Human immunodeficiency virus/acquired immunodeficiency syndrome-related discriminatory practices among health-care providers in apex health institutions of Bhubaneswar, Odisha.

CONTEXT: Stigma and discrimination in health-care settings, against human immunodeficiency virus (HIV)-positive patients, not only affects patient care but also creates an unnecessary culture of secrecy and silence based on ignorance and fear. AIMS: This study was designed to determine if there were any such discriminatory practices against people living with HIV/acquired immunodeficiency syndrome (AIDS) by health-care providers at apex hospitals in the city of Bhubaneswar, Odisha. SETTINGS AND
DESIGN: A cross-sectional study was designed in clinical departments, among all doctors and paramedical workers who had been providing health services to patients with HIV/AIDS for at least a year in the three large multidisciplinary tertiary care teaching hospitals in Bhubaneswar.
MATERIALS AND METHODS: A semi-structured questionnaire was used to collect data through in-person interviews after obtaining informed consent. STATISTICAL ANALYSIS USED: Data were entered into Microsoft Excel spreadsheet and were analyzed using Epi Info 7 (version 7.1.2.0); results represented using frequencies, proportions, Z-tests, and Chi-square tests.
RESULTS: Around 76.73% of the participants agreed that they were personally aware of discrimination that occurred in health-care settings. About 92.86% of the doctors, 78.12% of the nurses, while 38.09% of other health-care providers (HCPs) agreed to the fact there were some form of discriminatory practices at health facilities; this was also found to be statistically significant. As high as 88.10% of the doctors, 90.62% of the nurses, and 80.96% of other HCPs agreed that there were discriminatory practices against HIV/AIDS patients by HCPs, although this difference was not statistically significant.
CONCLUSIONS: Existence of discriminatory practices in these healthcare settings was due to the lack of correct information about HIV/AIDS and lack of protective materials needed for prevention of infection transmission. Copyright:

INTRODUCTION

Human immunodeficiency virus (HIV)-related stigma and discrimination exists worldwide. In India, as also in other places in the world, acquired immunodeficiency syndrome (AIDS) is perceived as a disease of “others” – of people living on the margins of society, whose lifestyles are considered “perverted” and “sinful.” Discrimination, stigmatization, and denial (DSD) are the expected outcomes of such values, affecting life in families, communities, workplaces, schools, and health-care settings. People living with HIV and AIDS (PLHA) continue to be burdened by poor care and inadequate services because of HIV/AIDS-related DSD.[1]

Southeast Asia is now an epicenter of the HIV epidemic. Of all countries in this region, India is estimated to have the largest burden, with about 21.17 lakhs (17.11 lakhs–26.49 lakhs) of people living with HIV (PLHIV), with around 86 (56–129) thousand new HIV infections in 2015.[2]

The health-care sector is perhaps the most conspicuous context for HIV/AIDS-related DSD. Negative attitudes from health-care staff generate anxiety and fear among PLHA. Globally, discrimination in these settings can be expressed in a variety of ways. The most commonly reported responses include a refusal to admit or treat HIV-positive patients,[34] the tendency to neglect patients, the habit of testing for HIV without consent, and breaches of confidentiality.[5] Consequently, many keep their serostatus secret, fearing still worse treatment from others.[6] It is not surprising that among a majority of HIV-positive people, AIDS-related fear and anxiety, and at times denial of their HIV status, can be traced to traumatic experiences in health-care settings.[6]

Although there have been a number of recent Indian studies,[1678] on HIV/AIDS-related DSD, no such studies have been reported from this part of eastern India. Hence, we took up this study to find the discriminatory practices existing in these health-care settings.

MATERIALS AND METHODS

Study design

Using a cross-sectional study design, data were collected through in-person interviews with a structured survey instrument.

Field of study

This capital city of the state has three important apex health facilities, i.e., three large teaching hospitals, all of which were selected, taking different levels of faculties and health workers purposively from four selected departments providing service for HIV/AIDS patients, namely Medicine, Skin VD, Obstetrics and Gynecology, and Surgery.

Study population/recruitment of participants

After approval from the hospital authorities and heads of selected departments, personnel who had been providing health services to PLHA for at least a year were contacted.

Inclusion and exclusion criteria

Those who had been providing health services to PLHA for at least a year and gave informed written consent were included.

All personnel who either refused outright or failed to make contact with the interviewer were excluded.

Period of study

This study was conducted from July 10, 2012, to August 10, 2013.

Study tool

Questionnaire development was guided by a theoretical understanding of stigma and discrimination as published in the literature.[1678910] Data regarding sociodemographics (age, sex, education, type of service provider, and length of time working in health care), provision of care to pregnant women, and training in the prevention of parent-to-child transmission (PPTCT) of HIV and HIV/AIDS general knowledge were also collected.

Provider awareness of the occurrence of anti-PLHA stigma and discrimination in health facilities and among peer health-care providers (HCPs) was used as a proxy measure for discrimination to avoid/minimize social desirability bias on the part of providers who might feel judged or otherwise exposed for admitting during the interview to mistreatment or disregard of PLHA.

To assess discriminatory practices in hospitals and health centers, participants read six statements of situations that could happen in health facilities and were asked, based on their personal experience, how often these things happened at their health-care settings (never, rarely, sometimes, and always).

Similarly, to assess the occurrence of discrimination among HCPs, participants read five statements of discriminatory behaviors and were asked to relate how often they thought providers behaved as such

Operational definitions

“Healthcare Provider” referred to the hospital staff who had contact with PLHA, i.e., medical doctors, nurses, nutritionists, laboratory personnel, and social workers.

“Discrimination” referred to active and passive denial of services, as well as breaches of confidentiality, segregation or isolation, and selective use of universal precautions (UPs).[11]

Sample size

Stigma and discrimination factors prevailing among doctors and paramedical workers have not been studied widely in this country and our state. Due to nonavailability of data on such prevalence, we included all the HCPs providing health services to PLHIV.

A total of 269 HCPs were delivering health services to PLHIV patients in the three selected facilities, of whom 184 satisfied our inclusion criteria, and from them, 159 (86.4%) consented for interview; the rest (13.6%) either refused to participate or failed to make contact with the interviewer, and hence, 159 taken as the sample size.

Ethical clearance

Ethical clearance was given by the Institutional Ethics Committee.

Data collection

Data was collected for seven months (August 2012 to March 2013). The interviewer maintained outmost confidentiality. To ensure that each study participant was asked every question in the questionnaire, the interviewer was trained to double-check the questionnaire for any accidental omissions before leaving each interview.

Data analysis

Data were entered into Microsoft Excel spreadsheet and were analyzed using Epi Info statistical software is a freely available software from CDC website(HYPERLINK “http://www.cdc.gov/info” www.cdc.gov/info). CDC is centre for disease prevention and control, U.S. Department of Health and Human Services. Associations were analyzed using Z-tests or Chi-square tests as appropriate, with P < 0.05 as statistically significant.

RESULTS

Demographic characteristics

Of the total 184 HCPs eligible and contacted, 159 agreed to participate in the study, with a response rate of 86.4%. Their mean age was 32.26 years (standard deviation ± 6.36 years) and the range was 23–64 years. Table 1 shows that overwhelming majority were females (76.73%). Among doctors, majority (69.05%) were males, whereas all nurses were females. All HCPs had minimum secondary education and above, diplomas (15.72%) or degrees (82.29%). Most participants (38.36%) worked in the antenatal clinics or labor and delivery wards, followed by pediatrics (10.06%), laboratory, and other wards. Of the participants (61.64%) providing care to pregnant women, only 5.03% were trained in PPTCT. The average year of service was 8.53 years (range: 1–38 years). Among the nurses, 32.29% had experience of 5–10 years; among the doctors, majority (45.24%) had experience of <5 years [Figure 1].

Table 1

Demographic characteristics of health-care providers (n=159)

Respondent characteristics	Respondents Frequency, n (%)
Age group (years)
20-30	72 (45.28)
31-40	74 (46.54)
41-50	10 (6.29)
51-60	2 (1.26)
>60	1 (0.63)
Sex
Male	37 (23.27)
Female	122 (76.73)
Type of health-care provider
Doctor	42 (26.42)
Nurse	96 (60.38)
Laboratory personnel	14 (8.80)
Social worker	4 (2.52)
Nutritionist	3 (1.88)
Number of completed years of practice in health care
<5	60 (37.73)
5-10	49 (30.82)
11-15	37 (23.27)
>15	13 (8.18)
Training attended in PPTCT
Yes	8 (5.03)
No	151 (96.97)

PPTCT=Prevention of parent-to-child transmission

Figure 1

Distribution of Health-care providers with length of time in healthcare

Common discriminatory practices at health facilities

The results, in Figure 2, show the (percentage-wise) opinions of the HCPs of the existing discrimination in health facilities.

Figure 2

Opinion of health-care providers on “Common Discriminatory Practices at Health Facilities”

Awareness of “discriminatory practices at health facilities with the type of provider”

The analysis of data on discrimination in health facilities compared participants who were aware of any discriminatory or stigmatizing behaviors toward PLHAs in health facilities to those who were unaware (i.e., answered “never” to statements) [Table 2]. For the analysis, we further divided the HCPs into doctors, nurses, and others (comprising laboratory technicians, social workers, and nutritionists).

Table 2

Awareness of “Discriminatory Practices at Health Facilities” with type of provider

Statement	Type of provider	Responses (n=159)
		Aware, n (%)	Unaware, n (%)
“Some hospitals/health centers do not offer treatment for other illnesses to a patient if he or she is known to be HIV+because he/she is going to die anyway”	Doctor (n=42)	31 (73.80)	11 (26.20)
	Nurses (n=96)	72 (75.00)	24 (25.00)
	Others (n=21)	8 (38.09)	13 (61.91)
	χ2=11.57	df= 2	P = 0.003
“Some hospitals/health centers do not perform surgeries or invasive procedures if the patient is known to be HIV+”	Doctor (n=42)	39 (92.86)	3 (7.14)
	Nurses (n=96)	75 (78.12)	21 (21.88)
	Others (n=21)	8 (38.09)	13 (61.91)
	χ2=23.78	df= 2	P <0.0001
“For the same services, some hospitals/health centers might charge HIV positive patients more than HIV- patients”	Doctor (n=42)	27 (64.29)	15 (35.71)
	Nurses (n=96)	50 (52.08)	46 (47.92)
	Others (n=21)	6 (28.57)	15 (71.43)
	χ2 = 7.16	df = 2	P = 0.003
“Some hospitals/health centers provide care to HIV-positive patients only if they can pay highly”	Doctor (n=42)	28 (66.67)	14 (33.33)
	Nurses (n=96)	54 (56.25)	42 (43.75)
	Others (n=21)	9 (42.85)	12 (57.15)
	χ2 = 3.34	df = 2	P = 0.188
“In some hospitals or health centers, HIV-positive patients are isolated in special sections of the hospital or health facility”	Doctor (n=42)	38 (90.48)	4 (9.52)
	Nurses (n=96)	93 (96.87)	3 (3.13)
	Others (n=21)	18 (85.71)	3 (14.29)
	χ2=4.65	df = 2	P = 0.01
“On-going treatments for a hospitalized patient is discontinued if it is discovered that he/she is HIV + positive in some hospitals or health centers”	Doctor (n=42)	22 (52.38)	20 (47.62)
	Nurses (n=96)	30 (31.25)	66 (68.75)
	Others (n=21)	7 (33.33)	14 (66.67)
	χ2= 5.74	df = 2	P = 0.06

*χ2 = chi-square; df=Degree of freedom; HIV=Human Immunodeficiency Virus

That “Some hospitals/health centers do not perform surgeries or invasive procedures if the patient is known to be HIV+” was agreed upon by as high as 92.86% of doctors, whereas 78.12% of the nurses were aware and 38.09% of the other HCPs were aware of such practices. This was also found to be statistically highly significant, with P < 0.0001.

Results in figure 3, shows the opinions of the participants(HCPs), who were personally aware of discriminatory practices against PLHIV. Discrimination by HCPs compared awareness of discriminatory behaviors toward PLHIVs by HCPs to those who were unaware (i.e., answered “never” to statements) [Table 3].

Figure 3

Opinion of health-care providers regarding “Awareness of people living with human immunodeficiency virus and acquired immuno-deficiency syndrome Discrimination among Health-Care Providers”

Table 3

Awareness of “discriminatory practices against people living with human immunodeficiency virus and acquired immuno-deficiency syndrome by health-care providers “with type of provider

Statement	Type of provider	Responses (n=159)
		Aware, n (%)	Unaware, n (%)
“Some health providers administer medications for symptomatic conditions but do not touch or physically examine patients with HIV/AIDS”	Doctor (n=42)	37 (88.10)	5 (11.90)
	Nurses (n=96)	41 (42.71)	55 (42.71)
	Others (n=21)	8 (38.10)	13 (61.90)
	χ2= 26.73	df = 2	P <0.0001
“Some health providers use protective wear (e.g., gloves, gowns, mask, etc.) to do nonintrusive physical exams on nonbleeding HIV-positive patients even if the patient does not have open sores +”	Doctor (n=42)	37 (88.10)	5 (11.90)
	Nurses (n=96)	87 (90.62)	9 (9.38)
	Others (n=21)	17 (80.96)	4 (19.04)
	χ2 = 1.63	df = 2	P = 0.44
“Some health providers do not maintain the confidentiality of HIV + individuals”	Doctor (n=42)	31 (73.81)	11 (26.91)
	Nurses (n=96)	51 (53.12)	45 (46.88)
	Others (n=21)	13 (61.90)	8 (38.09)
	χ2 = 5.24	df = 2	P = 0.07
“Some health providers try to cleverly deny admission of HIV- positive patients by giving excuses (e.g., “not enough beds,” “the doctor is not here,” etc.) but admission is not denied outright”	Doctor (n=42)	33 (78.57)	9 (21.43)
	Nurses (n=96)	65 (67.71)	31 (32.29)
	Others (n=21)	17 (80.96)	4 (19.04)
	χ2 = 2.62	df = 2	P = 0.27
“Some health providers postpone treatment or surgery for HIV- positive patients as long as possible”	Doctor (n=42)	27 (64.29)	15 (35.71)
	Nurses (n=96)	43 (44.79)	53 (55.21)
	Others (n=21)	12 (57.14)	9 (42.86)
	χ2 = 4.75	df = 2	P = 0.09

*χ2 = chi-square; df=Degree of freedom; HIV=Human immunodeficiency virus

DISCUSSION

Of the 159 HCPs interviewed, the mean age was 32.26 years ± 6.36 years. In a study done by Ekstrand et al. in Mumbai, the mean age was slightly higher among ward staff (39 years), as compared to 35 years for nurses and 34 years for doctors.[8] In another study done in a tertiary care hospital in South Africa, the age range was 20–75 years, with a mean of 37 ± 10.68 years.[12]

In our study, majority (76.73%) were females. Among the doctors, majority (69.05%) were males, whereas all nurses were females. In the study by Ekstrand et al. in Mumbai, half of the doctors (46%) and ward staff (51%) and almost all of the nurses (98%) were females.[8] Similar results were also found in other studies,[1213] clearly showing that females are a major group among the HCPs.

In our study, although 61.64% provided care to pregnant women, as few as 5.03% of the participants were trained in PPTCT. In a study done in China, around 68.1% of the HCPs were trained in HIV-care;[13] the provision of training and availability of trained staff can help in decreasing DSD.

Awareness of “discriminatory practices at health facilities towards people living with human immunodeficiency virus and acquired immunodeficiency syndrome”

As high as 76.73% of the HCPs agreed that discrimination occurs against PLHA in health facilities. Majority (93.71%) agreed that in their hospitals, PLHAs were isolated in special sections. In a study done by Mahendra et al., around 55% agreed that HIV-positive patients should be distanced from other patients.[6]

In our study, 57.23% of the HCPs agreed that certain health facilities provided care to HIV-positive patients only if they paid highly. In another study done by Mahendra et al., as few as 10% of the respondents agreed that HIV-positive patients should be made to pay higher charges.[6] This difference could be due to the gaps in attitude and practices at the two different settings.

Awareness of discriminatory practices by health-care providers toward people living with human immunodeficiency virus and acquired immunodeficiency syndrome

In our study, 59.75% of the HCPs agreed that they were aware of other HCPs not maintaining the confidentiality of HIV-postive individual's status. A study done by Humsafar trust reported that HCPs showed stigmatizing and discriminatory behaviors, such as files were marked “UP,” “positive,” or “sero-positive,” and the beds of PLHIV were kept in separate locations.[14] In another study done by Mahendra et al., 57% of the HCPs felt that PLHA should have the right to decide about disclosing their serostaus.[6] In a study in South Africa, 16% of the respondents reported to have seen patients being tested for HIV without informed consent.[12]

In our study, 54% of the HCPs agreed that “Some HCPs administer medications for symptomatic conditions but do not touch or physically examine PLHIVs.” In a study done by Mahendra et al., 49.77% of the HCPs agreed that “HIV can be transmitted by coming close to HIV-infected patient”.[6] The similar figures in both the studies hint on the gaps in the knowledge of HIV transmission, which aids these discriminatory practices. Other studies done by Humsafar trust and Ekstrand et al. also had similar findings.[814]

In our study, around 88.68% of the HCPs agreed that they were aware of “Some HCPs use protective wear to do nonintrusive physicalexamination.” Similar findings were also seen in other studies.[1214]

Limitations: HCPs in our study being from tertiary care facilities were likely to be better informed of issues related to HIV care and treatment; hence, there should be caution in generalizing these findings to a different population and other geographic locations. The study being based on self-reported data issues of recall and reporting bias cannot be ruled out.

CONCLUSIONS

The study identified a lack of correct information and education about that HIV/AIDS, prevention of infection and lack of protective materials needed to treat PLHA, led to discriminatory practices in these healthcare settings. Within the health-care system, the concept of universal precautions needs to be promoted, and the irrational and selective use of inappropiate “safety measures” reduced. Human rights principles of informed consent and confidentiality need to be more widely adhered to in medical practice so that the HCPs do not violate patients' rights to informed choice, privacy, and counseling. To reduce stigma and discrimination, it is important to assess and improve HIV/AIDS-related knowledge of all HCPs. Further research is needed to determine whether any improvements are observed after providing appropriate HIV/AIDS education to the hospital staff at all levels.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.