HIV stigma in the healthcare setting: Monitoring implementation of the Dublin Declaration on partnership to fight HIV/AIDS in Europe and Central Asia

Background

If the AIDS epidemic is to be brought to end by 2030, it is crucial to combat HIV-related stigma and discrimination in healthcare settings, as per United Nations (UN) Sustainable Development Goal 3 Target 3.3 [1] and the Paris Declaration [2]. The UNAIDS target related to stigma and discrimination is that less than 10% of people living with HIV and other key populations experience stigma and discrimination [3]. HIV stigma is a recognised barrier to achieving positive health and well-being, linked to negative healthcare outcomes such as delayed care, avoidance of health facilities, and poor adherence to medication, ultimately hampering HIV prevention and treatment efforts.

Understanding how and in which contexts stigma manifests in healthcare settings, and what underpins stigmatising actions and behaviour among healthcare workers, is necessary to understand how best to intervene and address individual and institutional drivers of stigma and discrimination towards people living with HIV.

Methods

The European Centre for Disease Prevention and Control (ECDC) and the European AIDS Clinical Society (EACS) recently worked together to acquire knowledge on the occurrence of HIV-related stigma and discrimination among people working in various healthcare settings in Europe and Central Asia. A survey was developed by a multi-stakeholder group (see Annex 1), based on an existing questionnaire. This survey, which addressed anyone working in the healthcare sector, including clinical and non-clinical professionals, was undertaken between 15 September and 5 December 2023. A non-probability sample was recruited via a multi-channel campaign, leveragingnational and international healthcare professional networks, social media, newsletters, and direct communications at professional events. Data collection involved an online questionnaire, available in 38 languages, inquiring about the agreement of the respondents with HIV- related statements, training, personal attitudes and behaviour towards people living with HIV, and observed practices and policies related to HIV at their healthcare facilities. Due to the non-probability nature of the sample, there are limitations on the extent to which the results can be generalised. However, the findings provide indications of the level and characteristics of HIV-related stigma in the healthcare setting across Europe and Central Asia.

Findings

A total of 18 430 responses were received from 54 countries, with substantial variation across countries (see Annex 2). The number of country responses ranged from 1 to 2 816 responses. Ten countries had fewer than 50 responses.

Most respondents were female (74%), more than half (52%) aged 25−44 years, and they performed a variety of healthcare roles, although the majority were doctors (44%) and nurses (22%). Most respondents were not aware of having treated any person living with HIV (45%) or the number of patients treated was less than five (27%). Only 9% had treated more than 100 people living with HIV during the past year. Most respondents worked in a hospital (58%) but several other healthcare settings were also mentioned, such as primary care (17%), and 18% of respondents worked in infectious disease or HIV care departments.

Knowledge of HIV and the concept of ‘undetectable equals untransmittable’ (U=U), post-exposure prophylaxis (PEP), and pre-exposure prophylaxis (PrEP) varied across types of professional roles and health facilities, with many (69%) lacking knowledge on key concepts relating to HIV transmission and prevention. Doctors were the healthcare workers with the highest knowledge concerning HIV in the areas measured in the survey. Healthcare workers who provided care to larger numbers of people living with HIV reported substantially higher levels of HIV knowledge. More than half of the respondents said they would be worried when providing care to people living with HIV, including drawing blood (57%) and dressing wounds (53%). Concern about treating people living with HIV was inversely related to the level of HIV knowledge.

A small, but noticeable percentage (8%) of healthcare workers reported that they would avoid physical contact and a quarter (26%) of respondents reported that they would wear double gloves when providing care to a person living with HIV. Similarly, a substantial proportion of healthcare workers harboured reservations about providing care to specific groups of people living with HIV: 12% strongly preferred not to provide care to people who inject drugs, while 6% strongly preferred to avoid providing care to men who have sex with men (MSM), sex workers, and transgender men and women, reportedly influenced by a lack of training and a perception of increased risk.

While many facilities had protocols and guidelines to protect against HIV infection and prevent discrimination, there was still a lack of awareness or implementation of these policies in some settings. Discriminatory practices were reported, with 22% having witnessed unwillingness to provide care, 19% having witnessed disclosure of HIV status without consent, 18% poorer quality of care, and 30% discriminatory remarks or talking badly about people living with HIV.

Conclusions

The report provides insights into the level and characteristics of HIV-related stigma in the healthcare setting in Europe and Central Asia and outlines areas that need to be addressed. The report identifies an urgent need for robust, multifaceted interventions, encompassing education and facility-level guidelines to eliminate stigma, improve HIV knowledge among healthcare workers, and ensure equitable, non-stigmatising care for all people living with HIV, ultimately contributing to the global goal of ending the AIDS epidemic by 2030