World Journal of AIDS, 2011, 1, 100-103
doi:10.4236/wja.2011.13015 Published Online September 2011 (
Copyright © 2011 SciRes. WJA
Health Care Discrimination in HIV Care
Jayakumar Palanisamy1, Senthilkumar Subramanian2
1Primary Health Center, Periyapothu, Pollachi, Coimbatore, India; 2Department of Public Health and Preventive Medicine, Coimba-
tore, India.
Received July 21st, 2011; revised August 14th, 2011; accepted August 26th, 2011.
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 physica l and psychological impacts caused b y other chronic conditions will be supplemen ted by social
impact in the HIV infected population. Th is 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 in tervention strategies.
Keywords: HI V , AIDS, Discrimination, Healthcare
1. Introduction
HIV (Human Immunodeficiency Virus) infection and its
social impacts stigma/discrimination are always traveling
together like a train track. With education stigma/dis-
crimination 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 [1,3-9]. 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.
2. Hypothesis
2.1. 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 dis-
criminatory behavior while treating HIV patients still
exists [1-6].
Patients coming to the outpatient department for
medical or surgical problem may be referred for HIV
screening [6] to Integrated Counseling and Testing Cen-
ter (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/ad-
mitted in respective departments as inpatients [5-7]. 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 feed-
ing and intravenous(IV) antibiotics as per case records
but in the ward that patient is neither on Ryle’s tube nor
on IV line}.
2.2. 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 ligh t ray get dev iated)
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/sh e may
gain entrance into the playfield of health system. The
positive person is referred from one department to an-
other 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
Health Care Discrimination in HIV Care101
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 play-
field 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 neu-
rology 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 differ-
ent HealthCare Workers (HCW’s).
3. Discussion
In addition to the depression and psychological distur-
bances caused by diagnosis of HIV [12-14]. 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 [1,2,8-11].
Stigmatizing/ Discriminatory behavior may be high in
developing countries but it exist in developed countries
too [1-11]. The Stigmatizing/Discriminatory behavior
includes adopting Universal precaution (UP) measures
only against PLHAs, fear of infectivity, burn ing linens of
PLHAs, informing HIV status to family members with-
out the consent of PLHA, isolating them in wards, post-
poned/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 de-
serve the disease and also showed their desire for sepa-
rate ward to treat PLHA [2,7].
Following Universal precaution is an important meas-
ure in reducing the stigma/discrimination. Differing de-
gree 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 coun-
tries [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 knowledg e, availability of materials,
inadequate staffing, long working hours, absence of sus-
tainable 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 tech nical skills
by most studies [7,16,20-23].
Universal precaution knowledge was high for both
doctors and nurses but doctors’ practice better UP meas-
Tyndal PhenomenonPinballphenomenon
Start Entry
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.
Copyright © 2011 SciRes. WJA
Health Care Discrimination in HIV Care
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/nur-
ses [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 Expo-
sure Prophylaxis (PEP) was noted with surgical trainee
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 train-
ing are more likely to favor restrictive policies towards
PLHA [7]. Discriminatory attitud e and fear of infectivity
among HCWs decreases as contact with PLHAs/Homo-
sexuals increased [9]. Adequate UP training improves the
knowledge, adherence and supplies of UP in hospitals
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 meas-
ures and lack of knowledge are mainly responsible for
the discriminatory behavior among HCWs towards PLHAs.
4. Conclusions
After the decades of HIV identification contact with
PLHAs over the time might made HCWs sensitized and
involved in caring PLHAs. Varying degr ee of knowledge
among professionals and countries should be tackled
with targeting multidisciplinary approach by providing
knowledge with training, workshop and creating profes-
sional/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 ex-
plored by further studies to improve the care in HIV in-
fected clients.
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