Health Care Discrimination in HIV Care

Human Immunodeficiency Virus (HIV) infected population is experiencing enormous amount of social discrimination and stigmatization compared to other patients with any other chronic illness. Healthcare setup is not an exception where the HIV infected patients are shuttled from one place to another to get their basic services compared to HIV negative patients. This referral game of manipulation imparts additional stress to the already stressed HIV infected population. The physical and psychological impacts caused by other chronic conditions will be supplemented by social impact in the HIV infected population. This referral game in healthcare can cause the HIV infected to avoid their health seeking behavior and it may bring them back to their high risk activities, which can result in higher mortality/morbidity and failure in prevention and intervention strategies.


Introduction
HIV (Human Immunodeficiency Virus) infection and its social impacts stigma/discrimination are always traveling together like a train track.With education stigma/discrimination in the society coming down but still the changes are not up to the mark.The situation is same for the health care setting too [1,[3][4][5][6][7][8][9].In this review article the social impacts of stigma and discrimination in the healthcare setting are tried to get explored and the net effect is hypothesized.

The Discrimination and Referral Game
Even though the healthcare professionals are ready to treat HIV patients along with other diseases with their improved knowledge and newer development, the discriminatory behavior while treating HIV patients still exists [1][2][3][4][5][6].
Patients coming to the outpatient department for medical or surgical problem may be referred for HIV screening [6] to Integrated Counseling and Testing Center (ICTC) and if the patient is found to be positive for HIV then they will be referred to Antiretroviral Therapy (ART) Centre, where the client is going to stay for their remaining lifetime.
When HIV patients are referred to other medical or surgical specialties, they are less likely to be treated/admitted in respective departments as inpatients [5][6][7].Most often the referred departments refer back the patients with the advice of conservative management, even for the genuine cases which need an intensive specialized management.Few cases which get admitted are managed by case sheet entries not the clinical management.These patients are also segregated in the wards.{Example:A meningoencephalitis patient is getting Ryle's tube feeding and intravenous(IV) antibiotics as per case records but in the ward that patient is neither on Ryle's tube nor on IV line}.

Tyndal Effect to Pinball Effect
Here we explain the above mentioned referral game by combining the physics of Tindal effect (When the ray of light hit the particle in a media, the light ray get deviated) and the ball game Pinball (Manipulation by hitting the ball away in a closed playfield).When a person is found to be HIV positive he/she may gain entrance into the playfield of health system.The positive person is referred from one department to another department particularly when they are critically ill and need specialist care which is comparable with the manipulation of pinball to score more.Most of the times healthcare professionals are not ready to admit or treat HIV infected patients.This manipulation of referral game results in unnecessary stress to the already stressed HIV positive clients.The end of the game will be the positive person gets frustrated and gets out of the playfield of health system by not seeking medical attention at all or may die or may get back to their HIV Physician (Figure 1).
Examples: 1) When a patient is referred from ART centre to medical department for meningoencephalitis, the medicine department people refers that case to neurology department, but the neurologist refers that case to the Sexually Transmitted Diseases (STD) ward and vice versa, at the end treatment is denied by this referral game.
2) Surgeons may advice medical management where pure surgical intervention is indicated.Intradepartmental discrimination of People living with HIV and AIDS (PLHA) also possible with difference in knowledge, fear of infectivity and discriminating behavior among different HealthCare Workers (HCW's).

Discussion
In addition to the depression and psychological disturbances caused by diagnosis of HIV [12][13][14].The referral game adds the stress to the already stressed.The above explained overwhelming psychosocial stressors could result in rapid disease progression following deprived immunological status.Reasons given by most studies for stigma and discrimination in hospitals among health care workers (HCW) include lack of training, education, anxiety regarding infectivity, etc [1,2,[8][9][10][11].
Stigmatizing/ Discriminatory behavior may be high in developing countries but it exist in developed countries too [1][2][3][4][5][6][7][8][9][10][11].The Stigmatizing/Discriminatory behavior includes adopting Universal precaution (UP) measures only against PLHAs, fear of infectivity, burning linens of PLHAs, informing HIV status to family members without the consent of PLHA, isolating them in wards, postponed/changed treatment with identification of infective status, refusing treatment and charging PLHA for cost of infection control, etc [6,7].Many developing country HCWs believe that PLHAs behaved immorally and deserve the disease and also showed their desire for separate ward to treat PLHA [2,7].
Following Universal precaution is an important measure in reducing the stigma/discrimination.Differing degree of knowledge in using Universal precaution, fear of infectivity, discriminatory behavior and willingness to treat PLHAs noted among HCWs worldwide [20].HCW adopting Universal precaution against PLHAs only, shows discriminatory behavior and fear of infectivity, which is seen in both developed and developing countries [20,25].Poor adherence with universal precaution practices is high with developing country HCWs as compared to developed countries [20].Poor UP practices attributed to lack of knowledge, availability of materials, inadequate staffing, long working hours, absence of sustainable educational program, insufficient water supply, emergency nature of procedure, patient perceived to be at low risk of Blood Borne Pathogens (BBPs), pressure of time and UP equipment interference with technical skills by most studies [7,16,[20][21][22][23].
Universal precaution knowledge was high for both doctors and nurses but doctors' practice better UP meas- ures compared to nurses except hand washing practices where nurses are better [20,22].There is no difference in knowledge and discriminatory attitude with doctors/nurses [8,21].Some studies show incomplete knowledge among nurses but even a perceived knowledge has weak effect on compliance with UP and willingness to care BBP infected [18,19].High risk perception was noted with doctors and poor knowledge of UP and Post Exposure Prophylaxis (PEP) was noted with surgical trainee [15,17].Some studies notified least discriminatory behavior with physician compared to nurses and the same is high with servants [1,2], which may reflect knowledge and educational influence on HCW towards attitude with PLHAs.Provider not adopting UP and inadequate training are more likely to favor restrictive policies towards PLHA [7].Discriminatory attitude and fear of infectivity among HCWs decreases as contact with PLHAs/Homosexuals increased [9].Adequate UP training improves the knowledge, adherence and supplies of UP in hospitals [24].
Various studies done across the world so far have proven that the mindset of HCWs regarding the immoral behavior of PLHAs, the lacunae in adopting UP measures and lack of knowledge are mainly responsible for the discriminatory behavior among HCWs towards PLHAs.

Conclusions
After the decades of HIV identification contact with PLHAs over the time might made HCWs sensitized and involved in caring PLHAs.Varying degree of knowledge among professionals and countries should be tackled with targeting multidisciplinary approach by providing knowledge with training, workshop and creating professional/social models to interact.
To improve the care of the HIV infected the referral game should be demolished.So training for all healthcare professionals is necessary regardless of their branch in medicine.The hypothesized referral game should be explored by further studies to improve the care in HIV infected clients.

Figure 1 .
Figure 1.HIV infected patients are undergoing referral game which starts as a Tyndal effect and ends with death or not seeking medical care of the client because of discrimination in healthcare setting which can be compared with Pinball Game.