Perceived Disapproval from Health Care Providers Hinders HIV Care

&LOS ANGELES, Sept. 6 -- About a quarter of low-income HIV patients feel stigmatized by their health-care provider at the first appointment, researchers here said.

The proportion falls to one in five after six months of care, Janni Kinsler, Ph.D., of the University of California at Los Angeles, and colleagues, reported in the August issue of AIDS Patient Care and STDs.

But while the perception of stigma improves over time, it is significantly associated with low access to care, both at the start of treatment and after half a year, the researchers said.

"Whether or not it is actual stigmatization is hard to measure, because it's coming from the patients that we interviewed," Dr. Kinsler said in a statement.

"The point is that these people feel that way, and that's bad enough, because they're less likely to seek the care they need," he said.

As part of a multi-center study evaluating outreach programs aimed at hard-to-reach HIV-infected people, the researchers questioned 223 prospective patients in baseline interviews from May 2004 through June 2005.

Follow-up interviews took place six months after the initial interview and 77% of the participants completed the second questionnaire.

Participants were asked if, during the time since they had contracted HIV, any health care provider had:

• "Been uncomfortable with you?"
• "Treated you as inferior or in an inferior manner?"
• "Preferred to avoid you?"
• "Refused to serve you?"

The researchers found that 26% of patients answered Yes to one or more of those questions at baseline; a full 19% said that they'd been refused treatment by a health care provider.

After six months, the percentage who reported stigma fell to 19%, with only 9% reporting refusal of care.

The patients were also asked six questions about access to health care: 1) whether they had gone without medical care because of the expense, 2) if medical care was conveniently located, 3) whether they could obtain medical care whenever they needed it, 4) if they had easy access to medical specialists, 5) if emergency care was easily obtainable, and 6) if they could be admitted to hospitals with no trouble.

At baseline, 58% reported difficulties on at least one of the six aspects of accessing care. Nearly the same proportion -- 57% -- reported problems six months later.

A multivariate analysis showed that those who perceived stigma at baseline were more likely to have low access to care (odds ratio 3.29, 95% confidence interval 1.55 to 7.01).

The same was true six months later: Those who perceived stigma were nearly three times as likely to have low access to care (OR 2.85, 95% CI 1.06 to 7.65).

"We found that those who perceived stigma from a health care provider had more than twice the odds of reporting low access to care," the researchers said, "even after examining the effect prospectively and adjusting for a host of sociodemographic and clinical characteristics."

The researchers noted that the study involved a relatively marginalized population and may not be easily generalized to all people with HIV. But they noted the study provides "valuable information" on the link between perceived stigma and access to care.