Introduction

Human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS)-related stigma can be described as a “process of devaluation” of people either living or associated with HIV and/or AIDS.¹ This stigma often stems from the underlying stigmatization of risky behaviors and affects the decision and manner of treating people living with HIV.¹ It can be categorized into four broad, loosely defined groups: physical, social, verbal, and institutional.² In 2015, the World Health Organization (WHO) released new treatment guidelines emphasizing the need to address barriers, such as stigma and discrimination, to accessing HIV treatment.³

The most significant form of stigma and discrimination is arguably that observed among health care workers towards people living with HIV/AIDS, with health care settings representing the “predominant locations where stigma occurs”.⁴

Studies have linked HIV-related stigma with delayed HIV testing, nondisclosure to partners, poor engagement with HIV services, and the direct negative consequences they have on the quality of life for people living with HIV/AIDS.^5-9 They have also revealed that most health care providers reported that the stigma and discrimination were influenced by their personal beliefs and attitudes, overestimated risk of HIV transmission, and level of education.^10-12

Although Bahrain has a low prevalence of HIV, a total of 208 patients were diagnosed with HIV until 2014.¹³ His Majesty, King Hamad bin Isa Al Khalifa, has ratified Law No. (1) of 2017 for the protection of society from HIV infection and protection of the rights of people living with HIV.¹⁴

Despite the unavailability of written guidelines, a committee formed by the Ministry of Health is working on protecting patients with HIV from discrimination. There is a special protocol applied for newly detected HIV cases by the Public Health Directorate to protect patients’ confidentiality and dignity while accessing all medical health care services.

The HIV-related stigma and discrimination in the health care sector has not been studied in Bahrain, most probably due to the low prevalence of HIV and AIDS in our country according to the Joint United Nations Programme on HIV/AIDS (UNAIDS).¹⁵ Therefore, the aim of this study was to assess HIV-related stigma and discrimination among primary health care physicians in the Kingdom of Bahrain. This research will help in understanding the level of the problem in our community and correcting it.

Methods

Study Design

This was a cross-sectional study conducted to assess HIV-related stigma and discrimination. A self-administered, paper-based questionnaire was distributed to the physicians, and a verbal consent was also obtained from them simultaneously. Data was collected in the first 2 weeks of October 2017, on working days (Sunday to Thursday) from 7 am to 2 pm, from doctors working in the evening shift hours. The questionnaires were distributed personally to 335 primary health care physicians who were available during the data collection time frame. They were given sufficient time to complete the questionnaires, which were then collected directly by the research team. Ethical approval for conducting the research was provided by the Family Physician Residency Program (FPRP) research committee.

Participants

We included all the 404 primary health care physicians working in 27 primary health care centers and 2 clinics (airport and Al Budaiya Clinic) in the Kingdom of Bahrain, in the study. No sample size was calculated as the population size was considered small according to the Ministry of Health Statistics released in 2015.¹⁶

Variables and Data Sources Measurement

A standardized questionnaire based on the results of the field testing by the United States Agency for International Development (USAID)-funded Health Policy Project’s “Measuring HIV Stigma and Discrimination Among Workers in Health Facilities Questionnaire” was used.¹⁷ It focused on 4 main areas considered to affect HIV-related stigma and discrimination that included: fear of HIV infection among health facility staff; stereotypes and prejudice related to people living with or thought to be living with HIV; observed stigma; and secondary stigma and discrimination as well as policies within the work environment.

The questionnaire contained 5 sections and 1 module in the following order:

1. Background information: age, gender, job, working years, and number of HIV-cases encountered. It also asked whether the physicians had worked in specialized centers for HIV and whether they had received training in HIVrelated stigma and discrimination.
2. Infection control: pertaining to the infection control in the health facility.
3. Health facility environment: related to the practices in the health facility and the participant’s experience while working in a facility that provided care to people living with HIV.
4. Health facility policies: regarding the institutional policy.
5. Opinions about people living with HIV: measured the attitude of participants toward HIV-infected patients.

Module 1: Antenatal care, prevention of motherto- child transmission, labor, and delivery. The participants were instructed to ignore this module as it was not applicable to a primary health care physician’s practice. It was also not included in the statistical analysis.

Recall bias was difficult to be avoided due to the paucity of HIV patients seeking medical attention in primary care.

Quantitative variables were analyzed using descriptive statistics tables. The answers were grouped into 2 main categories – agree/disagree and yes/no/I do not know.

The data was analyzed with SPSS version 23.0 program. Missing data was given codes during the statistical analysis and excluded from the results.

Results

Participants

Out of the 404 physicians selected originally, 133 did not participate due to absenteeism or retirements and 2 physicians refused to participate. A total of 269 out of 335 primary health care physicians (including family physicians and general practitioners) participated in the study, with 80% response rate. The qualification of the participants varied and comprised physicians in the Family Residency program, general practitioners, consultant family physicians, and Family Medicine specialists.

Descriptive Dat

In the study population, 59.4% of the primary health care physicians were below the age of 40 years. Most of the participants were females (76.9%). The percentage of primary health care physicians who had worked for <10 years was 45.5% (Table 1). Less than 5 cases of HIV had been noted by most of the participants in the previous year.

The type of training received by the primary care physicians is elaborated in Table 2.

For Table 1 and 2, please refer to the PDF.

Outcome and Main Results

Table 3 shows the awareness of the primary health care physicians regarding the health facility policies. Among the study participants, 80.8% agreed on obtaining the patient’s consent prior to HIV testing. Although, there are no written guidelines available for protecting HIV patients from discrimination, 21.4% of the physicians answered “yes” to a question about their knowledge of the presence of such guidelines. In relation to the work environment, 64.9% of the physicians were hesitant to work with HIV co-workers.

For Table 3, please refer to the PDF.

Regarding providing health care services to people living with HIV, 87.4% of the physicians were concerned about dressing the wounds of HIV patients and 91.9% were worried of drawing blood from HIV patients. In addition to that, 40.3% of the participants were worried of less invasive measures like touching clothes of people with HIV and 44.1% were worried of checking the temperature of such patients (Table 4).

For Table 4, please refer to the PDF.

Table 5 presents the opinion of primary health care physicians toward people living with HIV. Although 50.6% of them agreed that people with HIV get the infection from engaging in irresponsible behaviors, 89.3% of the physicians agreed that people with HIV should not feel ashamed of themselves. In addition, 62.6% of the primary health care physicians preserved the rights of women living with HIV to have babies if they wished to. Almost 63.5%, 63.1% and 68.4% of primary health care physicians agreed to providing services to people who injected themselves with illegal drugs, men who had sex with men and sex workers, respectively.

For Table 5, please refer to the PDF.

With regard to observed stigma (stigma noticed by others), 74.2% and 87.9% of the primary health care physicians never observed health care workers unwilling to care for people living with HIV or provide a poor quality of care to them, respectively. When assessing the secondary stigma (stigma directed toward people taking care of people living with HIV), 85.8% of the physicians who provided care to people with HIV never encountered people talking badly about them. Furthermore, 63.9% of the physicians used special infection control measures while providing care to people with HIV; however, only 28.1% of the physicians avoided physical contact with people living with HIV as demonstrated in Table 6.

For Table 6, please refer to the PDF.

Discussion

UNAIDS and WHO cite fear of stigma and discrimination as the main reason for the reluctance of people to get tested, disclose their HIV status, and take antiretroviral drugs.¹⁸ This complicates the decisions related to preventive behaviors, including use of family planning services.²

Multiple factors including those related to HIV disease, physicians, and institutes were found to affect the results of our study.

As already mentioned in the introduction, the Kingdom of Bahrain is considered as a lowprevalence country for HIV/AIDS cases, which contributed significantly to our results as there were less number of HIV patients visiting the primary health care physicians per year.

Regarding physicians-related factors, 97% of the primary care physicians were exposed to less than 5 HIV cases per year in their daily practice. This might have influenced their responses to the questionnaire as they were not exposed to these situations before. In addition, most of the primary health care physicians were less than 40 years old and were considered young in the medical field, which might have contributed to the non-judgmental answers regarding HIV patients. This is similar to what was observed in a study conducted in 2005 among service providers in China, which reported that younger-age people had a more liberal attitude towards HIV-related patients.¹⁰

Furthermore, knowledge has been considered to be a major factor for HIV-related stigma and discrimination in multiple studies which found that physicians who had a low level of HIV-related knowledge showed higher levels of stigma and discrimination.^19-21

Nevertheless, most of the primary health care physicians did not receive training in HIV-related stigma and discrimination which affected their attitude, opinion, and behavior towards HIV-infected patients. Training must be supported by the institute in which the physicians work–in the Ministry of Health in Bahrain. Several studies have concluded that HIV-related stigma and discrimination have an inverse relationship with the training received by health care providers.²²

The cultural background of the participants affected the results of our study as well. This was demonstrated by the opinions of the primary care physicians about HIV patients. Although most of the opinions were non-discriminatory toward HIV patients, around 50% of the physicians agreed that people living with HIV get the infection because they engage in irresponsible behaviors. This is most likely due to cultural and social concepts in Bahrain that HIV virus is transmitted mainly by extra-marital affairs, homosexuality, and illegal drug injections. A similar observation was made in a study conducted in Iran which has cultural characteristics almost similar to our community.²³

It is important to increase awareness about HIVrelated stigma and discrimination through several methods such as communication, education, policies, systems, and environment. Communication in the form of public service announcements, health fairs, mass media campaigns, and newsletters for increasing the awareness about healthy behaviors should be encouraged. As for policies, we think that formulating national guidelines for HIV/AIDS management will standardize health care services that will help in decreasing HIV-related stigma and discrimination.²² Furthermore, implementing health education strategies like organizing courses, training programs, and support groups would help in lowering the stigma and discrimination related to HIV.

Conclusion

Primary health care physicians in the Kingdom of Bahrain have obvious stigma and discrimination towards people living with HIV.

Some limitations were encountered during this research, such as recall bias and lack of similar studies in the Middle-East and Kingdom of Bahrain to compare our results with.

We recommend conducting training courses for the primary health care physicians in the field of HIV-related stigma and discrimination. In addition, more studies are needed to assess this behavior in secondary health care and also to link the knowledge of the physicians with the type of subspecialty and compare it with those who have not specialized yet.

Conflict of Interests

No conflict of interests in this study.

Acknowledgment

Special thanks to the research committee in primary health care in the Ministry of Health of Kingdom of Bahrain, for their continuous guidance and support during the research work.