et al., 2014;Leidel et al., 2015).
One study found how PLHA shared positive experiences with health workers. About 76% of predominantly gay men PLHA in a Dutch health care setting received equal treatment, extra attention, respect, social support provision, and assurances of confidentiality as compared to negative experiences in their interaction with their care workers (Stutterheim et al., 2014). On the other hand, health providers perceive that the burden of HIV-related stigma can be higher than mental illness or other physical health conditions (Servin et al., 2014). However, the success of helping HIV affected client is a two-way process and does not solely rely on the health provider alone. The health workers believe that patients should be made aware of their HIV status to gain a better understanding of the illness process and make them more engaged in treatment and adhere to medication regimens (Bofill et al., 2014).
Health care providers believe that their patients do not understand that they too are at risk for contracting the disease. The most dominant attitude among health care providers toward patients with HIV/AIDS is dealing with fear which is typically found among those who have no experience with these patients (Zarei et al., 2015). Several authors have suggested that care providers feel the need to improve on their competencies as health workers caring for HIV/AIDS patients. Specific areas needing focus are on HIV prevention, HIV care and treatment, psychosocial support, and approaches to working with vulnerable groups MSM and sex workers (Rogers et al., 2014;Valencia-Garcia et al., 2017;Scorgie et al., 2013). Healthcare workers acknowledge the need for more knowledge and experience in caring for patients with HIV/AIDS such as those of MSM and SW and agree for more training to provide the optimum care their patients deserve (Stutterheim et al., 2014;Rogers et al., 2014). The white coat, warm heart (WW) intervention by Li et al. (2013) was able to improve the attitudes and behaviors of health care workers after being implemented in their work environment. Less prejudicial attitudes and avoidance toward PLHA were achieved during evaluation 12 months after. This approach primarily focused on how to support health workers earns occupational safety apart from providing only essential information in providing care for HIV/AIDS clients.
Childbearing among HIV-affected couples is one of the most controversial issues among PLHA where stigma and discrimination are real and palpable (Coll et al., 2015;Mmeje et al., 2016;Valencia-Garcia et al., 2017;). Most often, couples are judged by the public when they express their desire to build a family and have children. Generally, people consider this a taboo for HIV-affected couples having children of their own based on the possibility of transmitting the infection to their children or their uninfected partner. On the same note, health providers perceive that patients do not fully understand the necessity of viral suppression before sexual contact with their partners and safer conception methods and thinking that undetectable viral status is deemed in good health (Coll et al., 2015).
In the health sector, providers consider safer conception counseling as an effective means of reducing fears associated with childbearing (Mmeje et al., 2016;Coll et al., 2015). Through this, the best interest of supporting the reproductive autonomy among PLWH as persons are upheld and protected. A lot of effort still needs to be done in improving this practice through the conduct of formal training programs among the health care team and extending even to the community level in the hope that getting pregnant among HIV affected couple is possible and doable with very minimal risks (Mmeje et al., 2016;Coll et al., 2015).

Perception of health providers' attitude among HIV infected persons
There are reports where health providers' are biased against sex workers which come in forms of hostility and denial of treatment; blaming and shaming; long waiting lines; higher user fees; and even discriminatory treatment to family members (Scorgie et al., 2013). This finding is a cause of concern considering that these are patients who need attention due to the risk of contracting sexually transmitted infections. The exercises of biases in the health system are contributory to the double-stigma towards a high-risk group because of the nature of their job as sex workers, homophobia, and possibly HIV carriers. These vulnerable groups may be the contributors to the exponential rise of the HIV/AIDS epidemic and therefore needs due treatment and health management.
Literature suggests that stigma is an unavoidable circumstance that exists between the health care providers and PLHA and may come in varying degrees. The study of Valencia-Garcia et al. (2017), revealed that the experience of being stigmatized by health care providers is the most frequent distressing stigma. There are instances where patients experience many forms of maltreatment during care which may include the fear of being 'marked.' This raises the issue of the right to confidentiality. There are certain hospital routines and procedures which may deliberately jeopardize the patients' right to privacy. For instance, chart flagging to alert care providers on the HIV status of patients is a naive practice in the hospital. For health workers, this is a simple practice where its primary purpose only is to communicate and take precautionary measures in the health team (Valencia-Garcia et al., 2017;Stutterheim et al., 2014). However, this may already be considered as a breach of patients' right to confidentiality and is discriminatory. Physical isolation in the health care setup is another example of compromising patients' rights and cultivates a stigmatizing environment (Valencia-Garcia et al., 2017).
Nurses, Physicians, and other members of the health care team at the forefront play a crucial role in having HIV patients engaged in treatment and rehabilitation. Individual patients' outcomes lie in the hands of this team who provides direct contact to every HIV case. They must, therefore, be prepared and equipped with the necessary skills, especially in dealing with stigma and discrimination to strengthen the patient-provider caring relationship and retention to care. Magnus et al. (2013) surmised that when women and elderly patients feel they are being disliked to be cared for, or when they think their caregivers lack attention on them, they tend to lose interest in self-care and prefer a break or delay entry to HIV care. How patient perceives the health providers interest to help them cope with HIV as well as the overarching shame and stigma rooted from a myriad of sources are critical elements affecting patients' involvement and adherence to treatment.

The consequences of HIV/AIDS Stigma
A change in actions or dealings with a person for the reason of being an HIV carrier allows an atmosphere that stigmatizes the working relationship between care providers and patients. Zarei et al. (2015) revealed that the stigmatized attitude of health care personnel is found to be associated with unwillingness to provide services. This unwillingness to provide services is an intentional form of bias on the part of the provider, which may be interpreted as selective caring in a discriminatory environment. This inequity and the stigmatized situation between carers and patients are detrimental to the realization of patient satisfaction and improved health outcomes (Li et al., 2013).
Stigma acts as a significant barrier to treatment and cares for PLHA (Sison et al., 2013;Bofill et al., 2014). Similarly, the distance to treatment centers, access to treatment services, lack of HIV care providers, absence or lack of insurance coverage, medication shortages are factors inhibiting people from getting tested are contributory factors that dwindle adherence to HIV therapy (Servin et al., 2014).
Participating in focus group discussions where patients get to share their experiences has shown to improve familial and social relationships and help patients in the process of overcoming perceived stigma and improve their engagement in caring for themselves (Bofill et al., 2014).
This study is not without limitations. First, the review is limited to three research databases, and only those within the years 2013-2018 were included; hence the results cannot claim generalizability. Second, the analysis made focused exclusively on the content and was not able to compare findings or perform a meta-analysis of the studies retained. Future researchers are Limitations of the Study encouraged to utilize a more extensive literature review.
The literature discussed that stigma on HIV/AIDS can come from a variety of sources such as family, partners, social circle, the community in general, and even among the healthcare team. Primarily it revealed that it is the lack of knowledge that contributes to stigma as experienced by MSM, sex workers, and HIV couples. Health workers understand the problematic situation of a PLHA. They believe they have a role to play in improving the lives of their patients by enhancing their knowledge, practice, and interactions with them. In contrast, a PLHA does not consider health facilities and health professionals as a refuge, but rather a perilous threat of stigma and discrimination experience. HIV/AIDS stigma is a barrier between the patient and the health care team and can lead to the detriment of the patient's health outcomes and satisfaction.
The issue of HIV/AIDS stigma and discrimination is a major issue that potentially affects patient-care provider interaction. It plays a crucial role in a successful working atmosphere between an HIV affected person and their health care provider as they both interact toward a safe and equitable care environment and achieve optimum health goals. How the health care providers perceive this concept is necessary to be appropriately identified and addressed accordingly, being persons entrusted by the self-stigmatized HIV/AIDS patients. Health care providers must show professionalism in dealing with these cases and avoid additional stressors that may be detrimental to the overall well-being of patients. The literature revealed that health care provider still needs more training in handling stigma and discrimination among patients with HIV. Patients also perceive this as existent and tangible in their experience in actual health care settings. Hence, a worldwide movement of capacity building on this matter is essential.
The author declares no conflicts of interest.
The author has no funding to disclose.

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