1. Lahore Garrison University, Lahore, Pakistan; MeetWithSyeda@gmail.com
2. College of Traditional Chinese Medicine, China;  Gao-changqing@chinainstitute.com
3. College of Traditional Chinese Medicine, China; Jiang-anyong@chinainstitute.com

*           Correspondence: MeetWithSyeda@gmail.com

Keywords: AIDS victims, South East Asia, discrimination, community

1. INTRODUCTION

The human immunodeficiency virus (HIV), which causes AIDS, attacks CD4 cells in the immune system, which aid in the body’s response to infection. HIV multiplies inside the CD4 cell, destroying the cell. People affected by HIV/AIDS frequently deal with stigma, which is sometimes defined as prejudice, devaluation, undermining, and distinction. This covers those who have the illness, their loved ones, and communities directly associated with this pervasive sickness, including injectable drug users, sex workers, and men who have same-sex relationships [1]. By the end of 2021, 38.4 million [33.9–43.8 million] people worldwide were HIV positive. Globally, 0.7% [0.6-0.8%] of adults between the ages of 15 and 49 are thought to be HIV positive, while the epidemic’s toll varies greatly between nations and areas. 3.8 million of the 37.9 million HIV-positive individuals living in the world in 2018 resided in 11 countries in the WHO’s South-East Asia Region. This research is important because it discusses how HIV affects society and advances knowledge of the factors that fuel stigma towards PLWHA. PLWHA are excluded from the community as a result of stigma and discrimination, which has a detrimental effect on their quality of life [2]. HIV-related stigma stems from a number of factors, such as: (1) fear of infection, as PLHIV may be perceived as dangerous due to the virus’s contagious nature; (2) concerns about lifespan and productivity, which lead PLHIV to be perceived as having limited potential for relationships, employment, and companionship; and (3) the upholding of societal norms, since HIV vulnerability is linked to behaviours that society views as stigmatised (such as same-sex relationships, drug injection, and sex work). As a result, PLHIV are devalued because of their perceived associations with these behaviours [3]. Reducing stigma associated with HIV/AIDS is essential for preserving service accessibility as well as for protecting people’s sense of self, mental health, happiness, and general quality of life [4]. In addition to low care-seeking behaviour, there is a lack of incentive to obtain preventive interventions and routine HIV testing [5]. One of the main causes of this discriminatory attitude and the social exclusion of people living with HIV is a persistent and severe misunderstanding about the routes of transmission, which has been noted to exist among health professionals as well as among laypeople, regardless of their level of education or awareness. While many other studies have examined discrimination and stigma towards PLWHA in various contexts, the majority of these studies concentrate on the individual levels of stigmatisation, such as gaining insight into the diverse attitudes and behaviours of HIV-negative people towards diagnosed patients [6–8]. This review of the literature seeks to identify the causes of society’s discriminatory attitudes towards PLWHA as well as the extent to which PLWHA in Southeast Asia are stigmatised by society.

2. MATERIALS AND METHODS

In order to determine how South East Asian society stigmatises AIDS patients, we methodically reviewed the literature. In order to perform our research, we adhered to the PRISMA for an exhaustive literature review recommendations (preffered reporting items for systematic reviews and meta-analyses). A survey of articles published between 2013 and 2023 is part of the methodology, and it makes use of resources such as Google Scholar, PubMed, Med-line, PakMediNet, Science Direct, and Cochrane (Central Library). The following keywords, along with a database-specific heading (MeSh) and Boolean apparatus, are found in each database: stigma, AIDS, and south-east Asia. The publications that were included discussed the causes of stigma, such as discrimination, social exclusion, self-stigmatization, and false beliefs about how it spreads. The full text papers have to be issued in English, have a publication time between 2013 and 2023, and be electronically accessible in order to meet the inclusion criteria. The study does not include any of the identified studies, such as review articles, qualitative studies, and papers written in languages other than English that did not match the inclusion requirements. During the initial stage of research selection, the writers individually went through the retrieved papers based on their titles and abstracts. In the second step, two reviewers separately examined the whole text of the papers that made it past the screening. Previously, two authors had vetted all of the titles and abstracts that the searches had turned up. The remaining two writers scrutinised all the full-text articles that were found. Data from listed papers were collected by the other author using the standard PRISMA standards (checklist) 2023. Data on the characteristics of the included research (such as the nation and year of publication) and ethical issues (such as autonomy, genorosity, non-malificence, and fidelity) were separately extracted by the two reviewers. After carefully assembling the gathered data, the research characteristics seen in these kinds of investigations were explained. Our software of choice for data extraction and synthesis was Microsoft Excel. In compliance with PRISMA Guidelines 2023 (checklist), we employed a narrative method in this systematic study. The authors did not carry out qualitative synthesis and meta-analyses of the chosen studies in accordance with the inclusion criteria.

3. RESULTS AND DISCUSSION

As illustrated figure 1, the six databases (Google Scholar, PubMed, Med-line, PakMediNet, Science Direct and Cochrane) yielded 575 papers. We eliminated 104 duplicates and screened the remaining papers or title and abstracts (n= 471). After screening the titles and abstracts, and removing 389 publications for various reasons detailed in figure 1, 82 were left. After examining the full text of the remaining 82 articles, we excluded 69 due to topic’s irrelevance or the absence of full text in the English language. As a result of the database searches, 13 publications were analyzed. This systematic review presents the range of drivers of Stigma and other moral issues faced by PLWHA by healthcare professionals, family, friends, society and workplace colleagues. Our results show that most frequently reported drivers of stigma were social isolation and discrimination followed by reluctance and barriers to treatment followed by misconception about transmission followed by self-stigma.  From the 13 papers reviewed, author’s identified or discussed the following drivers of stigma faced by PLWHA. Social Isolation and Discrimination was addressed in 92.3% (n= 12/13) studies, reluctance and barriers to treatment were discussed in 76.9% (n= 10/13), misconception about transmission 53.8% (n= 7/13) studies, self-stigma 38.4% (n= 5/13). The findings show that most of the stigmatizatibng attitude observed in reviewed literature is influenced by factors, such as, misconception about transmission, social isolation and discrimination, reluctance and barriers to treatment and self-Stigma. 3/6 studies conducted in Indonesia reported misconception about transmission [1, 2, 7]. Half studies in Thailand reported misconception about how HIV spreads and contributes to stigma against PLWHA [6, 10]. A quantitative study conducted in Bangladesh by Ahmed reported Misconceptions particularly in developing countries including Muslim nations where many are unaware of non-immoral transmission methods [3]. One of the authors Aung conducted a cross sectional study in Laos which reported HIV related stigma within healthcare settings [4]. Victims of HIV stigma reported instances of healthcare neglect including denial of treatment, premature discharge from hospitals and dismissal of their pain [2]. A study conducted in Bangladesh discussed about sex workers not being provided any healthcare or testing facilities; consequently spreading the virus unchecked [3]. Out of the 2 studies conducted in Thailand one emphasized that 80% of Thai adults expressed reluctance to get tested due to fear of societal reactions [6]. One article from Malaysia explores healthcare provider stigma as a barrier to care for vulnerable populations like HIV infected individuals [12]. A significant number of Indonesian individuals experienced verbal abuse including derogatory names and unwarranted reprimandal along with instances of isolation during meals [1,2,7]. 41% of Thai adults expressed reluctance to buy from an HIV positive vendor while 1/5th believed children with HIV/AIDS should be kept of regular classrooms indicating serious discrimination [6]. Stigmatizating attitudes hinder medical treatment-seeking due to apprehensions about judgment, rejection or mistreatment by healthcare providers [9]. Negative attitudes of healthcare personnel contribute to discrimination among PLWHA [12]. Stigma can cause patient feel ashamed or embarrassed about their condition leading to not disclosing their status to others [13]. A large proportion of PLWHA in Indonesia reported experiences of negative self-perception like Feeling that they did not deserve to live, being ashamed of having AIDS/HIV, feeling absolutely worthless[2].A mixed method analysis of internalized HIV-related stigma has  assessed negative self-views among PLHIV [5]. Sudies in Thailand reported Internalized stigma has been noted as more important and impactful than external stigma and discrimination. The study found that the negative self-image subscale score was the highest, followed by disclosure concerns [10]. The pervasive social stigma associated with AIDS has hampered advancements in prevention, treatment, and support, and has also highlighted the urgent need for thorough research to shed light on its complex effects and pave the way for more inclusive and successful interventions. Our systematic review discusses certain stigmas related to AIDS i.e. social isolation and discrimination, self-stigma, reluctance/barriers to treatment and misconceptions about transmission. The barriers may include complete rejection of HIV patients by society and government which may lead to unchecked spread of the virus as patients are not provided with proper investigation or treatment facilities [1]. According to our results, 53.8% (7/13) of the authors recognized or explained misconceptions about transmission as an important stigma towards AIDS. A study conducted by Zgambo et al. Showed that most HIV patients did not tell their partners they were infected even though they were aware of their diagnosis (range: 76–100%), and some did not use protection (condoms) to stop the spread of HIV and other STDs (range: 35–55%). Adolescent disclosure was low across studies and was linked to apprehension about the fallout from disclosure, such as stigma and discrimination (range 40–57%) [5]. Though, there are inconsistent findings, the study complies somewhat with the results in our systematic review. In our study, analysis showed that 76.9% (10/13) of the articles discussed reluctance/barriers to treatment as another important stigma towards AIDS. In a research conducted by Katz et al, 6 of 7 longitudinal studies (86%) revealed a null finding, while 24 of 33 cross-sectional studies (71%) reported a positive relationship between HIV stigma and ART (Antiretroviral therapy) non-adherence [6]. Results of our study indicated that 92.3% (12/13) of the articles discussed social isolation and discrimination as another important stigma associated with AIDS. In a research by Jackson-Best and Edwards et al., the majority of evaluations (94%) revealed that behavioral interventions that target stigma were more prevalent than structural ones in the primary studies [7]. The findings comply with the ones in our study.

4. CONCLUSION

The results demonstrate that the majority of the causes linked to stigma include self-stigmatization, social marginalisation and prejudice, resistance to treatment, and misconceptions about transmission. The examined material raises awareness of the stigmatising sentiments that continue to exist in Southeast Asia in a variety of contexts.

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