HIV-Related Stigma and Discrimination (S&D) among Healthcare Workers (HCW) in Government Healthcare Facilities in Malaysia: Is It Real?

Stigma and discrimination (S&D) undermine quality of life of people living with HIV (PLHIV) and their access to health services. In this context, an understanding of current stigmatizing attitudes among HCW towards PLHIV from the perspective of Malaysia healthcare setting is crucial to plan for service delivery improvement that is non-stigmatizing and non-discriminatory. The objective of this study was to examine and measure the level of S&D towards PLHIV among HCW in selected government facilities. A cross-sectional study was undertaken from July to August 2020 in five government hospitals and six government health clinics in Malaysia. Two sets of a validated self-administered questionnaires, one for HCW and another one for PLHIV were used to assess HIV-related S&D. This survey was conducted via web-based platform. Overall, 3880 HCW and 1173 PLHIV participated in this study. This study found significant proportion of HCW were having stigmatizing attitudes towards PLHIV. This includes fear of taking blood from PLHIV (87%) and double gloving when attending PLHIV (64%) probably due to fear of contracting HIV. In addition, 45% of HCW agreed that women living with HIV (WLHIV) should be prohibited from having children. Although HCW have fears for contracting HIV, their consciences and integrity allowed them to display some positive attitudes towards PLHIV with the majority of HCW 84% and 79% stated that they having observed others in their facility expressed willingness to care and providing good care to PLHIV. On PLHIV experience, only 12% of them reported that they had ever experienced stigma when accessing health services. The findings of this study shared a worrying magnitude of stigma towards PLHIV among HCW in Malaysia. Nevertheless, ethics and professionalism are upheld through giving good care and services to PLHIV. However, stigma reduction intervention programmes are still needed for HCW to ensure continuous excellent service delivery.


Introduction
Despite global progress in the treatment and care of human immunodeficiency virus (HIV), PLHIV still continue to report experiencing HIV-related S&D within the healthcare setting (Vorasane et al., 2017). The S&D that a PLHIV experienced at a healthcare setting resulted in lower access to HIV treatment, low utilization of HIV care services, poorer antiretroviral therapy (ART) adherence and thus poorer treatment outcomes (Pitasi et al., 2018;Tran et al., 2019).
well-being, life satisfaction and quality of life have all been reported to be negatively impacted by S&D (Vorasane et al., 2017;Houstan et al., 2019).
Research has shown that HIV-related S&D in healthcare setting may occur in many different forms, including: denial of care to a PLHIV (Ogden & Nyblade, 2005), verbal abuse to a PLHIV (Mukasa, 2006;Nyblade, Stangl, Weiss & Ashburn, 2009), lower standards of care to a PLHIV (Maluwa, Aggleton & Parker, 2002;Chambers et al., 2015), placement of a PLHIV at the end of a queue (Ogden & Nyblade, 2005), disclosure of a patient's HIV status to colleagues/family members without consent, irrespective of when PLHIV arrived at the facility and gossiping about the patient (Mukasa, 2006).
In this context, an understanding of current stigmatizing attitudes among HCW towards PLHIV from the perspective of Malaysia healthcare setting is crucial to plan for service delivery improvement that is non-stigmatizing and non-discriminatory. The objective of this study was to examine and measure the level of S&D towards PLHIV among HCW in selected government facilities.

Study Setting and Sample Size
This study was a cross-sectional study using a validated self-administered questionnaire survey which was conducted from July to August 2020 via online. Five government hospitals and six government health clinics were selected from six states; Penang, Selangor, Kuala Lumpur, Johor, Melaka and Pahang. The six states were selected as 70% of the 2019 reported new HIV cases were contributed from these states (Malaysia Global AIDS Monitoring, 2020). All the eleven selected study sites provided HIV/AIDS care services to the public.
There were two target subjects for this study which were HCW and PLHIV. The inclusion criteria for HCW included: worked for at least six months in the selected study sites, directly involved in care of PLHIV and agreed to participate in the study voluntarily. PLHIV were enrolled according to the predetermined inclusion criteria: age 18 years and above, registered as patient in the selected study sites, living with HIV, able to understand Malay or English language and willing to provide informed consent. No personal information was asked to maintain anonymity.
For the recruitment of potential HCW, a recruitment message with a hyperlink or QR code to the online survey website was disseminated via email or smart phone messenger apps (e.g., Whatsapp, Telegram), while PLHIV were approached by clinic staff or case worker during their scheduled appointments.
Sample size was calculated to be 3675 consisting of 1904 HCW and 1771 PLHIV assuming 95% confidence level with 5% margin error and 50% response rate.

Survey Tool
The instrument used in this study is a self-administered online questionnaire survey via web-based platform. Two sets of a questionnaires, one for HCW and another one for PLHIV were used to assess HIV-related S&D. The questionnaire for HCW was adapted from a globally standardised tool for measurement of HIV-related stigma among health facility staff (Nyblade et al., 2013) and the questionnaire for PLHIV experience was adapted from similar study in Thailand (Srithanaviboonchai et al., 2017).
The HCW questionnaire consisted of two main parts. The first part consisted of socio-demographic section which intended to discover the demographic namely gender, HIV/AIDS training and experience of working with PLHIV. The second part consisted of five sections; infection control, health facility environment, health facility policies, opinions about PLHIV and antenatal care, prevention of mother-to-child transmission and delivery wards. While the questionnaire for PLHIV included information on patient experience at the healthcare facility.

Ethical Considerations
The study received ethical approval from the Medical Research and Ethics Committee, Ministry of Health Malaysia and this study was registered under Malaysia National Medical Research Registry (NMRR) with the identification number NMRR-20-1932-55728.

Statistical Analysis
Statistical analysis was done using the Statistical Package for Social Sciences (SPSS 26.0) software. Data was entered, cleaned and checked before data analysis. Frequencies and simple associations were calculated. P-value less than 0.05 was taken as the significance level for all analyses.

Demographic Characteristics
In total, 3880 HCW and 1173 PLHIV participated in this study. HCW were predominantly female 3300 (85%) with 1: 5.96 male and female sex ratio. Of the 3880 HCW, 3086 (80%) worked in hospitals and 794 (20%) in health clinics. While for PLHIV, 767 (65%) receiving care in hospitals and 406 (35%) in health clinics. More than two-thirds of the HCW 2581 (67%) had attended training on HIV/AIDS and 2037 (53%) HCW claimed having experience in working at hospital/clinic/department that specialized in HIV care and treatment.

Infection Control Concerns in Regards with a PLHIV in Health Facility
The findings in this section are shown in Table 1. Eighty seven percent (87%) and 84% of the HCW responded fear of taking blood and dressing the wounds of a PLHIV, respectively. However, the differences were not statistically significant. More than half (64%) of HCW stated that they wore double gloves when attending PLHIV with a significant difference. Sixty three percent (63%) of HCW also indicated that they always wear gloves during all aspects of the care and services for a PLHIV with a significant difference. Seventy three percent (73%) of HCW responded using additional specific infection measures when attending PLHIV, however, the difference was not statistically significant.

Health Facility Environment in Regards with a PLHIV
The findings from this section are shown in Table 2. Majority of HCW 84% and 79% reported having observed others in their facility expressed willingness to care and providing good care to PLHIV with a significant differences. HCW were also unconcerned about stigmatization from family members and friends for providing care to PLHIV (all the P values < 0.05). Sixty five percent (65%) of the HCW were also comfortable to work with colleagues living with HIV.

Health Facility Policies in Regards with a PLHIV
The findings in this section are shown in Table 3. Eighty two percent (82%) of the HCW disagreed with testing patients for HIV infection without consent with a statistically significant. Majority of HCW (97%) agreed that their facility has standardised procedures/protocols on HIV that reduce risk of infection. More than two-thirds (68%) of HCW also agreed that their facility has written guidelines to protect PLHIV from discrimination. However, the differences were not statistically significant.

Opinions about PLHIV
The findings from this section are shown in Table 4. Slightly more than half (53%) of the HCW agreed that those infected with HIV because they engaged in irresponsible behaviours with a significant difference. As for reproductive right, 55% of HCW agreed that WLHIV should be allowed to get pregnant.

Antenatal Care, Prevention of Mother-to-Child Transmission and Delivery Wards
The findings in this section are shown in Table 5. Majority of HCW (81%) stated that they were worried when assisting during labor and delivery of WLHIV, however, the difference was not statistically significant. Seventy percent (70%) of HCW agreed that family of pregnant WLHIV has a right to know her HIV status with a significant difference. More than half (62%) of HCW agreed that WLHIV should not get pregnant if they already have children.

PLHIV Experience
On PLHIV experience, only 12% of them reported that they had ever experienced stigma when accessing health services, however, the difference was not statistically significant (Table 6).

Discussion
The current study noted a relatively high prevalence of HIV-related stigma among HCW in the country. In this study, 34-87% of HCW were worried about performing various day-to-day duties i.e., touching clothing, dressing wounds, drawing blood and taking temperature for PLHIV. This study also revealed that majority of HCW (81%) involved in the wards or labor rooms were worried when assisting during labor and delivery of WLHIV. Findings in this study are slightly higher compare to other research; in Thailand, 32-66% of 738 HCW were worried about similar duties, while 23-67% of more than 1000 HCW from multiple countries were similarly concerned (Nyblade et al., 2013;International Health Policy Program Thailand, 2014).
In term of HIV-related practices, 63-73% of HCW indicated that they wore double gloves, wearing gloves during all aspects of the care and services and using additional specific infection measures when attending PLHIV. However, these practices are not in line with the national Policies and Procedures on Infection Prevention and Control, in which double gloving is only recommended during some Exposure Prone Procedures (EPPs) e.g., orthopaedic and gynaecological operations or when attending major trauma incidents (Policies and Procedures on Infection Prevention and Control, 2019). Similar to the findings of this study, a study in Ghana found 65.7% of nurses put on gowns and gloves with any contact with PLHIV emanating from fear of contracting HIV during clinical practice (Boakye & Mavhandu-Mudzusi, 2019). This finding highlights a lack of understanding regarding the primary principle underlying Standard/Universal Precautions i.e., the precaution applies universally and not selectively. The value of Standard/Universal Precautions is that they protect HCW and patients against infection with a range of pathogens, not just HIV (Yasin, Fisseha, Mekonnen, & Yirdaw, 2019).
Stigma often leads to the discriminatory attitudes and avoidance of duties. However, in this study, majority of HCW reported having observed others in their facility being willing to care and providing good care to PLHIV. Majority of HCW (94%) also stated that they never observed others in their facility neglecting WLHIV during labor and delivery. Moreover, HCW were also unconcerned about stigmatization from family members and friends for providing care to PLHIV. At the same time, 65% of the HCW in this study were comfortable to work with colleagues living with HIV. These findings were also confirmed through the PLHIV experience where only a small percentage of them had ever experienced stigma when seeking health care (12%). Many of them also indicated that the clinic was welcoming and friendly and they were treated with respect when accessing health services. This was quite encouraging and commendable, considering HCW demonstration of fear of infection through day-to-day duties. The findings of this study are in corroborated with studies conducted by Boakye & Mavhandu-Mudzusi (2019) and Ledda et al. (2017), that although HCW have fears for contracting HIV, their consciences and integrity allowed them to overcome their fear and display some positive attitudes when attending to PLHIV. knowledge or permission of the patients. This belief is in keeping with the current practice in Malaysia, which follows the guidelines issued by the World Health Organization (WHO) in 2007 where explicit consent must be obtained from the patient before HIV testing can be done. In critically ill or unconscious patients who may not be able to provide informed consent to HIV testing and counselling, consent should be obtained from the patient's next-of-kin, guardian or other care given. Only in the absence of such a person, healthcare providers should act according to the best interests of the patient concerned (WHO, 2007).
Similar to other studies conducted by Lui, Sarangapany, Begley, Coote & Kishore (2014) and Ledda et al. (2017), this study found that a fraction of HCW had negative or prejudicial attitudes towards PLHIV. Slightly more than half of the HCW (53%) opined that people get infected with HIV because they engage in irresponsible behaviours. Despite, ethics and professionalism are upheld through their services. More than half of the HCW have no issues on providing services to key populations i.e., people who inject illegal drugs, men who have sex with men and female sex workers.
This study revealed that 45% of the HCW did not agree with the idea of WLHIV having the right to procreate and 62% of the HCW also agreed that WLHIV should not get pregnant if they already have children. Similar findings were reported in a multinational study of over 1000 HCW, 40% were against WLHIV having the right to procreate (Srithanaviboonchai et al., 2017). This is unfortunate, considering that the availability of effective ART to suppress viral load which allows WLHIV to get pregnant without risk of HIV being passed on to their baby. In addition, the rights to have children is the women to choose, regardless of HIV status.
In this study, 70% of HCW opined that family of pregnant WLHIV has a right to know her HIV status. Nevertheless, 88% of HCW reported that they never observed others in their facility disclosing the status of a WLHIV to others without her consent. These findings were also compatible with the PLHIV experience where 95% of them stated that their privacy and confidentiality was protected during their accessed to health services. This is consistent with the current practice in Malaysia where the HIV status of a patient can only be revealed with the explicit consent of a PLHIV.
This study had several limitations that should be taken into account in interpreting the results. Similar to studies in this area, these findings relied on self-reported responses and are subject to reporting and social desirability biases. Moreover, the study assessed only HCW employed in the government sector, with variable responses across governorates. As such, those working in the private sector may have different views and attitudes.

Conclusion
The findings of this study shared a worrying magnitude of stigma towards PLHIV among HCW in Malaysia. This stigma, however was not demonstrated in a form of discriminatory action in providing care and services towards PLHIV. Ethics and professionalism are upheld through giving good care and services to PLHIV. Nevertheless, stigma reduction intervention programmes are still needed to ensure continuous excellent service delivery in order to achieve "Three Zeros goals: Zero new HIV infection, Zero AIDS-related deaths and Zero HIV-related S&D".