NYS HIV Quality of Care Clinical Advisory Committee Meeting August 15 th, 2016 HIV Stigma in Healthcare Settings: Health Effects and Mechanisms of Intervention Whitney S. Rice Postdoctoral Fellow UAB/VA Health Services, Outcomes and Effectiveness Research Training Program
Stigma The process by which a group of individuals is labeled as socially undesirable These individuals are devalued due to attributes or behaviors that are societally deemed as deeply discrediting
What is known about the effects of HIV-Related Stigma? Qualitative and mainly cross-sectional studies have found that HIV-related stigma is associated with poor engagement in HIV care and ART adherence*, including: Lower acceptance of HIV testing Lower access to medical care Poorer ART adherence Lower utilization of HIV care *Katz et al., JIAS, 2013; Sweeney and Vanable, AIDS Behav, 2016.
White House Meeting on HIV Stigma (March, 2016) Working to ensure that HIV prevention, testing, and care can be delivered in a stigma-free manner is vital to achieving better health outcomes for people living with HIV
Why Addressing HIV Stigma in Healthcare Settings is Important Persons living with HIV (PLWH) may have frequent contact with healthcare providers Fears of stigma, discrimination, and lack of confidentiality in health facilities can discourage people from: accepting HIV testing linking to HIV care after receiving an HIV-positive test result adhering to HIV visits and treatment Getting other kinds of healthcare that they need
HIV-related stigma in healthcare settings and health outcomes among people living with HIV Whitney Smith Rice, Janet M. Turan, Robin G. Lanzi, and Bulent Turan Presented at the 11 th International Conference on HIV Treatment and Prevention Adherence and the 2016 International Conference on Stigma
HIV Stigma How does social stigma affect intrapersonal processes and outcomes at an individual level?
The HIV Stigma Framework (HSF) Earnshaw et al., 2013, AIDS Behav
Modified HIV Stigma Framework (HSF)
Modified HIV Stigma Framework (HSF)
Mediation
Participants Patients from an HIV clinic (N = 203) 74 women/129 men; 73 white/130 black Excluded those not on ART and substance users HCS stigma, internalized stigma, anticipated stigma (from community; friends/family; healthcare workers), trust in physicians were assessed using validated self-report measures Data on depressive symptoms, duration of ART, and viral load were extracted from clinic records
Health Care Setting (HCS) Stigma Six items adapted from the field-tested version of the enacted stigma section of an international tool for measuring HIVrelated stigma among health facility staff 1 Cronbach s α =.73 1 Nyblade L, Jain A, Benkirane M, et al. A brief, standardized tool for measuring HIVrelated stigma among health facility staff: Results of field testing in China, Dominica, Egypt, Kenya, Puerto Rico and St. Christopher & Nevis. Journal of the International AIDS Society. 2013;16(Suppl 2)(2):18718.
HCS Stigma Sample items: 1. Healthcare workers were unwilling to care for you because you are living with HIV. 2. Healthcare workers provided poorer quality of care to you than to other patients because you are living with HIV.
Statistical Analyses
Viral load Experiencing stigma in a HCS was associated with non-suppressed viral load Adjusted Odds Ratio = 3.23, p =.03, 95% CI (1.15, 9.06) (controlling for sex, race, age, SES, time on ART) This association remained significant when other stigma mechanisms were added Adjusted Odds Ratio = 4.60, p =.046, 95% CI (1.03, 20.56)
Depression Indirect effect: B=0.40, p <.05, CI (0.01to1.17)
Trust in Physicians Indirect serial effect: B = -0.01, p <.05, CI (-0.04 to -0.0006)
Conclusion Reducing experienced stigma in healthcare settings is critical to improve linkage and retention in care, as well as health outcomes for people living with HIV
Conclusion A deeper understanding of how different stigma mechanisms affect outcomes and the mediating pathways involved is important in designing interventions aimed at reducing the effects of HIV-related stigma.
Limitations Self-report measures Cross-sectional design Limited generalizability Moderate sample size
Intervention strategies Targeting stigma in the healthcare system Blocking the experienced stigma - internalization of stigma pathway Targeting internalized stigma anticipated stigma pathway
FRESH (Finding Respect and Ending Stigma around HIV) Intervention Batey DS, Whitfield, S et al. Adaptation and Implementation of an Intervention to Reduce HIV-Related Stigma Among Healthcare Workers in the United States: Piloting of the FRESH Workshop. AIDS Patient Care and STDs. 2016, 30(11): 519-527.
FRESH Workshop Objectives Provide contact and collaboration opportunities for participants to mutually understand stigma and their stigma experiences Sensitize participants to their stigma experiences and strategies for coping with and challenging stigma Design of a new tool that can be used to increase awareness and reduce stigma among the larger population public health and primary healthcare workers
FRESH Workshop Logistics ~10 health workers Nurses, social workers, receptionists, disease intervention specialists, etc. ~10 community participants (persons living with HIV) Facilitated by one health worker (social worker) and one client (PLHIV) 1.5 days In a neutral location (UAB School of Public Health)
FRESH Workshop Topics Understanding Stigma Intersecting Stigmas Outcomes of Stigma HIV Knowledge Update Coping with Stigma Why is Stigma Hard to Change Stigma reduction strategies Designing a tool to reach Public Health and Community workers
FRESH Workshop Evaluation Health Workers: Socio-demographics Discrimination experiences (race, gender, etc.) Stigma scales Workshop experience Risk perception HIV knowledge Empathy Contact Community Participants: Socio-demographics Discrimination experiences (race, gender, etc.) Stigma scales Workshop experience Patient empowerment HIV-related self-efficacy Self esteem Coping
Initial FRESH Workshops Workshop #1: 13 participants (7 HWs, 6 PLHIV, some overlap) Workshop #2: 23 participants (11 HWs, 12 PLHIV, some overlap) Health worker participants from local department of health, state department of health, AIDS service organizations, university clinics, etc. High satisfaction with the workshop experience by the participants
FRESH pilot results Satisfaction with the workshop experience was high 87% PLWH and 89% HW rated the workshop excellent Content analysis of open-ended items revealed that participants felt that the workshop: Was informative, interactive, well-organized, understandable, fun, and inclusive Addressed real and prevalent issues Although sample sizes were small, positive trends in prepost test measures were observed: increased awareness of stigma in the health facility among HWs decreased uncertainty about HIV treatment among PLWH
Acknowledgements Research grant support provided by: UAB Center for AIDS Research (CFAR), an NIH funded program (P30 AI027767). Principal Investigator (PI): Janet Turan (FRESH Study) UAB School of Public Health PI: Janet Turan (FRESH Study Phase II) Trainee support to W.S.R. provided by: UAB/VA Health Services, Outcomes and Effectiveness Research (HSOER) Training Program, funded by AHRQ PI: Kenneth G. Saag Collaborating Partners: AL PHTC; ADPH; JCDH; Health Services Center, Hobson City, AL; Birmingham AIDS Outreach; AL Primary Health Care Association; UAB Deep South CME Network