Introduction

Stigma and prejudice continue to hinder people living with HIV/AIDS (PLWHA) from seeking treatment and care despite growing scientific knowledge about HIV and worldwide advances in related treatment and care (Arrey et al., 2017; Gesesew et al., 2017; Geter et al., 2018). Stigma has been shown to be particularly toxic in healthcare systems, contributing to poor health outcomes among HIV-positive people (Egbe et al., 2020; Turan et al., 2017). Three likely reasons for stigma against PLWHA in healthcare settings include fear of becoming infected with HIV at work (Fauk et al., 2021; Kambutse et al., 2018), perceptions linking HIV to immoral activities (Letamo, 2019; Seid & Ahmed, 2020), and lack of sensitivity of the perpetrators to their own potentially stigmatizing attitudes and behaviors (Dong et al., 2018; Stringer et al., 2016). In addition to increasing the willingness of HIV sufferers to seek related health services, another important reason to eliminate stigma is to reduce the impact of related negative attitudes and behaviors on patients' self-esteem (Adimora et al., 2019), psychological health (Zhang et al., 2018), life satisfaction (Chan et al., 2021), and overall quality of life (Reinius et al., 2018).

Stigma exists at the intersection of culture, power, and difference in lifestyle preferences and reflects how people think and how societies are organized (Stangl et al., 2019). The concept of stigma used in the HIV/AIDS literature is heavily influenced by the 1963 research of Goffman, who described stigma as prejudice, discriminatory, and degrading or discounting a person's value (Goffman, 1963). For PLWHA, stigma consists of demeaning sentiments, stereotypes, beliefs, discriminatory behaviors and actions, and overall societal devaluation of people and activities associated with the disease (Chollier et al., 2016; Turan et al., 2017; Waluyo et al., 2022). Stigma is performed and experienced in different ways depending on each person's point of view and social attitudes and is therefore dynamic. PLWHA can experience prejudice from people who are HIV negative, including healthcare personnel, either as internalized stigma or through direct observation (Wouters et al., 2016). Passive and proactive expressions of stigma respectively involve two distinct processes. Both devalue a feature or trait such as HIV disease and associate it with negative beliefs. These beliefs expressed through actions result in perceived or actual distancing from the devalued person (Vorasane et al., 2017).

Although similar, stigma and prejudice differ in that prejudice focuses on human characteristics (e.g., race, gender) and stigma focuses on deviant behavior, identity, disease, and disabilities (Read & Harper, 2020). HIV prejudice may thus be encapsulated as negative feelings, attitudes, or reactions against PLWHA and may involve feelings of fear attributed to the disease that varies based on individual perspectives (Read & Harper, 2020). Discrimination against PLWHA, on the other hand, is an individual's behavioral response to their subjective feelings of prejudice (Vorasane et al., 2017), which may be explained in terms of social processes of power and dominance between groups that devalue the stigmatized group, in this case, PLWHA.

High rates of stigma against PLWHA have been reported in many lower income nations that have limited access to antiretroviral treatment (Gesesew et al., 2017). Studies show that stigma against PLWHA is more common among people with greater levels of religiosity (Reyes-Estrada et al., 2018), lower incomes (Kane et al., 2019), lack of knowledge about the disease (James & Ryan, 2018), limited exposure to information about HIV (Vorasane et al., 2017), and fear of accidental transmission at work (Nyblade et al., 2018).

Indonesia is a lower-middle-income country with a large and growing HIV-positive population and has one of the highest HIV positivity rates in Southeast Asia (UNAIDS, 2021). The current population of PLWHA in Indonesia is estimated at 640,000 (Riono & Challacombe, 2020). Little empirical research has explored the problem of HIV-related stigma among healthcare providers in Indonesia. However, case studies show that healthcare professionals in Indonesia sometimes stigmatize and discriminate against PLWHA (Fauk et al., 2021; Irmayati et al., 2019). For example, one recent report found that around 21% of those who were HIV positive in Gunungkidul District, a rural district in Indonesia, had experienced stigma and discrimination from healthcare workers (Langi et al., 2022). In addition, some healthcare workers avoid PLWHA and refuse to care for them (Fauk et al., 2021; Irmayati et al., 2019). However, the factors that relate to stigma in Indonesian healthcare professionals and the practices of discrimination against patients with HIV/AIDS in Indonesia are poorly documented. It is especially important to understand HIV-related stigma and discrimination in the Indonesian healthcare sector, as Indonesia has joined other countries in committing to end HIV/AIDS by 2030 (UNAIDS, 2021). Therefore, the objective of this study was to identify the factors associated with holding stigmatizing attitudes toward people living with HIV among professional healthcare workers in Indonesia to facilitate the development of strategies that improve patient access to care and treatment.

Methods

Study Design

A descriptive cross-sectional design was used in this study. Healthcare workers were recruited online using convenience sampling via email and social media. The inclusion criteria included being a nurse, physician, or midwife who (a) was registered with their professional council; (b) was currently working in a hospital, clinic, or medical center or another setting that allows hands-on work with PLWHA; and (c) agreed to volunteer to take part in this study. The exclusion criteria were being (a) a current student of nursing, midwifery, or medicine and (b) a recent graduate with no professional experience. G*Power 3.1 computer software was used to calculate the sample size (effect size f² = 0.15, [alpha] = .05, power = 0.8, number of predictors = 1), and we increased the minimum number of participants required in the sample to reduce the possibility of error. Data were subsequently collected from 252 participants.

Data Collection

Data collection was performed in February and March 2022 using a self-administered, structured questionnaire. The questionnaire was published online on the Google Forms platform, and participants could access it by clicking the provided link. The questionnaire was disseminated by the investigators via email, Facebook messenger, and WhatsApp. To ensure participants' working status, professional qualifications, and fit with the study criteria, the investigators distributed the questionnaire among known colleagues and friends' Facebook accounts and WhatsApp groups, who then further disseminated the questionnaire to their friends and colleagues (snowballing).

Measures

Dependent variable

The dependent variable, stigmatizing attitudes, was measured using the 17-item HIV Stigma Scale created by Stein and Li (2008). This scale has five subscales, including (a) discriminatory intent at work (four items that assess whether or not a respondent engages in discriminatory behavior while taking care of PLWHA), (b) prejudicial attitudes (four items that evaluate the respondent's feelings of prejudice toward PLWHA), (c) internalized stigma (three items that assess the respondent's feelings of shame while treating those who are HIV positive), (d) fear of PLWHA (three items that measure the respondent's feeling of fear toward PLWHA), and (e) opinions regarding healthcare for PLWHA (three items that assess the respondent's feeling of not being able to adequately care for PLWHA). Each item is graded on a 5-point Likert scale that ranges from 1 (strongly agree) and 5 (strongly disagree), with higher scores indicating stronger stigmatizing attitudes toward PLWHA. The scale has good internal consistency, with a Cronbach's alpha score of .80 (Stein & Li, 2008).

Independent variables

The demographic characteristics collected included age, gender, educational level, and marital status. Information related to professional background, including the type of institution where they worked (i.e., hospital, clinic, or primary healthcare center) and other settings where they may encounter but not provide direct care to PLWHA (e.g., drug rehabilitation centers, pulmonary centers, prison clinics, in the community). Information on number of years worked as a professional healthcare provider, type of profession (nurse, midwife, physician), duration of time (years) providing HIV care as a professional healthcare worker, and total number of HIV cases encountered during their professional work experience was also collected. In addition, information regarding settings where participants provide HIV care and formal training related to HIV/AIDS was gathered. Not all of the participants who worked in hospitals, clinics, or public health centers had previously provided care to PLWHA.

The knowledge variable was measured using the 18-item HIV Knowledge Questionnaire created by Carey and Schroder (2002). The questionnaire has 18 questions about HIV transmission and prevention. Answers to items on this scale are coded as "1" for correct and "0" for incorrect or "I don't know." The 18 item scores are totaled, and a higher score indicates greater knowledge about HIV. This questionnaire has been adapted and validated for an Indonesian population with good internal consistency (Cronbach's alpha = .81; Arifin et al., 2022).

The variable of fear of getting infected with the HIV virus was measured in this study using an instrument adapted from Hossain and Kippax (2010, 2011) called the "Irrational Fear about HIV Scale," which is designed to measure unreasonable fears of HIV transmission among healthcare professionals. Possible responses to questions are "true," "false," and "don't know," with each correct response scored as 1 and each incorrect or "don't know" response scored as 0. Higher total scores indicate a higher level of irrational fear of becoming infected with the HIV virus. This questionnaire has been used on Indonesian healthcare workers by other Indonesian scholars (Harapan et al., 2013). In the original article introducing the Indonesian version of this scale, the reliability coefficient per item was very good (.91).

Data Analysis

IBM SPSS Statistics Version 25 (IBM Inc., Armonk, NY, USA) was used for data entry and all statistical analyses. Multiple linear regression was employed to assess the variables associated with stigmatizing attitudes among healthcare workers. Linear regression assumptions, including linearity, normal distribution, and variance uniformity, were examined and found to be satisfactory (p > .05). Variables that were significant (p < .05) in the bivariate analysis were put into the multiple linear regression model. At the bivariate level, the correlation coefficient was calculated to assess the associations between the dependent and independent variables for both continuous and categorical variables. We used a one-way analysis of variance, Pearson's correlations, and t tests to investigate the relationship between the dependent variable and the categorical and continuous independent variables.

Ethical Considerations

The Research Ethics Committee of the Faculty of Nursing, Universitas Sumatera Utara, Indonesia, approved this study (reference number: 2486/II/SP/2022). Participants provided informed consent via a mandatory question asking for agreement from the respondent to participate in this survey. All of the data collected were treated as confidential in accordance with the guidelines of the Declaration of Helsinki.

Results

Demographic Characteristics of Participants

Participants' demographic characteristics are shown in Table 1. Of the 252 respondents, eight (3.2%) were physicians, 200 (79.4%) were nurses, and 44 (17.5%) were midwives. The mean age (in years) was 35.27 (SD = 10.13) for physicians, 33.02 (SD = 5.16) for nurses, and 29.58 (SD = 4.60) for midwives. Most of the participants were female (n = 180, 71.4%). Female nurses outnumbered male nurses (n = 132 [66.0%] vs. n = 68 [34.0%], respectively), there was an equal number (four each) of male and female physicians, and all of the midwives were female (n = 44, 100%). Please note that, in Indonesia, midwifery students are only female, never male. In terms of education, a slim majority of the participants (52.0%) held bachelor's degrees. Two of the physicians held bachelor's degrees, and two held master's degrees. Of the nurses, 59.5% held a baccalaureate degree, 39.0% held an associate degree (diploma), and 1.5% held a master's degree. Only 13.6% of the midwives held a baccalaureate degree.

Table 1 Demographic and Professional Background Data

A plurality of the participants worked in hospitals (47.6%), and almost 60% had worked in healthcare for 6-15 years. Just over a half of the participants (50.4%) had provided care to PLWHA (25% of physicians, n = 2; 54% of nurses, n = 108; and 39% of midwives, n = 17), with the average length of time providing care for PLWHA ranging from 1 to 5 years. Nurses and midwives had encountered more HIV cases (54% and 39%, respectively) than physicians (25%). Most HIV care had been provided in hospital settings. In terms of formal HIV-related training, over two thirds (65.1%) had no HIV training and approximately one third (34.9%) had attended one to two HIV training sessions during their professional career. Most HIV training had been provided in Indonesia (n = 86, 34.1%), with only two participants reporting receiving training abroad (n = 2, 0.8%). The physicians had a higher average level of HIV knowledge (M = 13.38, SD = 2.82) than either the nurses (M = 10.60, SD = 3.41, p = .074) or the midwives (M = 11.26, SD = 3.28, p = .487). Furthermore, the physicians reported more fear of HIV transmission (M = 5.13, SD = 2.1) than either the nurses (M = 4.17, SD = 2.49, p = .775) or the midwives (M = 4.32, SD = 2.45, p = .089). In addition, the physicians were more likely to hold stigmatizing attitudes toward PLWHA (M = 56.13, SD = 4.79, p = .077) than either the nurses or the midwives (M = 51.93, SD = 7.5, p = .077 for both groups).

Factors Related to Holding Stigmatizing Attitudes Toward People Living With HIV/AIDS Among Professional Healthcare Workers

The relationships between stigmatizing attitudes and the examined variables are presented in Table 2. Higher stigmatizing attitude scores were shown to relate significantly to lower levels of HIV knowledge (r = -.23, p < .01) in nurses and midwives. However, the physicians had concurrently both the highest HIV knowledge and stigmatizing attitude scores. Statistically significant results were also found for the variable fear of HIV transmission, with higher stigmatizing attitude scores found to relate significantly to greater fear of HIV transmission (r = .14, p < .05). In addition, a statistical correlation was found between the institution where participants worked and stigmatizing attitudes (F = 2.69, p < .05). However, no significant difference between categories for this variable was found in the post hoc analysis.

Table 2 Bivariate Analysis of the Relationships Between Stigmatizing Attitudes Among Health Workers and Demographic Characteristics, Knowledge of HIV, and Fear of HIV Transmission

With the exception of place of work, no significant relationships were found between the dependent variable (stigmatizing attitudes about HIV) and the examined demographic characteristics: age (r = .06, p > .05), educational level (F = 1.41, p > .05), marital status (F = 1.14, p > .05), profession (F = 2.07, p > .05), years of experience as a healthcare professional (F = 2.07, p > .05), providing care to PLWHA (t = 1.03, p > .05), length of time working with PLWHA (F = 0.85, p > .05), number of PLWHA encountered (F = 1.01, p > .05), setting for providing HIV care (F = 2.21, p > .05), having received formal HIV training (t = 0.51, p > .05), number of times attended HIV training (F = 0.50, p > .05), and location of HIV training (F = 0.49, p > .05). Cultural and social differences in study settings may result in these findings differing from those of other studies.

Multiple Regression Model Predicting Stigmatizing Attitudes Against People Living With HIV/AIDS Among Professional Healthcare Workers

The results from the multiple linear regression analysis are presented in Table 3, with findings showing greater HIV-related stigma among healthcare professionals in Indonesia to be associated with lower levels of HIV-related knowledge ([beta] = -.22, p < .01) and greater fear of HIV transmission ([beta] = .13, p < .05). However, the institution where the participants worked was not found to be statistically significant in the multivariate analysis. By contrast, the multiple linear regression revealed one additional variable that, although not significant in the bivariate analysis, was significant in the multivariate analysis. This variable was the settings where participants provided HIV care (community health center, hospitals, clinics). On the basis of the multiple linear regression test results, stigmatizing attitudes were associated with this variable ([beta] = -.41, p < .05).

Table 3 Multiple Linear Regression Analysis of Variables in Relation to Stigmatizing Attitudes Among Healthcare Professionals in Indonesia

Discussion

The goal of this study was to identify the factors associated with stigmatizing attitudes against PLWHA among professional healthcare providers in Indonesia. The questionnaire results provide evidence that health workers in Indonesia harbor stigmatizing attitudes toward PLWHA. The data show that less than half of the physicians, nurses, and midwives had any formal HIV training or experience providing HIV care, which may partly explain why they held stigmatizing attitudes toward PLWHA. These attitudes may prevent patients with HIV from accessing healthcare services as well as undermine the Indonesian government's efforts to aggressively prevent, control, and treat HIV.

In addition, the results indicate that healthcare worker knowledge about HIV is significantly correlated with holding stigmatizing attitudes toward PLWHA, with higher levels of HIV/AIDS knowledge generally associated with lower stigmatizing attitudes in this study. This result is similar to previous studies conducted in other countries such as Laos (Vorasane et al., 2017), China (Yin et al., 2021), and Cameroon (Egbe et al., 2020). Having limited knowledge feeds healthcare providers' misperceptions about how the disease is transmitted, which, in turn, can be linked to incidents of HIV-related stigma in healthcare settings. However, the relationship between knowledge level and stigmatizing attitude in this study was contradictory, as physicians, who had the highest level of knowledge about HIV/AIDS, also had the highest level of stigma.

In addition, some researchers have also highlighted how sociocultural factors (Dawkins et al., 2021; Jin et al., 2021; Mahamboro et al., 2020) and beliefs or religion (Aghaei et al., 2020; Reyes-Estrada et al., 2018; Taggart et al., 2021) contribute to healthcare providers' negative behavior toward PLWHA. Vorasane et al. (2017) suggested that any intervention that relies only on HIV education to change stigma is insufficient. That study further showed stigma and discrimination may exist in healthcare workers despite their having a high level of knowledge about HIV. Therefore, reducing stigma requires interventions that can reach beyond knowledge and address the attitudes and cultural beliefs of healthcare workers (Andersson et al., 2020; Vorsane et al., 2017).

Furthermore, programs that address HIV-related stigma in healthcare settings should be holistic and include comprehensive knowledge about HIV, addressing the emotional and social factors that shape stigmatizing attitudes and practices. For example, previous studies have found that people associate HIV disease with being gay (Arscott et al., 2020; Catungal et al., 2021; Logie et al., 2020) and with activities considered to be immoral (Letamo, 2019; Seid & Ahmed, 2020). Thus, antistigma education is needed to address such beliefs and should include the historical aspects of HIV transmission, which indicate that no particular social group should be blamed or held morally responsible for spreading HIV. Moreover, strict workplace policies may also help protect PWLHA from stigmatizing attitudes among healthcare workers. Workplaces should provide convenient access to free and confidential HIV testing for healthcare workers (Blake et al., 2020; Vorasane et al., 2017). Together, this approach may reduce stigma and increase health workers' willingness to provide care to PLWHA.

At the level of community healthcare, intensive campaigns that highlight stigma and its negative consequences may reduce stigma and be implemented using posters, flyers, or short videos set up in strategic locations (e.g., the registration room, waiting room, examination room; Mukenge, 2020; Rana et al., 2022). At the hospital level, special programs that are particularly intended to reduce HIV stigma may be needed, including, for example, providing HIV testing services that are convenient and anonymous. Both clinics and hospitals require programs to address the fear of HIV transmission at work to ensure that employees are safe and protected and have sufficient supplies. These supplies include protective equipment such as gloves, containers for sharp tools, hand sanitizer, and postexposure prophylaxis treatment that may be deployed in the event of an accident involving HIV exposure during care (Barbier et al., 2020; Mammbona & Mavhandu-Mudzusi, 2019). Finally, at the policy level, developing new policies and enforcing them strictly in healthcare settings may significantly reduce stigma in healthcare settings in Indonesia. Current laws and policies that criminalize a person for deliberately spreading HIV should be repealed (Fauk et al., 2022), as this law contributes to stigma and hinders patient access to HIV services.

One predictor significantly associated with stigmatizing attitudes among healthcare workers in Indonesia is the fear of contracting HIV in the workplace. This finding is similar to that of Zarei et al. (2015) in Iran, who found that many healthcare workers refused to accept PLWHA because they felt anger and disgust when they imagined patients engaging in certain behaviors (e.g., nonmarital sex, same-gender sexual activities, injecting drugs) and feared being exposed to the disease. Likewise, a study conducted by Mahamboro and colleagues (2020) in Indonesia who studied HIV-positive patients among married men stated that irrational fear of HIV transmission among healthcare workers leads to discrimination in healthcare settings, as it contributes to unwillingness to provide treatment to PLWHA. A similar result was obtained in Tsukuda et al. (2022), which was designed to understand the characteristics of COVID-19-related stigma experienced by nurses caring for patients with COVID-19. The content analysis identified two categories and seven subcategories of stigma experienced by clinical nurses. The category "directly experienced prejudice and discrimination" included the subcategories "being avoided," "being treated as dirty," "discrimination toward family members," and "others prying." The category "self-imposed coping behavior" included the subcategories "keeping oneself apart," "feeling guilty," and "nondisclosure."

The discriminatory and unequal treatment of PLWHA compared with other patients by healthcare personnel affects the quality of the treatment performed by healthcare providers and may deprive PLWHA of their basic health rights. In addition, such stigmatizing attitudes may be a major reason PLWHA hide their disease and elect not to seek treatment (Freeman et al., 2020; Horter et al., 2019; Ndione et al., 2022). Improving healthcare workers' knowledge through comprehensive and up-to-date education and training, together with providing proper personal protective equipment, can help decrease irrational fear of HIV and, hopefully, improve the quality of healthcare services provided to PLWHA and reduce providers' stigmatizing attitudes.

The findings also showed that the institution where participants worked (community health centers, hospitals, clinics) was significantly associated with the level of stigmatizing attitudes. In particular, healthcare workers in hospitals had lower levels of stigma toward PLWHA than those working in other settings such as community health centers, clinics, and other institutional settings. This suggests that healthcare workers who work in hospitals have more exposure to PLWHA and gain more experience working with them. As a result, health workers in hospitals are more familiar with the disease, which makes them more confident psychologically about delivering care and treatment to PLWHA. This finding is similar to those of studies conducted in India and Vietnam (Machowska et al., 2020; Vorasane et al., 2017).

This study has several limitations that should be taken into account. First, the cross-sectional design means causal relationships between variables cannot be identified. Second, as HIV-related stigma is a very sensitive matter in Indonesia, using a self-report questionnaire may not reflect the true attitudes of healthcare workers, which would reduce data validity. Third, some otherwise qualified individuals refused to take part in this survey because they felt unfamiliar with online surveys or had unreliable internet signals (especially in rural areas). In addition, the percentage of physicians in the sample was very small. Finally, because the study used convenience and snowball sampling, the findings of this study cannot be generalized to all healthcare workers in Indonesia. Despite such limitations, the findings contribute to the HIV literature and may be used by governments as a foundation for developing future programs, policies, and social welfare to benefit PLWHA in Indonesia.

Conclusions

Many healthcare professionals in Indonesia still hold negative attitudes that stigmatize PLWHA, and many healthcare workers in Indonesia have had limited formal HIV training, have low levels of HIV knowledge, and fear contracting the HIV virus. Tackling the stigmatizing attitudes on a case-by-case basis may be a first critical step in changing these negative attitudes. To increase their knowledge, educational programs for all health workers not only must teach how HIV is transmitted but also should include workshops that are more comprehensive, are up-to-date, and convey the negative effects of stigma on patients' lives. Giving healthcare workers training and providing them with essential equipment will improve their confidence at work and reduce their irrational fears of contracting the virus.

Acknowledgment

We would like to thank to Stefani Pfeiffer for providing language editing support.

Author Contributions

Study conception and design: All authors

Data collection: JH, RM, SN

Data analysis and interpretation: JH, RM, MYC

Drafting of the article: JH, RM, SN

Critical revision of the article: MYC

References