Research Article: Reducing HIV-related stigma and discrimination in healthcare settings: A systematic review of quantitative evidence

Date Published: January 25, 2019

Publisher: Public Library of Science

Author(s): Garumma Tolu Feyissa, Craig Lockwood, Mirkuzie Woldie, Zachary Munn, Jerome A. Singh.


Stigma and discrimination (SAD) related to HIV compromise access and adherence to treatment and support programs among people living with HIV (PLHIV). The ambitious goal of ending the epidemic of HIV by 2030 set by the United Nations Joint Program of HIV/AIDS (UNAIDS) will thus only be achieved if HIV-related stigma and discrimination are reduced. The objective of this review was to locate, appraise and describe international literature reporting on interventions that addressed HIV-related SAD in healthcare settings.

The databases searched were: Cumulative Index to Nursing and Allied Health (CINAHL), Excerpta Medica Database from Elsevier (EMBASE), PubMed and Psychological Information (PsycINFO) database. Two individuals independently appraised the quality of the papers using appraisal instruments from the Joanna Briggs Institute (JBI). Data were extracted from papers included in the review using the standardized data extraction tool from JBI. Quality of evidence for major outcomes was assessed using Grading of Recommendations, Assessment, Development and Evaluation (GRADE).

We retained 14 records reporting on eight studies. Five categories of SAD reduction (information-based, skills building, structural, contact-based and biomedical interventions) were identified. Training popular opinion leaders (POLs) resulted in significantly lower mean avoidance intent scores (MD = -1.87 [95% CI -2.05 to -1.69]), mean prejudicial attitude scores (MD = -3.77 [95% CI -5.4 to -2.09]) and significantly higher scores in mean compliance to universal precaution (MD = 1.65 [95% CI 1.41 to 1.89]) when compared to usual care (moderate quality evidence). The Summary of Findings table (SOF) is shown in Table 1.

Evidence of moderate quality indicates that training popular opinion leaders is effective in reducing avoidance intent and prejudicial attitude and improving compliance to universal precaution. Very low quality evidence indicates that professionally-assisted peer group interventions, modular interactive training, participatory self-guided assessment and intervention, contact strategy combined with information giving and empowerment are effective in reducing HIV-related stigma.Further Randomized Controlled Trials (RCTs) are needed. Future trials need to use up-to-date and validated instruments to measure stigma and discrimination.

Partial Text

In the last three decades, the HIV/AIDS epidemic has been one of the most challenging public health problems in the world [1]. Out of the 36.9 million people living with HIV (PLHIV) globally in 2017, only 75% of them knew their HIV positive status. Out of these, only 21.7 million were accessing HIV treatment in 2017 [2]. Currently, there is a global commitment to end the HIV/AIDS epidemic by 2030 [3]. As a roadmap to end the epidemic (as a public health threat) by the year 2030, the United Nations Joint Program of HIV/AIDS (UNAIDS) has set ambitious targets to be achieved by 2020. These targets include making sure 90% of all PLHIV know their sero-status, 90% of those who know their sero-status are receiving treatment, and 90% of PLHIV on treatment having suppressed viral loads [4]. If these targets are to be achieved, the stumbling blocks of stigma and discrimination (SAD) need to be addressed [4, 5].

This systematic review was prepared using PRISMA reporting guidelines (S1 Table) for systematic reviews [26]. The review was conducted in accordance with the Joanna Briggs Institute methodology for systematic reviews of effectiveness evidence [27] and an a-priori protocol registered in PROSPERO 2017 CRD42017071799 (available from During the conduct of the review, we considered the following inclusion criteria.

The search yielded a total of 2,927 records. After removing, duplicates, 2,856 documents were retained for further examination. After screening the titles and abstracts, 167 records were retained for full text examination. Based on pre-defined inclusion criteria, 30 records were included for critical appraisal. Finally, 14 records reporting on eight studies were retained (Fig 1). Sixteen studies [41–56] were excluded based on reason. Almost all studies excluded based on reason had significant measurement bias.

This systematic review attempted to locate, critically appraise, and describe the best available evidence on interventions to reduce HIV-related stigma and discrimination in healthcare settings among HCWs. Studies included in this review employed different measures, intervention types and durations of intervention. Hence, we could not pool the results of the primary studies using meta-analysis.




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