INTRODUCTION

HIV/AIDS stigma among health workers continues to be a major obstacle to accessing health services, affecting efforts to prevent and control the disease [1-3]. A survey by the Asia Pacific Network of People Living with HIV/AIDS (APN+) in India, Indonesia, the Philippines, and Thailand revealed that over 50% of people living with human immunodeficiency virus(HIV; PLHIV) had encountered stigma within the healthcare system. Additionally, PLHIV who face stigma in healthcare settings may experience delays in starting treatment [4,5].

Various studies have recognized that stigma occurs at several levels and have conceptualized it as a multi-level phenomenon [6]. In healthcare, stigma can be predicted based on individual and social levels [7]. At the individual level, the origin of stigmatization lies in the perceptions that individuals hold, which become cognitive representations associated with emotional and behavioral reactions toward PLHIV. Often, PLHIV are associated with behaviors that violate societal norms [8,9]. Additionally, limited knowledge can lead to misconceptions about HIV, potentially increasing irrational fears of HIV transmission [10,11].

At the societal level, HIV-related stigma within the health sector is perceived as a breach of the professional ethics upheld by healthcare workers. These ethical principles are essential for providing high-quality health services and encompass justice, patient autonomy, and non-discrimination. Additionally, professional ethics incorporate social principles and norms, which include a strong sense of social responsibility that influences the quality of services offered [12,13]. Recognizing the crucial role of institutional support, the provision of safe and inclusive facilities can foster an environment where stigmatization is minimized.

Many HIV/AIDS communities have emphasized that reducing stigma is crucial for curbing the HIV/AIDS epidemic [14-19]. Therefore, it is essential to explore and address HIV/AIDS stigma from the perspective of health workers. Previous research has not thoroughly examined the impact of knowledge, professional ethics, and institutional support on both perceived and actual HIV-related stigma among health workers. Therefore, this study aims to assess how these variables—knowledge, professional ethics, and institutional support—affect perceived and actual HIV-related stigma within healthcare settings. Additionally, we will explore in greater detail the various indicators that constitute these variables using partial least squares structural equation model (PLS-SEM) analysis.

METHODS

Design and Sampling

This study employed a cross-sectional design to explore the relationships of HIV/AIDS-related stigma among health workers. Padang and Bukittinggi, cities with the highest incidence of HIV cases in West Sumatra Province, Indonesia, were chosen for the study from among 19 regions. Our focus was on public hospitals and primary public healthcare facilities in these areas. In each city, a main public hospital known for providing essential HIV treatment services was selected. In Padang, 10 primary public health care facilities were randomly chosen from a total of 23. Similarly, in Bukittinggi, three facilities were selected from a pool of seven. A comprehensive sample of 283 participants, including doctors, midwives, and nurses, was randomly drawn from these facilities. Data collection was conducted using a structured and internally administered questionnaire.

Statistical Analysis

Individual characteristics were presented using numbers and proportions for categorical variables, and mean±standard deviation for numerical variables. This study employed PLS-SEM analysis using SmartPLS 4 software. We ensured that the data were adequately prepared for analysis. The interrelationships among research variables were examined through 2 stages of analysis: (1) reflective measurement model analysis (outer model) and (2) structural model estimation analysis (inner model).

Reflective measurement model analysis was conducted by evaluating four key values. First, indicator reliability was assessed by examining the outer loading (λ) value of each indicator. Second, internal consistency reliability was evaluated using the composite reliability (ρ_c) value for each latent variable. Third, convergent validity was assessed through the average variance extracted (AVE) value. Fourth, discriminant validity was determined by comparing the λ values across indicators (cross-loadings).

Structural model estimation analysis elucidated the direct correlation between various factors and HIV-related stigma by considering the path coefficient (β), collinearity via the variance inflation factor (VIF), coefficient of determination (R²), effect size (f²), and relevance [20,21]. The modified path model, which excluded insignificant paths, was employed to re-estimate the measurement model evaluation values.

Instrument

This study employed constructs derived from various survey questionnaires. The stigma variable, an endogenous latent response variable, was assessed using the Health Care Provider HIV/AIDS Stigma Scale (HPASS) questionnaire. HPASS is a validated tool comprising 30 items that evaluate prejudice, stereotypes, and discrimination [22].

Ethics Statement

All procedures received approval from the Faculty of Medicine Ethics Committee at Universitas Andalas (No. 750/UN.16.2/KEP-FK/2022). Participants voluntarily provided informed consent prior to responding to the survey. The questionnaire included the purpose of the study and other relevant information, and participants were assured that the information collected would remain confidential.

RESULTS

Descriptive Results

Table 1 presents the characteristics of the study participants. The average age was 39.1 years, with a predominance of women participants. Nearly half of the participants were nurses with over 10 years of experience. The mean stigma scores were generally low across all sub-variables, showing only minor variations (a lower score indicates higher stigma). Additionally, the data revealed an even distribution around the mean value (mode=mean), suggesting that health workers continue to harbor significant stigma towards HIV/AIDS. The subsequent sections detail the results from the measurement and structural model evaluations using PLS-SEM.

Reflective Measurement Model Analysis (Outer Model)

The results of the PLS-SEM analysis for the latent variable measurement model, which includes HIV-related stigma, perceptions regarding HIV/AIDS, knowledge, professional ethics, and institutional support, indicate generally high reliability values (λ>0.7) for each indicator. This suggests that the indicators are robust and can be retained in the model. However, the reliability of one indicator under perceptions regarding HIV/AIDS, specifically perceived contagiousness, is moderate (λ=0.446). Despite this, the indicator can still be considered valid for the model because it demonstrates good internal consistency reliability (ρ_c>0.70) and adequate convergent validity (AVE >0.50). Conversely, the reliability value for the institutional support indicator, specifically rewards and punishments, is low (λ=0.446) and therefore should be removed from the model. Furthermore, all constructed indicators are confirmed as valid for measuring latent variables, as evidenced by satisfactory results in the discriminant validity assessment. This is demonstrated by each indicator’s λ value in the cross-loadings being greater than the λ values of indicators for other latent variables. Details are provided in Table 2.

Structural Model Estimation Analysis (Inner Model)

The path coefficient results from the PLS-SEM model, which describe the direct correlations between various factors and HIV-related stigma, are presented in Table 3. The findings indicate that all variables are significantly and directly correlated with HIV-related stigma (p<0.01). Furthermore, the estimated path coefficient value is near +1, suggesting that perceived HIV, knowledge, professional ethics, and institutional support positively and significantly influence HIV-related stigma.

The path coefficient results from the PLS-SEM model reveal correlations among knowledge, professional ethics, and institutional support in relation to HIV-related stigma, with perceived HIV serving as a mediating variable. The analysis indicates a significant indirect relationship between knowledge and stigma, mediated by perceived HIV (ρ=0.128, p<0.05). However, the relationships between professional ethics and stigma, as well as between institutional support and stigma-with perception as the mediating variable-were not significant (ρ=0.009 and 0.019, respectively; p>0.05). These findings are presented in Table 3.

The modified path model, with non-significant paths removed, was re-estimated to obtain accurate model evaluation values. The results of this re-estimation are shown in Table 3 and Figure 1. Among health workers, the direct relationship between knowledge and stigma is stronger than the indirect relationship through perception. This is evidenced by the coefficient value of the direct relationship (β=0.296) being more significant than that of the indirect relationship (β=0.138), with a p-value of 0.001.

Table 4 presents the results of the PLS-SEM modified path model, which includes evaluations of the VIF, effect size (f²), and the coefficient of determination (R²). All latent variables have VIF values below 5, suggesting that they are suitable for retention in the model. The effect size (f²) assesses the impact of exogenous variables on endogenous variables. In this model, effect size (f²) is used to evaluate how the variables of perceived knowledge, professional ethics, and institutional support contribute to HIV/AIDS-related stigma. The analysis shows that knowledge and professional ethics have a significant impact (f²≥0.15), whereas perception and institutional support have a lesser impact on HIV-related stigma (f²≥0.02). The coefficient of determination (R²) for the health worker stigma variable is 0.408, indicating that knowledge, professional ethics, institutional support, and perception collectively explain 40.8% of the variance in stigma. Additionally, the R² value for the perceived variable is 0.217, demonstrating that the knowledge variable alone accounts for 21.7% of the variance in perception (Figure 1).

DISCUSSION

HIV-related stigma in health services must be addressed. It is crucial to identify the factors influencing HIV/AIDS stigma from the perspective of health workers, as this is a key strategy in reducing stigmatizing behavior within health services. This study identified several significant factors that directly correlate with the occurrence of HIV-related stigma, including perceived stigma, level of knowledge, professional ethics, and institutional support. These factors are considered the primary predictors of stigmatizing behavior among health workers. Additionally, our findings reveal an indirect correlation between the level of knowledge and the degree of stigmatization, with perceived stigma acting as a mediating factor. This suggests that stigma may originate from perceptions, which are the initial predictive factors that can lead to emotional reactions such as stereotyping and prejudice, and subsequently to discriminatory behavior in service delivery that adversely affects PLHIV. Many individuals harbor unrealistic beliefs about HIV transmission, viewing it as a deadly disease linked to sexual behavior that breaches societal norms and attributing it to past actions that contravene religious teachings [8-10,23].

The second significant predictor was HIV-related knowledge. The perceived fear of HIV transmission stems from a lack of knowledge and is linked to misconceptions about how HIV is transmitted. This fear often leads health workers to avoid contact with HIV/AIDS patients as much as possible, which is indicative of stigmatization [10,11,24,25].

The third significant predictor of stigmatization is the factor of professional ethics. Our findings indicate that the application of health workers’ professional ethics, evaluated in terms of accountability, self-awareness, motivation, trust, self-control, and interpersonal communication, positively influences the reduction of stigma. The final predictive factor identified in this study is institutional support, which includes supporting facilities, infrastructure, and division of workload. This finding is corroborated by previous research, which demonstrates that greater perceived institutional support correlates with fewer discriminatory intentions toward PLHIV in the workplace [26].

These results underscore the need to evaluate and improve healthcare workers’ knowledge, encompassing their grasp of professional knowledge, policies, best practices, standards, and clinical procedures pertinent to healthcare professional ethics. Interventions aimed at reducing stigma often concentrate solely on boosting general knowledge, neglecting the importance of more specialized knowledge [27-30]. Additionally, it is crucial to acknowledge that ethical breaches can impinge on patients’ rights. Therefore, heightened professionalism is anticipated to reduce stigma and discrimination in healthcare settings [26]. In this regard, institutional support is vital to ensure that health workers have access to adequate facilities and equipment necessary for preventing workplace transmission, including sterile hand practices, personal protective equipment, and HIV testing availability. This support can alleviate anxiety associated with HIV infection and mitigate discriminatory attitudes towards PLHIV [31]. It is important to highlight that the enforcement of professional ethical standards is measured by the degree to which health workers internalize and adhere to these standards, thereby ensuring they practice non-stigmatization towards PLHIV.

This study demonstrates that stigma associated with HIV/AIDS is prevalent in healthcare settings. Our structural model indicates that high perceptions of HIV, insufficient knowledge, weak professional ethics, and a lack of institutional support contribute to elevated levels of HIV/AIDS-related stigma. Training programs focused on HIV/AIDS are crucial, and the development of policies to protect PLHIV can aid in reducing this stigma among healthcare workers. Consequently, intervention strategies aimed at diminishing HIV-related stigma in healthcare services should focus on enhancing knowledge, reinforcing professional ethics, bolstering institutional support, and implementing necessary changes. It is hoped that these efforts will foster a more inclusive and supportive care environment for PLHIV and promote care practices among health workers that are both more empathetic and free of stigmatization.

Notes

Conflict of Interest

The authors have no conflicts of interest associated with the material presented in this paper.

Funding

None.

Author Contributions

Conceptualization: Triana V, Effendi N. Data curation: Triana V. Formal analysis: Triana V. Devianto D. Funding acquisition: None. Methodology: Triana V, Sri Pra Hastuti B. Project administration: Semiarty R. Writing – original draft: Triana V, Ilmiawati C, Afrizal A, Bachtiar A, Raveinal R, Effendi N, Sri Pra Hastuti B, Devianto D, Semiarty R. Writing – review & editing: Triana V, Ilmiawati C.

Acknowledgements

Figure. 1.

Diagram of the partial least squares structural equation model modified path model. HIV, human immunodeficiency virus.

REFERENCES

• 1. United Nations Programme on HIV/AIDS. Reducing HIV stigma and discrimination: a critical part of national AIDS programmes: a resource for national stakeholders in the HIV response; 2007 [cited 2022 Jul 12]. Available from: https://www.unaids.org/sites/default/files/media_asset/jc1521_stigmatisation_en_0.pdf
• 2. Hafeez H, Zeshan M, Tahir MA, Jahan N, Naveed S. Health care disparities among lesbian, gay, bisexual, and transgender youth: a literature review. Cureus 2017;9(4):e1184. https://doi.org/10.7759/cureus.1184ArticlePubMedPMC
• 3. Chen WT, Han M, Holzemer WL. Nurses’ knowledge, attitudes, and practice related to HIV transmission in northeastern China. AIDS Patient Care STDS 2004;18(7):417-422. https://doi.org/10.1089/1087291041518247ArticlePubMed
• 4. United Nations Programme on HIV/AIDS. AIDS epidemic update; 2006 [cited 2022 Jan 20]. Available from: https://data.unaids.org/pub/epireport/2006/2006_epiupdate_en.pdf
• 5. United Nations Programme on HIV/AIDS. Global report: UNAIDS report on the global AIDS epidemic; 2013 [cited 2022 Jan 20]. Available from: https://www.unaids.org/en/resources/documents/2013/20130923_UNAIDS_Global_Report_2013
• 6. Rao D, Elshafei A, Nguyen M, Hatzenbuehler ML, Frey S, Go VF. A systematic review of multi-level stigma interventions: state of the science and future directions. BMC Med 2019;17(1):41. https://doi.org/10.1186/s12916-018-1244-yArticlePubMedPMC
• 7. Stringer KL, Turan B, McCormick L, Durojaiye M, Nyblade L, Kempf MC, et al. HIV-related stigma among healthcare providers in the Deep South. AIDS Behav 2016;20(1):115-125. https://doi.org/10.1007/s10461-015-1256-yArticlePubMedPMC
• 8. Dijker AJ, Koomen W. Extending Weiner’s attribution-emotion model of stigmatization of ill persons. Basic Appl Soc Psychol 2003;25(1):51-68. https://doi.org/10.1207/S15324834BASP2501_4Article
• 9. Bos AE, Schaalma HP, Pryor JB. Reducing AIDS-related stigma in developing countries: the importance of theory- and evidence-based interventions. Psychol Health Med 2008;13(4):450-460. https://doi.org/10.1080/13548500701687171ArticlePubMed
• 10. Fauk NK, Ward PR, Hawke K, Mwanri L. HIV stigma and discrimination: perspectives and personal experiences of healthcare providers in Yogyakarta and Belu, Indonesia. Front Med (Lausanne) 2021;8: 625787. https://doi.org/10.3389/fmed.2021.625787ArticlePubMedPMC
• 11. Huang J, Shum YY, Zhang J, Yu NX. Social distance mediates the association between fear of infection and better-off-dead beliefs about people living with HIV. J Int Med Res 2020;48(3):300060519890819. https://doi.org/10.1177/0300060519890819ArticlePubMed
• 12. Williams JR. Medical ethics manual 3rd edition; 2015 [cited 2023 Mar 12]. Available from: https://www.wma.net/wp-content/uploads/2016/11/Ethics_manual_3rd_Nov2015_en.pdf
• 13. Desai MK, Kapadia JD. Medical professionalism and ethics. J Pharmacol Pharmacother 2022;13(2):113-118. https://doi.org/10.1177/0976500X2211114Article
• 14. Goldin CS. Stigmatization and AIDS: critical issues in public health. Soc Sci Med 1994;39(9):1359-1366. https://doi.org/10.1016/0277-9536(94)90366-2ArticlePubMed
• 15. Malcolm A, Aggleton P, Bronfman M, Galvão J, Mane P, Verrall J. HIV-related stigmatization and discrimination: its forms and contexts. Crit Public Health 1998;8(4):347-370. https://doi.org/10.1080/09581599808402920Article
• 16. Cameron E. The deafening silence of AIDS. Health Hum Rights 2000;5(1):7-24. https://doi.org/10.2307/4065220ArticlePubMed
• 17. United Nations Programme on HIV/AIDS. Report on the global HIV/AIDS epidemic-June 2000; 2000 [cited 2022 Jan 12]. Available from: https://data.unaids.org/pub/report/2000/2000_gr_en.pdf
• 18. Foreman M, Lyra P, Breinbauer C. Understanding and responding to HIV/AIDS-related stigma and discrimination in the health sector. Washington, DC: Pan American Health Organization; 2003
• 19. Feyissa GT, Abebe L, Girma E, Woldie M. Stigma and discrimination against people living with HIV by healthcare providers, Southwest Ethiopia. BMC Public Health 2012;12: 522. https://doi.org/10.1186/1471-2458-12-522ArticlePubMedPMC
• 20. Hair Jr JF, Hult GT, Ringle CM, Sarstedt M. A primer on partial least squares structural equation modeling (PLS-SEM). Los Angeles: SAGE Publications; 2017. p. 190-208
• 21. Sarstedt M, Ringle CM. Partial least squares structural equation modeling. Cham: Springer: 2017, p. 1-40
• 22. Wagner AC, Hart TA, McShane KE, Margolese S, Girard TA. Health care provider attitudes and beliefs about people living with HIV: initial validation of the health care provider HIV/AIDS Stigma Scale (HPASS). AIDS Behav 2014;18(12):2397-2408. https://doi.org/10.1007/s10461-014-0834-8ArticlePubMed
• 23. Latifa A, Purwaningsih SS. The role of harmonious society in reducing the stigma and discrimination against people living with HIV AIDS. J Kependudukan Indones 2011;6(2):51-76. (Indonesian)
• 24. Sadarang RA. Prevalence and factors affecting discrimination towards people living with HIV/AIDS in Indonesia. J Prev Med Public Health 2022;55(2):205-212. https://doi.org/10.3961/jpmph.21.502ArticlePubMedPMC
• 25. Mahamboro DB, Fauk NK, Ward PR, Merry MS, Siri TA, Mwanri L. HIV stigma and moral judgement: qualitative exploration of the experiences of hiv stigma and discrimination among married men living with HIV in Yogyakarta. Int J Environ Res Public Health 2020;17(2):636. https://doi.org/10.3390/ijerph17020636ArticlePubMedPMC
• 26. Ahmadi K, Reidpath DD, Allotey P, Hassali MA. Professionalisation and social attitudes: a protocol for measuring changes in HIV/AIDS-related stigma among healthcare students. BMJ Open 2013;3(5):e002755. https://doi.org/10.1136/bmjopen-2013-002755ArticlePubMedPMC
• 27. Waluyo A, Culbert GJ, Levy J, Norr KF. Understanding HIV-related stigma among Indonesian nurses. J Assoc Nurses AIDS Care 2015;26(1):69-80. https://doi.org/10.1016/j.jana.2014.03.001ArticlePubMed
• 28. Harapan H, Feramuhawan S, Kurniawan H, Anwar S, Andalas M, Hossain MB. HIV-related stigma and discrimination: a study of health care workers in Banda Aceh, Indonesia. Med J Indones 2013;22(1):22-29. https://doi.org/10.13181/mji.v22i1.518Article
• 29. O’Neill A. Professionalism and professional accountablity in clinical skills practice. In: NHS Lothian accountability workbook. 2014, p. 7
• 30. Andrewin A, Chien LY. Stigmatization of patients with HIV/AIDS among doctors and nurses in Belize. AIDS Patient Care STDS 2008;22(11):897-906. https://doi.org/10.1089/apc.2007.0219ArticlePubMed
• 31. Li L, Wu Z, Wu S, Zhaoc Y, Jia M, Yan Z. HIV-related stigma in health care settings: a survey of service providers in China. AIDS Patient Care STDS 2007;21(10):753-762. https://doi.org/10.1089/apc.2006.0219ArticlePubMed

Figure & Data

References

Citations

Citations to this article as recorded by