Stigma and discrimination remain rife in many parts of the world and punitive laws continue to deter those most at risk from seeking essential HIV services.
A significant amount of denial about HIV risk exists in many communities. There is also fear and stigmatization of those who have HIV. HIV prevention programs are recognizing the importance of combating negative attitudes, misinformation, discomfort, stigmatization, and fear among the people and in the communities where they are working.
In the United States, although many continue to express discomfort at the idea of interacting with people living with HIV, the reported levels of discomfort have decreased over the past several years. In a 2011 survey by the Kaiser Family Foundation, the number of people saying they would be “very comfortable” working with someone who has HIV increased from about a third of those responding in 1997 to roughly half in 2011. There have also been striking declines since the early years of the HIV epidemic among those with the view that AIDS is a punishment or the belief that people who contract the disease are at fault (Kaiser Family Foundation, 2011).
Stigma occurs when an attribute creates a deep gap between who we think we are and how we are seen by others. This gap cuts the stigmatized person off from society and from himself, so that he stands as a discredited person against an unaccepting world. Stigma is enabled by underlying social, political, and economic powers. It begins when a difference is labelled, then is linked to negative stereotypes, leading to a separation of “us” from “them,” and finally to status loss and discrimination for those carrying the trait (Stangl et al., 2013).
Stigma originates from the ancient practice of branding or marking someone who was thought to be “morally flawed” or to have behaved badly and therefore ought to be avoided by other members of society. Stigma is often described as a process of devaluation. If you are stigmatized, you are discredited and seen as a disgrace or perceived to have less value or worth in the eyes of others (IPPF, 2008).
HIV-related stigma often builds upon and reinforces other existing prejudices, such as those related to gender, sexuality, and race. The stigma associated with HIV is often based upon the association of HIV and AIDS with already marginalized and stigmatized behaviors, such as sex work, drug use, and same-sex and transgender sexual practices. HIV-related stigma affects those living with HIV and—through association—those who they are associated with, such as their partner or spouse, their children and the other members of their household (IPPF, 2008).
Stigma is founded on fear and misinformation. Theodore de Bruyn observed that stigma is associated with HIV/AIDS because “It is a life-threatening disease; people are afraid of contracting HIV; it is associated with behaviors that are considered deviant; a belief that HIV/AIDS has been contracted through unacceptable lifestyle choices; and, some believe it is the result of a moral fault that deserves punishment.” The stigma associated with HIV/AIDS is such some patients may feel ambivalent about seeking medical care if, by doing so, they risk disclosing their condition. Others may have learned from experience to expect rejection and therefore may not trust care providers (Bidwell, 2011).
The United Nation’s Millennial Development Goals has established the elimination of stigma, discrimination, and gender inequalities in those with HIV or AIDS as one of its ten targets and commitments. Stigma, discrimination, and oppressive legal environments in many settings discourage men who have sex with men from seeking HIV testing and appropriate, high-quality prevention, care, and treatment services (UNAIDS, 2013a).
Cultural sensitivity or cultural competency is the ability to interact effectively with people of different cultures, particularly in the context of health and social services where employees work with individuals from different cultural and ethnic backgrounds (Kentucky CHFS, 2012). Understanding cultural differences is particularly important because, although minorities currently make up 37% of the nation’s population, by 2060 they are expected to make up more than half of the population in the United States (Loftin et al., 2013).
An important aspect of cultural competency is the healthcare provider’s willingness to understand that a patient’s cultural background influences health-related beliefs and behaviors, and adverse experiences of a personal or cultural nature may have made some patients distrustful of medical care. In addition, some patients’ distrust of medical research impedes their willingness to accept new drug therapies. Culturally competent communication between provider and patient may substantially affect compliance with therapies.
Healthcare providers should carefully explore what each patient believes about his or her health, what would be appropriate treatment, and who should be involved in medical decision making. Additionally, healthcare providers must examine their own prejudices about high-risk behaviors and recognize that judgment has no place in medicine. Rather, they should apply the Golden Rule: Do unto others as you would have them do unto you.
Although in the United States attitudes are rapidly changing, many caregivers—both personal and professional—have moral judgments about those infected with HIV. How a person became infected is not an opportunity for a healthcare provider or caregiver to pass judgment or moralize. It is critical that we examine our prejudices about risk behaviors that may have led to infection. Caregivers and healthcare providers may find it necessary to acknowledge their own experiences, prejudices, and feelings when dealing with all aspects of this disease. The good news is that attitudes are changing as people become more educated about HIV and AIDS. In a 2011 Kaiser Family Foundation national poll, 29% of respondents agreed with the statement “In general, it’s people’s own fault if they get AIDS” (down from 51% in 1987). Additionally, 16% believed “I sometimes think that AIDS is a punishment for the decline in moral standards” (down from 43% in 1987) (Kaiser Family Foundation, 2011).