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ABSTRACT

HIV and AIDS are recognized as one of the most prevalent chronic disorder in the world. It has been estimated that the infection is responsible for affecting millions and killing thousands in a single year worldwide. Different reports have identified Ghana as one of the most affected regions of the world. The state is realized to have high morbidity and mortality rate in response to the HIV/AIDS. It has been determined that the primary reason for such high impact is mainly the factor of stigmatization and discrimination towards the people living with HIV/AIDS.

fear of stigmatization appears so high in the society that people tend to avoid screening and seeking medical help for their condition. This study has aimed to carry out a comprehensive research on the preceding elements of stigma in Ghana. A systematic review has been designed for the purpose that recognized religion, social assumptions, cultural values, fear of contamination and other civil deprivations as the main factors that may lead to discrimination among the affected people. Researchers of the study have recommended that there is a dire need of educating and training such entities, particularly the religious leaders, social representatives and community councils, for creating amiable grounds for the affected individuals.

INTRODUCTION

Overview

After becoming more evident in the 1980s, Acquired Immune Deficiency Syndrome (AIDS) managed to become a major health concern all around the world. According to the report presented by the World Health Organization (WHO), the global prevalence of AIDS has been estimated reach about 36.7 million by the end of 2015. Hence, the incidence of the disease throughout the year 2015 was recorded and measured to be 2.1 million (World Health Organization, 2016).

HIV or human immunodeficiency virus has caused about 35 million mortalities worldwide (World Health Organization, 2016). Amongst the affected countries, Ghana has been identified to be one of the states with the highest prevalence of AIDS. According to statistics of UNAIDS, there are 2.7 million people living with AIDS in Ghana. Although the prevalence rate is only 1.6%, 19,000 patients have been determined to be younger than the age of 14 years. Amongst the prevailing rates, 150,000 have been the women.

Ghana has presented a high mortality rate that values for 160,000 deaths caused only due to the disease of AIDS in the year 2015 (Unaids.org, 2015). Majority of cases of AIDS in Ghana have comprised of the women and blood donors. Thus, health workers tend to reach to women more often than men for the purpose of screening. Moreover, it is considered necessary for every pregnant woman to go through an HIV test in Ghana. Similarly, every six months, most people voluntarily donate their blood to the hospitals. After the donation of the blood and screening of the collected specimen, the health professionals get to know a large number of people who appear positive for HIV (Feldman, 1994).

A number of interventional steps have been taken to reduce, treat and control the spread of HIV infections among the population. The interventions include the formation of Technical Committee in 1985 to work with the World Health Organisation for the control and prevention of AIDS. Screening Facility in 1987 and AIDS control program manager was introduced in 1988. Other interventions included the pilot interventions and wide ranged educational interventions to subdue the increasing number of infected individuals (Feldman, 1994).

Although, the interventions were introduced in the very beginning still the effects of the interventions have not been deemed fruitful as indicated by the low condom use despite the easy availability and reduced prices. One of the major barriers in the success of educational programs directed to educate the young people is stigmatization, which is basically recognized as the act of judgmental or accusation. Social and cultural beliefs associate AIDS with female prostitutes and assume that the disease is contracted through an intimate interaction of the patient with them or because they themselves have been performing the job. Residents of the most prevalent areas of Ghana also think that AIDS can be transmitted by meeting and spending time with the infected people.

Those people are reported to follow self-assumed preventive measures e.g. not even attending the funeral of a suspected patient. In general, the patients of AIDS in Ghana face a substantial amount of stigma and discrimination from common people and even health service providers. The study will aim to find out the factors leading to this discrimination and stigmatization by health workers against HIV infected young individuals.

The discrimination towards AIDS patients is not limited only to common residents of Ghana, but evidence reports stigmatization and discrimination towards patients by health workers as well, which makes the enigma even worse. The health services and preventive education is not available for the patients because of the behaviour of the doctors and other health service providers. Detailed studies should be employed to estimate and determine the factors that lead to the improper administration of health care to the AIDS infected individuals so that interventions can be designed to reduce the stigma and discriminatory behaviours of health workers ultimately leading to prevention of the controlled spread of the disease.

The research on the determinants of the stigmatization and discrimination against the HIV positive people will not only result in adding to the knowledge pool but also can be implied to generate interventions that can develop the value of lifetime of the people living with HIV/AIDS, and also help in reducing the spread of the life-threatening disorder.

Research Question / Aim

What factors lead health workers to stigmatize and discriminate against youth adult living with HIV/AIDS?

Study Objectives

• To gather and review the literature regarding the stigmatization against people living with HIV/AIDS by Health workers in Ghana.
• To undertake a critical review and identify the factors responsible for stigmatization and discrimination against HIV/AIDS patient by health workers in Ghana.
• To evaluate and analyse the results of the systematic review and formulate conclusions and recommendations.

The Underlying Problem

It has been 20 years since the world has undergone the epidemic of HIV/AIDS. Despite extensive studies and community work, stigmatization and discrimination associated with the disease continue to impede the preventive approach. The persistent conservation of the attitude has been hampering people to get required care and support for their condition. Studies have expressed that the fear of stigma has been found associated with the factors leading people to refuse for screening, disclosing the information to their partners and seeking medical assistance for treatment and management. Ultimately, this attitude delivers negative attitude creating an internalized stigma.

This notion is realized to be a firm barrier observed between the medicinal help and suffering patient (Stangl et al., 2013).
In light of these approaches, it has been realized that before dealing with the treatment modalities of HIV/AIDS, it is necessary to determine the stigma mechanism that has been clinging with the disease since the early days. Researchers and health care practitioners have identified various factors that may assist in combating the high prevalence of this disease. These elements have included the clinical preventive measures of voluntary male circumcision,

preventive exposures to the prophylaxis and widespread screening and management for the disease on a population level (Dai et al., 2013: 256-263; Roberts & Matthews, 2012: 1555-1561). It has been deemed necessary that before implying to any of these approaches, it is first necessary to eradicate the factor of stigma from society. Only then, the effectiveness of these interventions will be attained (Earnshaw et al., 2013: 225).

Significance of the Study

Existing literature has highlighted that stigma plays a major role in the health conditions of people under the influence of race and ethnicity. Regardless of the identification of the factor, the social setbacks persist within the communities, where studies fail to provide any comprehensive insight into the mechanism of stigma driving the intense attitude. Yet, it is a well – known fact that HIV/AIDS is by far the most stigmatized clinical disease that is facing stubborn hurdles for the treatment and management approach.

Awareness regarding the associated risks and prevalence remains under discussion due to the sexual connotations of the disease thus, creating obstacles and discrimination for help and education. This study had planned to address all the probable factors of stigmatization concerning HIV/AIDS in order to determine their mechanism.

It has evaluated the factors on the levels of structure, victim and observer. It has been presumed that this study will identify the lingering processes of discrimination that ultimately leads to stigmatization and segregation. The approach will then help the policy makers to plan their models of intervention and education as per the identified the factors and perception of the society. It will assist in producing long term impact on the planning and implementation of the clinical framework dedicated to the HIV/AIDS.
LITERATURE REVIEW

Human Immunodeficiency Virus (HIV)

Human immunodeficiency virus or HIV, along with its subtypes, are known as retroviruses. These are considered the primary source of AIDS. Montagnier (1985) asserted that HIV connects back to the family of RNA or ribonucleic acid lentiviruses. These have been found to be responsible for suppressing the immune system and central nervous mechanism. It has been further noticed that these retroviruses live extended period of incubation that leads to the notion, where disease indications are not expressed even after the contraction of the virus (Montagnier, 1985: 689-993).

Origin and Transmission of Human Immunodeficiency Virus

These viruses have been originally found in the varying species of primates (Emerman & Malim, 1998: 1880-1884). Emerman & Malim (1998) have presented the transmission mechanism of these viruses. It has been discovered that lentiviruses are incapable of transmitting through the germ lines. Molecular epidemiology has suggested that HIV occurs in two types among the species that have been suffering from the contamination (Heeney, Dalgleish & Weiss, 2006: 462-466). These two types have included HIV 1 and HIV 2.
HIV 1 is very common worldwide and HIV2 causes and AIDS -like illness. HIV gets transmitted by various means:
• It is transmitted by blood or body secretions like semen and vaginal fluid of an infected person.
• It is transmitted by unprotected sexual intercourse with an infected person.
• It can also be transmitted by using infected needles or needle stick injury.
• It can be transmitted from infected mother to baby during pregnancy, birth or lactation (Robbins et al., 2015: 243-256).

Indications of HIV Infection

This condition does not have definite symptoms that may be prominent so people often confuse them with simple flu. This is why the disease progresses and gets more and more lethal (Robbins et al., 2015: 243-256). Few of its symptoms may include (Kinloch-de Loës et al., 1993: 59-65):
• Fever,
• A sore throat,
• A headache,
• Pain in muscles and joint pain,
• Swollen glands and lymph nodes,
• Rashes in the skin.
These symptoms may start after a few days or several weeks after a person gets infected. Then once the symptoms disappear that were caught initially, the patient again becomes symptom free for few time. And then the symptoms again reappear. This time the symptoms may be:
• Swelling in lymph nodes
• Extreme fatigue and tiredness
• Weight loss
• Fever
• Sweating in night
If the doctors find these symptoms in a person and don’t find any other cause of the symptoms and he decides to rule out for this disease. The doctor goes for find the antibodies in body secretions like urine, saliva or blood. Because the antibodies to this disease appear in body’s secretions.
Screening for HIV Infection

If the urine or saliva shows that the antibodies to this virus are found then the doctor would go for ELISA (enzyme linked immunosorbent assay) or a western blot. These two tests are blood tests. Stigma and discrimination against hiv/aids patients If the ELISA gets positive that means if the antibodies are found in the blood then we will go for western blot in order to confirm this disease. Once the virus is in the body, the antibodies show up in the blood within 3 months at least but it can take as long as 6 months. So, if the patient thinks he might have got infected by the disease, it is better to get the tests redone at 6, 12 and 24 weeks (Robbins et al., 2015: 243-256).

Treatment for HIV Infection

The treatment for this disease is called anti-retroviral therapy abbreviated as ART. These medications slow down the process of the disease by halting the replication rate of the virus. These medications can actually decrease the viral load in a patient’s body and help him live a healthy life. To see the progress of the disease, doctors go for two tests:
• Checking the viral load, that is the amount of virus in the blood
• CD4 cells, this shows the immunity of the human body.
In the course of treatment there comes a time when the medication does not work. Stigma and discrimination against hiv/aids patients This is because the patient gets resistant to the medication. The drugs in the antiretroviral therapy include:
• Nucleoside reverse transcriptase inhibitor which includes zidovudine, didanosine, stavudine, lamivudine, abacavir, tenofovir, Combivir, Trizivir, emtricitabine, Truvada, epzicom.
• Non-nucleoside reverse transcriptase inhibitor: Nevirapine, delavirdine, efavirenz, etravirine, rilpivirine.
• Protease inhibitor: saquinavir, indinavir, ritonavir, nelfinavir, amprenavir, lopinavir, atazanavir
• Entry inhibitors: enfuvirtide, maraviroc
• HIV integrase inhibitors.
• Raltegravir, elvitegravir, dolutegravir.

Pathogenesis of HIV Infection

It is a well-known biological factor that retroviruses are only capable of replicating inside the living body of the host cell. It does not contain the DNA or deoxyribonucleic acid. It has been seen that pathological mechanism of HIV progresses in the pattern of a life cycle that depends on the internal environment of the host cell and the population of virus in the affected region (Sundquist & Kräusslich, 2012).

The HIV is particularly attracted to the cells that express the CD4 receptor molecules on their membranes. Thus, upon invading the body, these viruses ultimately attack such cells whereby they either fuse to the cellular membrane or enter the cell with the aid of endocytosis. The possibility of expression of the infections merely depends on the number of virions that attack the body and availability of the host cell that may provide the site for accommodation to these viruses. Therefore, Stigma and discrimination against hiv/aids patients it is presumed that the expression of CD4 receptor molecules is the determinant factor of expressing HIV associated indications (Sundquist & Kräusslich, 2012).

HIV can be contracted through the orifices of the body including the oral cavity, cervix and vagina, and the surface of the digestive mucosa. The transmission can occur even without any disruption of the mucosal lining (Keele & Estes, 2011: 839-846; Belyakov & Berzofsky, 2004: 247-253). Stigma and discrimination against hiv/aids patients  It has been noted that HIV depends on CD4 molecular receptors for gaining access to the cell host, where it can replicate in number to form a colony.

These host cells mainly include the mononuclear phagocyte system. Stigma and discrimination against hiv/aids patients The system chiefly includes the monocytes and tissue macrophages, T lymphocytes, natural killer lymphocytes, dendritic cells (epithelial Langerhans cells and follicular dendritic cells in lymph nodes), hematopoietic stromal cells, and microglial cells in brain (Magérus-Chatinet et al., 2007: 67-74; Stebbing, Gazzard & Douek, 2004: 1872-1880).

Regardless of the well – established theories of pathogenesis, recent studies have identified that HIV can also penetrate the bodies of host cells without any dependence on the CD4 receptors. Even though this invasion is not to be efficient, it has still been presented as an existing progress by Lucas & Nelson (2015).

The invasion has been presumed to occur in the astrocytes, gut enterocytes, renal tubules, Stigma and discrimination against hiv/aids patients  cardiac myocytes, and vascular endothelium. Thus, it has been perceived that these are still many attributes of these infections that have not been studied well (Lucas & Nelson, 2015: 229-241).
It should be noted that while these still exists a large pool of probabilities in the domain of clinical manifestations and pathological mechanism. Thus, it is necessary to work on the social elements associated with the progress of the disease in order to lift the burden from the health care facilities and communities.

Acquired Immunodeficiency Syndrome (AIDS)

AIDS is a disease that is an ultimate etiological representation of the HIV infection in its chronic form. It is a condition that characteristically deteriorates then defence system of the system. Stigma and discrimination against hiv/aids patients Thus, the immune system withers off gradually as the disease progresses; the progression consumes a long time before delivering the final phase of lethality (Kumar, Aster & Abbas, 2015).

White blood cells are considered the significant part of the immune system. Immunity is majorly determined by the two cells that may include the T cells which assist the body in developing the adaptive immunity, Stigma and discrimination against hiv/aids patients  and B cells, which help in generating the humoral immune responses (Kumar, Aster & Abbas, 2015).

In terms of HIV, it has been seen that the virus characteristically invades the CD4 cells. It has been noted that T cells are basically the CD4 expressing cells. Therefore, the HIV invasion directly affects the adaptive immune system. T cells are programmed to notify the immune system about any antigen or attacking factor within the body. Though, initially, only small numbers of cells undergo the damage caused by the HIV invasion, with time the destruction becomes so progressive that disrupts the whole system. The major contributing factor behind the disruption is known to be the extensive replication of the HIV in the body (Kumar, Aster & Abbas, 2015).

It has been observed that the infection does not express the condition of AIDS instantly with its invasion. Rather, it develops in time and develops into a complicated ailment. As mentioned earlier, Stigma and discrimination against hiv/aids patients HIV itself expresses signs and symptoms that are commonly observed with the flu. Thus, the indications are not perceived seriously till the time when the infection fully develops into a syndrome. With the destruction of adaptive immunity, a body of an affected individual becomes prone to all the presenting infections around. From this point, a life of the individual becomes critically sensitive and vulnerable in both the physical and psychological terms (Kumar, Aster & Abbas, 2015).

Transmission of AIDS

Transmission of AIDS and contamination with HIV has been a sensitive issue since the early years. It is the fear of catching the lethal disease that has led to the rejection of patients from the society leaving them in the critical situation of isolation (Hu et al., 2014; Sande, 1986).
Literature has ascertained that the human immune-deficiency virus does not transfer from social interaction and may only deliver contamination with the contact of body fluids, particularly blood. Apart from blood, body fluids that primarily transmit the virus from one person to other include semen or seminal fluid and vaginal secretions, which primarily is exchanged during sexual intercourse. It may also involve the rectal fluid in some cases. The topical interaction does not contract the disease into the contacted person; the contaminated virus must get in touch with the mucosal membrane to get transmitted in an active form into the body.

Mucosal membranes are mainly located in the lining of the oral cavity, rectum and reproductive orifices like vagina and penis (HIV.gov, 2017). It must also be noticed that body fluids including saliva, sweat, tears, faeces and urine of an HIV positive person do not carry and transmit the virus (San Francisco AIDS Foundation, 2017).Stigma and discrimination against hiv/aids patients
The main aspects responsible for the HIV transmission have been recognized as two approaches: physical and sexual. Sexual behaviour has been attributed as the main factor leading to the virus transmission among people (Oppong & Oti-Boadi, 2013; Parker, Herdt, & Carballo, 1991).

It has been observed that unprotected attempts to sex pertains to high vulnerability to receive HIV. The risk remains the same for both anal and vaginal intercourse. Even though, oral sex has been considered as safe practice in terms of sexually transmitted disease as HIV has been observed to not sustain in the oral environment. Yet, it is still expressed to have a possibility to some extent (Paintsil et al., 2015).

Another factor that may cause the viral contamination, involves the contact with open wounds, cuts or sores that may appear to be small and may go unnoticed (San Francisco AIDS Foundation, 2017). Similarly, the probability of viral transmission gets stronger if contaminated needles and syringes are exchanged between the affected and healthy individuals. The sharing of needles, which may be either be used for drug abuse…