Question

Discussion: HIV stigma peer-reviewed studies

Please post thoroughly answering the following questions, including at least 1 reference.

Read the attached articles.

Identify at least three points that resonated with you in each one and describe why they did (2-3 sentences per point)

If you were a researcher, what further study would you develop or what program might you develop?

Article: Experiences of Stigma and Discrimination among Adults Living with HIV in a Low HIV-Prevalence Context

Abstract

Little is known about how people living with HIV in low prevalence contexts face the challenges of stigma and discrimination. Low prevalence and rural communities are unique environments in which HIV-related stigma and discrimination may be intensified due to a lower tolerance of differences among people and greater fear of HIV. This study examined the experiences of 16 individuals living with HIV who reside in a predominantly rural area with low HIV prevalence. We used in-depth interviews to explore participants’ experience with stigma and discrimination in social and health care settings and their behavioral and emotional responses. In their day-to-day lives, participants described feeling social rejection, being forced to follow different rules of social contact, and being treated differently. In healthcare settings, participants described specific instances when they felt providers were afraid of them and when they were refused or discouraged treatment or treated differently based on their HIV status. Participants experienced stigma and acts of discrimination in different settings (e.g., phy-sician and dentist offices and hospitals) and from a range of types of providers (e.g., physicians, nurses, anddentists). Behavioral and emotional responses to perceived acts of stigma and discrimination included anger, shame, social isolation, and self-advocacy. Findings point to a need to develop tailored interventions to address stigma and discrimination for individuals, healthcare personnel, and the community-at-large.

Induction

IntroductionHIV=AIDS remains the most highly stigmatized illness in the United States, profoundly affecting the lives of individuals living with HIV. As a socially constructed process, HIV-related stigma results in prejudice and acts of discrimination toward individuals living with HIV. Both stigmaand discrimination are associated with negative health out-comes for people living with HIV including poor antiretro-viral therapy adherence,1–3engagement in unsafe sexualbehaviors,4increased levels of depression3,5–8higher levelsof posttraumatic stress symptoms, greater severity of AIDS-related symptoms, lower perceived general health, and less health care satisfaction.3The majority of the research on stigma and discrimination date has focused on populations living in high HIV prevalence areas concentrated in urban locations.1–8Despite the fact that large numbers of people living with HIV and AIDS in the United States are distributed across metropolitan and nonmetropolitan regions with low prevalence of HIV,9thereis limited information about how stigma manifests itself within these regions including more socially isolated areas such as rural communities. The Centers for Disease Control and Prevention (CDC) reports that 46% of AIDS cases re-ported in the United States through 2006 were dispersed across 40 states with annual AIDS rates below the annual rate for the United States (12.7 per 100,000 in 2006).10Through2005, more than 48,000 persons diagnosed with AIDS were living in nonmetropolitan statistical areas (MSAs) (popula-tion<50,000) and an additional 83,372 were living in metropolitan statistical areas with populations between 50,000 and500,000.11AIDS case rates also vary considerably based on community size. For example, in 2005 AIDS case rates were6.4 per 100,000 for non-metropolitan areas compared to 9.3per 100,000 in areas with populations between 50,000–500,000and 21.1 per 100,000 for MSAs with populations of greater than 500,000.11Low prevalence and rural contexts present unique environment where people living with HIV=AIDS are more likely to reside in socially isolated conditions and have fewer resources at their disposal.12,13Stigma may be intensified in these areas where there is less tolerance of diverse lifestyles greater fear of HIV, and less anonymity.14–16In addition, unlike high prevalence or urban areas with high rates of HIV, low prevalence areas have fewer medical experts, have limited social support programs, and lack comprehensive AIDSservices, which alter people’s experiences.17–19Support services provided by the Ryan White Care Act, including case managers and funds to support transportation to doctor visits, dental care and associated services, are limited in low prevalence areas due to a funding allocation method, which is based on a number of AIDS cases diagnosed in a given county.20In addition, rural regions, in particular, are affected by inadequate health infrastructure, underfunded rural health and social services programs, higher poverty, geographic challenges and a higher proportion of people who lack health insurance.13,21–23The a handful of HIV-related stigma and discrimination studies conducted in rural areas suggests that social context matters. In a study comparing urban and rural people living with HIV=AIDS, Heckman et al.24found that rural people living with HIV, compared to their urban counterparts, reported significantly lower satisfaction with life, lower perceptions of social support from family members and friends, reduced access to medical and mental health care, elevated levels of loneliness, more community stigma, and heightened personal fear. In a study of people living with HIV in rural areas taking antiretroviral therapy, participants reported they skipped doses of medication to avoid the stigma associated with publicly taking medication that could disclose their HIV status.25Negative attitudes of rural health care providers also may impact people living with HIV who seek care in these areas. Discrimination in care and unwillingness to care for people living with HIV=AIDS has been found among physicians,26dentists,27and rural nurses.28In a recent study of HIV service professionals from rural areas in the midwestern part of the United States, providers reported stigma and discrimination perpetrated by other medical staff and physicians as a major barrier their clients face when referred for medical services.29Thus people living with HIV in low prevalence and rural areas appear to experience challenges that can intensify the impact of stigma.A small number of qualitative studies have examined patients experiences with HIV stigma and discrimination in health care settings but these have focused on urban samples.30–32One study examined stigma among groups of women living in New York City diagnosed with HIV prior to the introduction of highly active antiretroviral therapy (HAART)and post-HAART, finding that women in the pre-HAART group experienced enacted stigmatization more frequently and intensely and were more likely to have been verbally offended and discriminated against by family, friends and professionals than post-HAART participants.30Another study of veterans living with HIV in a large metropolitan city identified subtle forms of stigma and discrimination that occur during health care visits and found that stigma took on a variety of forms and ranged from ambiguous nonverbal cues to blatant discriminatory acts across different types of healthcare personnel.31In a qualitative study of a diverse group of low-income men and women living with HIV in Los Angeles,California, Sayles et al.32found that participants faced stigma in medical settings but less commonly in HIV specialty care clinics. Although findings from these studies provide insight into problems and issues related to stigma and discrimination that individuals living with HIV face, there is a gap in understanding how these same issues impact individuals living with HIV in rural or low HIV prevalence settings.Although studies of stigma, prejudice, and discrimination derived from different research traditions, each seeks to understand how individual experiences, interpersonal interactions between marginalized and nonmarginalized groups, and broader structural and social phenomena such as power and community practices impact individual health.33–35In a recent conceptual review, Stuber et al.35argue that studying the impact of stigma, prejudice, and discrimination will help improve understanding of how these experiences contribute to psychosocial stress and health outcomes of marginalized groups. HIV stigma has been defined to include prejudice, discounting, discrediting, and discrimination directed at people perceived to have AIDS or HIV.36In this paper, the term‘‘stigma’’ is used to refer to this broader set of attitudes, beliefs,and behavior, and ‘‘discrimination’’ is used to refer more specifically to prejudicial behavior or negative treatment.Specific aspects and dimensions of stigma and discrimination can be difficult to identify, quantify, and describe because of their subtle, nebulous, and untamed nature, and because stigma and discrimination can take on different forms in different environments. The purpose of this study is to contextualize and describe how people living with HIV in a predominantly rural area with low rates of HIV=AIDS experience and respond to perceived acts of stigmatization and discrimination in their day-to-day lives and in healthcare settings.

Methods

Study context this study was conducted in a three-county area in Oregon. The area is predominately rural and includes cities with populations no larger than 60,000. Oregon is one of 31 states with an annual AIDS rate below 10.0 per 100,000 in 2006.10Similar to other rural HIV care delivery systems,37one physician serves as the primary health care provider for the majority of people living with HIV=AIDS in the area. In addition, each county health department has a part-time Ryan White case manager who is responsible for ensuring that eligible clients have access to medical care, medications and drug treatments, and essential support services.38Participants and proceduresParticipants were adults living with HIV residing in the three-county area described above. To be eligible for the study, participants had to self-report be HIV positive and age 18 years or older. The primary recruitment source was a local physician who is the primary medical provider for persons diagnosed with HIV living in the three targeted countries. Four of the 16 participants were recruited by the physician as key informants to pilot the interview guide and obtain feedback on interview questions. Ten of the remaining participants were recruited by flyers distributed by the physician to patients during their regularly scheduled appointments. The final two interviews were conducted after efforts to recruit were expanded to include the distribution of flyers by one other local physician who provides care for a much smaller number of HIV patients and by case managers at two local health departments. The flyer provided basic information about the study including the project’s toll-free number. Interested persons phoned the project’s number; recorded greeting instructed them to leave a message. They were then contacted by project staff, screened for eligibility, and scheduled for interviews. Sixteen face-to-face interviews were conducted between October 2005 and June 2006. Fourteen of the participants resided in the targeted three-county area, and two resided in an adjacent county. Interviews were conducted in private rooms in public locations such as libraries. The first author conducted three of the key informant interviews. Trained interviewers conducted the rest of the interviews. Written informed consent was obtained from all participants before they were interviewed. All interviews were audio taped. Interviews were designed to take approximately 60 minutes to complete. Participants received a $25 gift card as compensation for their time. This study was approved by the Oregon State University Institutional Review Board

interview guide The interview guide included predominately open-ended questions and probes. The development of the interview guide was an iterative process: during and after the initial key informant interviews, questions were added, revised, or dropped based on information gleaned during the interview process. The final guide consisted of 22 main questions, as well as several follow-up questions and a series of probes. Topics covered included stigma, trust, and mistrust of health care providers, discrimination when getting health care, and health literacy. Questions were also included to better understand the community context of HIV (e.g., barriers to treatment, what itis like to be HIV positive in the community). In addition, structured questions to collect sociodemographic and health history data were included at the end of the interview guide. For this study, we were particularly interested in perceptions and experiences related to stigma and discrimination. Data analysis Audiotapes of the interviews were transcribed. Data we reanalyzed using content analysis techniques.39First, the AU-thorns independently read the complete transcripts and gen-erased a list of codes focusing on the main topics. They then discussed the codes and jointly developed a refined list of codes for major topics and themes. Next, they independently coded the transcripts. The authors then met and reviewed the transcripts page by page and compared coding of the text. For this paper, the analysis focused on text related to participant’s recent experiences with stigma and discrimination. There were no major inconsistencies in coding; minor differences were discussed and resolved. The final step was to summarize the results derived from the analysis and select verbatim quotations to illustrate each theme.

Answer 1

Some of the pointe which can be resonated here are

• Area: The study describes more about the HIV population in rural population. Here the population is very limited and consistent, so a disease of one person is easily identified and can threaten them that they are high risk of getting the infection if staying close by the area.
• Rate of prevalence: This is an important aspect the prevalence rate is high among sex worker MSM.In rural area if it affects a particular number of people on a whole it is always considered to be high prevalent by the local people.
• Women: The stigma existed greatly among women.They were isolated,abused non verbally, discriminated by family and professional.

Some future plan which can be done to improve their quality of life are

• Awareness and health education programs dine at work place
• The number of experts treating the sick has to be increased so a group work can be enforced.
• Mental health program to be conducted ingeneral at all public area
• Create awareness through social media
• People should not be isolated
• Counseling of family member to support the ill
• General precautions and care has to be taught to everyone
• A topic in brief can be included in the children's education.