Evidence Based Research on HIV Stigma Among Women

This evidence-based review explores the stigma associated with HIV among women patients and its impact on their mental health. The research question focuses on whether HIV-related stigma leads to depression, social isolation, or rejection in HIV-positive women. The review includes methodologies used, quality appraisal of the selected papers, and a summary of the findings. The implications for healthcare providers are discussed.

Running head: EVIDENCE BASED RESEARCH ON HIV STIGMA AMONG WOMEN
EVIDENCE BASED RESEARCH ON HIV STIGMA AMONG WOMEN
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1EVIDENCE BASED RESEARCH ON HIV STIGMA AMONG WOMEN
Table of Contents
Introduction................................................................................................................................2
Research Question......................................................................................................................3
Methodologies............................................................................................................................3
Quality Appraisal.......................................................................................................................4
Summary and Synthesis...........................................................................................................11
Implementation........................................................................................................................11
Conclusion................................................................................................................................12
References................................................................................................................................13

2EVIDENCE BASED RESEARCH ON HIV STIGMA AMONG WOMEN
Introduction
Health care providers who are part of the multidisciplinary team (MDT) always base
their decision-making and delivery of excellent care on the best available evidence in order to
achieve greater health outcomes. According to Dawes et al. (2005), evidence-based practice
can be defined as the decisions made by health care professionals based on valid, up to date,
applicable evidence, which is within the framework of accessible materials. From a patient’s
perspective, using evidence-based practice strengthens the patient’s confidence in the care
they are receiving. It also empowers health care professionals in their work and gives them
confidence in delivering the best quality of care (Carlson, Ross and Stark 2012).
In this evidence-based review, stigma associated with HIV among women patients
will be explored accounting internationally cited reports. The main rationale for conducting
research on this topic is that HIV related stigma has become a major social problem for
people diagnosed with HIV and because of stigma, HIV patients particularly women like to
stay away from treatment. Fear, shame and rejection from family prevent them from seeking
health care support on time (Oskouie et al. 2017). There have been very few studies, which
have evaluated experiences of stigma in HIV infected women. As this perceived stigma
seriously affects well-being of HIV-infected women, conducting research on this topic is
essential to enhance HIV women’s experience in care and promote patient safety in clinical
setting.

3EVIDENCE BASED RESEARCH ON HIV STIGMA AMONG WOMEN
Research Question
A research question was formulated using Population, Exposure and Outcome in
order to identify and set apart the elements of the formulated question, ‘For HIV positive
women, does HIV related stigma lead to depression, social isolation or rejection?’ . The main
reason behind choosing this question for the review is that stigma and depression or stigma
and loneliness are interlinked factors most commonly seen in people experiencing stigma.
Hence, as there is lack of studies that particularly examines outcomes of depression and
social isolation due to HIV related stigma, framing this research question for the paper was
important. Using PEO framework helps in producing a clinical question, as the ability to
answer a question is vital in locating literature that is relevant for evidence-based purposes.
P Population: women living with HIV
E Exposure: HIV related stigma
O Outcome: social isolation, rejection
Methodologies
The search was carried out using online data bases and some journals including
Nursing Times, BMJ Journal, Cochrane Library and CINAHL. CINAHL database was
searched using keywords, such as ‘HIV’, ‘women’ OR ‘HIV/AIDS’. Boolean operator,
‘AND’ was used to search terms such as ‘stigma’ OR ‘rejection’ OR ‘social isolation’..
Inclusion and exclusion criteria for article selection are as set out in the table below.
Inclusion criteria Exclusion criteria

4EVIDENCE BASED RESEARCH ON HIV STIGMA AMONG WOMEN
Women
Any country
English articles
Articles written in the last 10 years
Male, gays, lesbian
Written in different language
Result of the search strategy:
The PRISMA guideline was used to conduct the search process. As per the PRISMA
flow chart, 120 papers were retrieved after entering the search terms in selected databases.
After screening for the articles by identifying duplicates or same paper, about 30 duplicate
articles were removed. The next process of screening was done by reviewing the title and
abstract of the paper to ensure that paper is relevant to the research question. Only those
papers were taken which reviewed both stigma as well as any of the outcomes. Out of 90
remaining papers, 55 papers were removed at this stage based on the reason that relation
between stigma and depression or isolation was not considered. This leaved 35 papers, which
were screened for eligibility, based on inclusion and exclusion criteria. By taking this
approach, 30 papers were excluded and 5 papers were selected that were relevant to the
research topic. The following papers were included Mohit, Mohit and George (2015),
Oskouie et al. (2017), Alvarez-del Arco et al. (2018), Brickley et al. (2009), Kamen et al.
(2015). The summary of the search using PRISMA flowchart is given in appendix 1.
In reference to using the exclusion and inclusion criteria, 5 papers were selected that were
relevant to the research topic. The following papers were included;

5EVIDENCE BASED RESEARCH ON HIV STIGMA AMONG WOMEN
Article 1- (Oskouie et al. 2017)
Article 2- (Mohit, Mohit and George 2015)
Article 3- (Brickley et al. 2009),
Article 4- (Alvarez-del Arco et al. 2018)
Article 5- (Kamen et al. 2015)
Quality Appraisal
The quality of all the paper were analyzed using the CASP tool and the tool has been
attached in appendix 2. The main aim of the first article by Oskouie et al. (2017) was to
examine the experiences of HIV women witnessing stigma and evaluate the strategies to deal
with the issue. The use of qualitative approach is suitable for this study based on the aim as
qualitative research method helps to explore participant’s perception or opinion about a
phenomenon (Silverman 2016). Semi-structured interview method was used to collect data on
experience related to HIV stigma from twenty-five women. The significance using in-depth
interview method was that it helped to collect data on knowledge and experiences with the
disease. As it was a qualitative research design, the sample size of 25 was appropriate for the
study. The participants for the study were recruited by confirming HIV diagnosis using lab
data and other eligibility criteria was all participants must be above 18 years and Persian
speaking. The interview lasting 45-60 minutes was conducted in a closed room and all ethical
requirements related to obtaining permission and maintaining accuracy of transcripts was
considered.
The analysis of data was done using conventional content analysis and the advantage
of this analytical method is that it enhanced the quality of findings by considering credibility,

6EVIDENCE BASED RESEARCH ON HIV STIGMA AMONG WOMEN
conformability, dependency and transferability of the results. The main finding emerging
from the study was that different dimensions of stigma was reported by participants, leading
to fear, shame, rejection and frustration. Women with HIV/AIDs adapted negative strategy to
deal with stigma such as isolation, non-disclosure and loss of follow-up. Hence, the findings
are clearly stated in the form of themes. However, some factors that influence the internal
validity of the findings include recruitment of samples from only single center. This limits the
generalizability of the work as the same perception may not be experienced by other women
with HIV. Hence, there was a need for multiple center study. Despite this limitation, the
strength of the study is that it gives implications to implement services that can support HIV
positive women influenced by stigma.
Next, Mohit, Mohit and George (2015) used a cross-sectional study design to
investigate about the level of perceived stigma and depression among women with
HIV/AIDS and evaluate the relationship between the two. Descriptive epidemiological
approach was taken which is an appropriate approach to organize data about disease and its
impact on personal characteristics of patient (Webb, Bain and Page 2016). Purposive
sampling technique was used to recruit participants and this was done by choosing Bel-Air
hospital Panchgani, Maharashtra as the setting. As this center is home to large number of
patients, use of this approach was useful. The sample size was 50, which appropriate based
on the research design. The strength of data collection method was that data related to stigma
and depression was collected using perceived stigma scale and a self-report scale to measure
stigma and depression respectively.
The validity and reliability of the research is high apart from conventional research
using interview questionnaires, the researcher focused on analyzing the feasibility of the
work using a pilot study too. This ensured that flaws in research method were identified and
all possible modification was done before time (Eldridge et al. 2016). The main findings of

7EVIDENCE BASED RESEARCH ON HIV STIGMA AMONG WOMEN
this research was that almost all women perceived stigma because of HIV/AIDS and high
score in stigma perception scale was associated with high severity of HIV related stigma.
There were 74% of participants, who experienced depression most of the time and the rest
experienced it occasionally. Another important link found in the paper was that occupational
status was significantly associated with perceived stigma. The significance of this paper is
that it fulfills all ethical requirements related to informed consent and confidentiality. In
addition, no conflict of interest was found. Hence, these findings can be applied in local or
target setting.
In addition, the third paper by Brickley et al. (2009) aimed to explore the experience
of discrimination in HIV positive pregnant and post partum women in Ho Chi Minh City. To
achieve the study objective, in-depth interview and focus group discussions were used as a
study design to collect data from participants. After choosing the setting, an informational
letter recruited the participants and they were recruited only after they gave informed consent
for the study. The use of two methods of interview and focus group discussion is one of the
strength of the study as interview data helped to identify main themes related to the research
question whereas the focus group discussion helped to validate the data collected from the
interview. Thematic analysis was used as an approach to analyze the study findings and the
main advantage of using this approach was that it helped to get detailed and simple account
of complex data (Nowell et al., 2017).
The interview with 20 women with HIV revealed that almost all had experience
stigma and discrimination in some form at home or in the community. The profound impact
of such stigma on women is understood from women’s disclosure about committing suicide
because of it. Hence, fear of transmission of infection and moral judgments from people were
common perception for pregnant HIV women. However, the study was limited because of
flaws in recruitment design and sample setting too. For example, the study described

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experience of a specific population at specific time. However, random samples were not
taken contributing to possibility of biases. These findings can be used to plan specific
interventions that is needed by pregnant and post partum women with HIV to live with
dignity. Implementation of new laws and policy to empower women is also essential.
The fourth paper by Alvarez-del Arco et al. (2018) aimed to identify the factors,
shaping the desire for procreation and investigate about the impact of HIV on women. The
study was done using qualitative approach using interview as a research design. The use of
qualitative approach is considered suitable as this research design gives the opportunity to
explore about perceptions, experiences and factors shaping a phenomenon. Consistent with
qualitative research, the study used also used a conceptual framework. The interview question
for data collection was framed using the results from the literature review. Samples for the
study were randomly selected and total group of 20 women participated in the qualitative
survey. All the ethical requirements related to participant’s recruitment and consent was
done. Content analysis was the method of analysis for this research study too.
The interview was done with 20 women and the overall finding was summarized in
headings like impact of HIV diagnosis, concept of motherhood and dimension of
motherhood. Similar to other studies, this paper also reported about the feelings of fear, guilt
and isolation in women. Lack of acceptance of the diagnosis was common and they reported
lack of partners, poor economic stability and sacrifices associated with motherhood as some
of the barriers to procreation. The paper addressed the research question by linking HIV
stigma with anyone of the outcomes. However, one limitation of the finding is that the results
related to procreation and HIV cannot be verified as there is very less data on procreation
available in research literature. Despite this, the value of this research is that it gives health
care services and policy makers the implication to play a crucial role in women’s
reproduction related discussion.

9EVIDENCE BASED RESEARCH ON HIV STIGMA AMONG WOMEN
Lastly, the paper by Kamen et al. (2015) particularly focused on examining the
psychological functioning among Malawian women who were living with HIV/AIDS.
Malawi is a region in Africa where 11% of the adult population are living with the disease.
Hence, considering this setting for evaluating the impact of HIV/AIDS is significant. The
participants were taken in the study after gaining informed consent. Eligibility criteria like
age over 18 years. After taking ethical approval, survey method was used a research design to
get answers to the research question. By the use of survey questionnaire, the data was
collected from 59 Malawian women with HIV/AIDS. The questions mainly focused on
collecting data related to demographics, HIV-related stigma, HIV-related tension and
emotional distress. The significance of this paper is that it serves to address the research
question related to experience of depression or emotional distress in women living with HIV.
By using statistical tool SPSS 17.0 and hierarchical regression analysis, the results of
the supported that greater tension related to being diagnosed with HIV was associated with
greater distress in young Malawian women. Experience of emotional distress and depression
was common in women experiencing HIV stigma. The reliability of work has been seen by
comparison with various research literature where similar findings has been reported. The
significance of the study is that it suggest the need for health care providers to pay better
attention of emotional and psychological well-being of women apart from physical well-
being. The data can be used to plan culturally appropriate support programs for Malawian
women living with HIV/AIDS. Some possibility of bias is seen in the study because of small
sample size and use of convenience sampling technique. These limitations need to be
addressed in future research on the topic.

10EVIDENCE BASED RESEARCH ON HIV STIGMA AMONG WOMEN
Summary and Synthesis:
All the five papers have given insight into various aspects of the HIV disease
including the various stigmas and discrimination, the effect of disease at the time of
pregnancy. The common theme emerging from the finding is that diagnosis of the disease is
associated with experienced of stigma and feelings of fear, loneliness and rejections. It also
highlights the various factors that relate depression with HIV.
Implementation
Though the five papers retrieved from the literature search are suitable to give answer
to the research question and address the research gap, however the implementation or
application of the research finding to different setting are affected by barriers like
methodological quality of the paper and other policy related barrier. However, despite this,
the best quality evidence that has been found from the critical analysis of the paper includes
the research by Mohit, Mohit and George (2015) as the authors have considered all those
factors that contributes to biases and addressed those factors to enhance the feasibility of the
research.
The issues related to implementation have been explored using the PARISH
(Promoting Action on Research Implementation in Health Services) framework of
implementation. This framework analyzes the interaction between three elements such as
evidence (E), context (C) and facilitation (F) to identify barriers and facilitators to the
implementation process. The first point E evaluates whether the research is robust enough or
not. The recommended paper is considered robust as it is reliable, credible and without any
methodological limitation. Hence, lack of methodological drawback will facilitate application
of the research findings. The second step of context was judged by the level of adjustment
required to apply the research evidence in actual setting. In this context, it can be said that

11EVIDENCE BASED RESEARCH ON HIV STIGMA AMONG WOMEN
lack of training and poor attention to policies on supporting women with HIV may act as
barriers. Hence, there is a need to disseminate the findings to policy makers first before
appropriate campaign and HIV support programs can be implemented for women. The
facilitation aspect of implementation was evaluated by analyzing the things required to deal
with change. In this context, training was identified as a facilitator that would help health care
professionals to promote psychological well-being of women affected by HIV too.
Conclusion
From the critical analysis of five papers related to impact of HIV related stigma on
women living with HIV, it can be concluded that at least two high quality papers were
identified based on methodological quality. These two papers included the study by Mohit,
Mohit and George (2015) which used pilot study to enhance and evaluate the feasibility of
their research method and the paper by Brickley et al. (2009) which used both interview as
well as group discussion to validate the research findings. Hence, these two papers are
classified as good papers based on consideration of biases and taking steps to enhance the
validity of the papers. In contrast, the other three papers are bad paper though they answer the
research question as the authors used inappropriate recruitment method. The experience of
analyzing these papers has also helped to develop knowledge regarding the sufferings for
women with HIV. This knowledge will help nurse to sensitively deal with women living with
HIV.

12EVIDENCE BASED RESEARCH ON HIV STIGMA AMONG WOMEN
References
Alvarez-del Arco, D., Rodríguez, S., Pérez-Elías, M.J., Blanco, J.R., Cuellar, S., del Romero,
J., Santos, I., Boix, V., Masiá, M., Pascual, L. and Hernando, V., 2018. Role of HIV in the
desire of procreation and motherhood in women living with HIV in Spain: a qualitative
approach. BMC women's health, 18(1), p.24.
Brickley, D.B., Hanh, D.L.D., Nguyet, L.T., Mandel, J.S. and Sohn, A.H., 2009. Community,
family, and partner-related stigma experienced by pregnant and postpartum women with HIV
in Ho Chi Minh City, Vietnam. AIDS and Behavior, 13(6), p.1197.
Carlson, C.I., Ross, S.G. and Stark, K.H., 2012. Bridging systemic research and practice:
Evidence-based case study methods in couple and family psychology. Couple and Family
Psychology: Research and Practice, 1(1), p.48.
Dawes, M., Summerskill, W., Glasziou, P., Cartabellotta, A., Martin, J., Hopayian, K.,
Porzsolt, F., Burls, A. and Osborne, J., 2005. Sicily statement on evidence-based
practice. BMC medical education, 5(1), p.1.
Eldridge, S.M., Lancaster, G.A., Campbell, M.J., Thabane, L., Hopewell, S., Coleman, C.L.
and Bond, C.M., 2016. Defining feasibility and pilot studies in preparation for randomised
controlled trials: development of a conceptual framework. PloS one, 11(3), p.e0150205.
Kamen, C., Arganbright, J., Kienitz, E., Weller, M., Khaylis, A., Shenkman, T., Smith, S.,
Koopman, C. and Gore-Felton, C., 2015. HIV-related stigma: implications for symptoms of
anxiety and depression among Malawian women. African Journal of AIDS Research, 14(1),
pp.67-73.

13EVIDENCE BASED RESEARCH ON HIV STIGMA AMONG WOMEN
Mohite, V.R., Mohite, R.V. and George, J., 2015. Correlates of perceived stigma and
depression among the women with HIV/AIDS infection. Bangladesh Journal of Medical
Science, 14(2), pp.151-158.
Nowell, L.S., Norris, J.M., White, D.E. and Moules, N.J., 2017. Thematic analysis: Striving
to meet the trustworthiness criteria. International Journal of Qualitative Methods, 16(1),
p.1609406917733847.
Oskouie, F., Kashefi, F., Rafii, F. and Gouya, M.M., 2017. Qualitative study of HIV related
stigma and discrimination: What women say in Iran. Electronic physician, 9(7), p.4718.
Profetto-McGrath, J., 2005. Critical thinking and evidence-based practice. Journal of
Professional Nursing, 21(6), pp.364-371.
Silverman, D. ed., 2016. Qualitative research. Sage
Webb, P., Bain, C. and Page, A., 2016. Essential epidemiology: an introduction for students
and health professionals. Cambridge University Press.

14EVIDENCE BASED RESEARCH ON HIV STIGMA AMONG WOMEN
Records identified through
database searching
(n = 120)
Additional records identified
through other sources
(n = 0 )
Records after duplicates removed
(n =30 )
Records screened
(n = 90 )
Records excluded
(n = 45 )
Full-text articles assessed for
eligibility
(n = 35 )
Studies included (n = 5)
Full-text articles
excluded, with
reasons
(n = 30)
Appendix
1. PRISMA flow chart for the search process:

15EVIDENCE BASED RESEARCH ON HIV STIGMA AMONG WOMEN
2. CASP tool for critical appraisal:
1. Was there a clear statement of the aims of the research?
2. Is a qualitative methodology appropriate?
3. Was the research design appropriate to address the aims of the research?
4. Was the recruitment strategy appropriate to the aims of the research?
5. Was the data collected in a way that addressed the research issue?
6. Has the relationship between researcher and participants been adequately
considered?
7. Have ethical issues been taken into consideration?
8. Was the data analysis sufficiently rigorous?
9. Is there a clear statement of findings?
10. How valuable is the research?