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HIV stigma and discrimination in health care settings in the Eastern Mediterranean Region
- 1. 1 | HIV stigma and discrimination in health care settings in the Eastern Mediterranean Region Analysis by Daniel Lynx Bernard, consultant, WHO-Eastern Mediterranean Region Office (EMRO) Research design by Joumana Hermez, Technical Officer, AIDS and Sexually Transmitted Diseases, WHO-EMRO
- 2. 2 | Objectives of the research • Explore the attitude of health care providers vis-à-vis people living with HIV • Identify the forms of and reasons for stigma and discrimination against people living with HIV in health care settings
- 3. 3 | Countries participating Data collected: • Egypt • Iran • Lebanon • Morocco • Somalia (Somaliland)
- 4. 4 | “Voices” Anonymized De-emphasize country and profession Seek generalizations about Eastern Mediterranean Region
- 5. 5 | Objectives of the research Help health care providers to: ● Assess their views and actions towards people living with HIV in the light of the current knowledge of: • modes of HIV transmission • means of HIV prevention in health care settings ● Identify their rights to protection from HIV • and the means to fulfill those rights • without breaching the rights of people living with HIV
- 6. 6 | Methodology Focus groups, each with about 10 health care workers Format: Facilitated Q&A Presentation on HIV prevention and post-exposure prophylaxis Discussion producing recommendations
- 7. 7 | Desired outcome Discussions should empower health care providers to articulate recommendations related to: ● How a health worker may overcome prejudice, stigma and discrimination ● Occupational safety measures are required for health care workers to overcome their fear of contagion (standard precautions, post-exposure prophylaxis, etc) ● The right to health for people living with HIV
- 8. 8 | Findings Lack of resources Fear Stigma and discrimination Lack of knowledge
- 9. 9 | Knowledge and fear “A physician with an unreal HIV risk perception cannot treat the HIV-positive patients properly.”
- 10. 10 | Blame Blaming people with HIV is common When thinking of a person living with HIV, “Truly speaking, I see this person as promiscuous and that led to contract this virus. She got it through extramarital sex, even though there are other ways of contracting HIV.” “Obstetrics doctors should take care when examining foreigners, especially African descendents with doubtful practices.”
- 11. 11 | Rationalizing Blame comes with a preoccupation with the circumstances of how the person was infected “In a country like [ours], it is not necessary that he would have gotten the infection from sex. It could be from blood transfusion and he is a victim of neglect.” “We have to pay attention to barbers and raise their awareness because … ignorance is prevailing. People still go to barbers without clean instruments.”
- 12. 12 | Rationalizing “When I see an HIV person, I ask myself where did she or he get it from? … If they tell me [her husband] is a driver or khat seller, then I assume that he is a bad person, and I blame him for bringing HIV to his wife.” “I thought that this HIV-positive person was either a drug user like khat and alcohol, and maybe that is why she or he contracted the HIV in the first place.”
- 13. 13 | Isolating Desire to isolate people with HIV is common When thinking of a person living with HIV, “I feel that this person is terminally ill. Nothing can be done; and she can’t be able to work anymore. There are medications to deal with this condition but it helps a little and after taking the drugs they become a little bit healthy and can interact with other, HIV-negative people. This is not good. I think they should be given care and isolated so as to protect them from the community.”
- 14. 14 | Testing / Confidentiality Amid disagreement, some health care providers supported : Mandatory HIV testing Breaking HIV patient’s confidentiality “If the patient did not tell he is HIV-positive, it creates a barrier with the doctor. Confidentiality should not always be respected, and this is for the sake of the doctor’s own safety.” “Confidentiality is sometimes detrimental to the doctor and should be broken according to the doctor’s judgment, even without consent.”
- 16. 16 | Social pressure to stigmatize “Even physicians’ family members stigmatized the health care workers when hearing that they are serving people at high risk for HIV or HIV-positive patients.”
- 17. 17 | Social pressure to stigmatize “A girl who was my roommate for 10 years … came to me with a referral letter from a private hospital that showed her HIV status as positive… “She needed someone as a treatment supporter. Her brother refused to come alone with her as a treatment supporter, and she has no one else to turn to. “I thought of the possibilities that I can help this patient whom I have known for long time. Since I have a large family, could it be possible to take her to my family? And what will my mother will say if I do that? My conclusion was that I couldn’t be her supporter.”
- 18. 18 | Social pressure to stigmatize “Dentists and physicians, mostly at private sectors settings, have a big concern of losing their clients if they found that HIV-positive patients also visited their office.”
- 20. 20 | Education reducing stigmatization “On the contrary, we bring the information to the family of the patient that there is no justification for this fear, and we teach them how to prevent HIV.”
- 21. 21 | Recommendations Training, but .. “One of the main reasons making physicians to stigmatized HIV-positive patients is the risk perception. Even if they are familiar with the HIV routes of transmission, in reality they don’t believe it. They are not able to behave, exam and treat to a HIV patient.”
- 22. 22 | Recommendations Fear persists despite training “One patient…informed me immediately that he has HIV, and I respected his honesty. So I have done the procedure. However, due to my extreme fear at that time, I sterilized my instruments maybe 10 times in the autoclave.”
- 23. 23 | Recommendations Specialized training “There is not any special training for medical students, nurses and other health care personnel on how to behave with an HIV-positive patient. So how could we expect respectful stigma-free behaviors?” Recommended: “Training health care workers, particularly the new graduates, on how to prevent infectious diseases.”
- 24. 24 | Recommendations Peer training Recommended: “Awareness-raising on how to properly deal with HIV-positive patients through health conferences, and mandating the doctors who attend such conferences to brief his colleagues or to replicate the conference at a smaller scale to enable more doctors to benefit from the acquired information.”
- 25. 25 | Attitudes improving Some health care workers said they overcame past misperceptions. “The first time that I have seen an HIV-positive, I really got shocked, and I asked myself from where this person got the problem. The same HIV- positive patient touched me while I was on duty, and I ran away, because I was afraid that…I might get the disease as well. But now I understand that the HIV patients need care, and that it is our profession to care for the sick people.”
- 26. 26 | Attitudes improving “Previously we thought that only crazy people would contract HIV, but now we know that anyone can be infected with the virus.” “In the beginning of working on this issue, I used to be curious to know [how the infection happened]. But with experience, this has gone. The person might have gotten the infection by any means, and in all cases he is a victim, irrespective of how the infection happened.”
- 27. 27 | Attitudes improving “Awareness levels among … health care workers have increased a lot. I could say these [positive] opinions represent about 80%.”
- 28. 28 | In closing Things must be seen differently Words must be washed Words must be the wind by themselves Words must be the rain by themselves Umbrella should be closed! We should go under the rain We should take our mind, our memories into the rain With all people in the city We should feel the rain -- Sohrab Sepehri
Editor's Notes
- Hello, and thanks to the Qatar Foundation for its leadership in this area and so many other important topics. I am here representing the World Health Organization’s Office for the Eastern Mediterranean Region, located in Cairo, and Ms. Joumana Hermez, who designed this research.
- We will not take time here to substantiate that there *is* a problem with stigma and discrimination against people with HIV in this region. This has been well explored by speakers before me including Majdi Al Touhki of the World Bank and Rita Wahab, MENA ROSA. Our exercise is not quantitative, but qualitative. The objectives of the research activity are the following: To explore the attitude of health care providers vis-à-vis PLHIV Identify the forms of and reasons for stigma and discrimination against PLHIV in health care settings
- However, in the research findings and in this article, we generally seek to de-emphasize the country where the data was gathered, because we are trying to generalize about attitudes toward people with HIV throughout the region, not to point blame at any individual country. Furthermore, although these focus groups including different types of health care providers – nurses, surgeons, dentists, HIV specialists – we de-emphasize their specialties and job titles because we are seeking a general view of stigma and discrimination in the health care sector as a whole. All the quotations in this presentation are from participants in the focus groups in Somalia, Egypt, Lebanon, and Iran.
- … additionally, the research is aimed at helping health care providers to: Enable health care providers to assess their views and actions towards PLHIV in the light of the current knowledge of modes of HIV transmission and means of HIV prevention in health care settings Enable health care providers to identify their rights to protection from HIV and the means to fulfilling them without breaching rights of PLHIV
- The activity is aimed at facilitating health care providers themselves to articulate recommendations to the health care sector and policy-makers for steps that will improve the situation. This would cover areas including: How a health worker may overcome prejudice, stigma and discrimination What occupational safety measures are required for health care workers to overcome their fear of contagion (standard precautions, post-exposure prophylaxis, etc) The right to health for PLHIV
- First I should clarify that the statements we have excerpted here are those that are, we would say, the statements that most concern us. In the interest of time we could not generalize all the comments on all topics. So what you are seeing here are the most discriminatory attitudes. We also heard many positive comments in which the health care workers upheld principles of respect and dignity for patients. But we are focusing on the discrimination that does exist, and the reasons for it. So: (CLICK AND DESCRIBE THE FLOWCHART)
- (Iran)
- (Nurse Somalia) (Lebanon)
- (Egypt resident doctor)
- (Nurses from Somalia)
- (Nurse Somalia)
- (Lebanon) (Lebanon)
- Also, although we seek to discretely examine attitudes among health care providers, we find it is also necessary to acknowledge effects upon them by their own families and by patients.
- (Iran)
- This is a story told to us by one of the focus group participants. She is a health care provider, although she is describing an interaction she had in her personal life with a personal acquaintance. Still we can see the attitude she has about people living with HIV that probably affect her interactions with patients as well. She concluded that she could not act as a treatment supporter for this person. The reasons she gave were that she had a large family; and she was concerned about what her mother would think.
- (Iran)
- On the other hand, health care providers are highly respected in the region in general and thus are in a position to effectively influence the perceptions of the general public about people living with HIV. So the other side of the interrelation between the groups are that educational messages from the health care providers can reduce the pressure that they place upon the providers.
- (Egypt nurse in HIV treatment center)
- The obvious recommendation in the face of harmful attitudes or lack of knowledge are educational workshops. But, as the facilitator of the Somalia focus group noted, many of these health care practitioners already have had orientations on HIV prevention, at least once. Yet the negative perceptions return. (Iran)
- (Egypt surgeon)
- So the conclusion may be that what is needed is a specialized training looking at the specific question of how health care providers perceive people with HIV; and a training using a method that is effective in reaching the health care worker and affecting prejudices. (Iran) (Egypt)
- (Egypt)
- Some respondents recounted that they previously held discriminatory beliefs, but they had overcome those prejudices more recently in their professional development. (Somalia nurse)
- (Somalia nurse) (Egypt doctor)
- (Egypt doctor)
- So that we will not be disheartened about the chances of ending stigma and discrimination against people living with HIV, let us close with an uplifting note. The focus group from Iran included with its report this poem attributed to the Persian poet and painter Sohrab Sepehri