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Journal of Quality in Health Care & Economics Research Article 16 min read

Effect of Stigma on Quality of Life of People with Sexually Transmitted Infections

Aggarwal S*, Mahajan N and Singh T
* Corresponding author
ISSN: 2642-6250  10.23880/jqhe-16000186  Received: November 09, 2020  Published: November 23, 2020
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Keywords
Stigma Quality of Life Sexually Transmitted Infections
Abstract

Sexually transmitted infections (STIs) are known for causing burden of mortality and morbidity along with psychosocial consequences among individuals suffering from STIs due to perceived stigma against them at community levels. Therefore, this mini review aims to summarize the effect of stigma on the quality of life of people with STIs. People with STIs and their families often experience shame, anxiety, isolation, social boycott, rejection by the surrounding communities. Fear of isolation and prejudices in the society causes the sufferer to keep their disease status undisclosed even to their families because they are afraid of being socially boycotted. The reluctancy and attitude of concealment of information regarding their health leads to complications in health seeking practices. Therefore, several initiatives have been pioneered by governmental and nongovernmental agencies in India to provide timely diagnosis and treatment for STIs in total confidentiality. Additionally, financial assistance, education and employment opportunities have also been sought for them. Prevention of the infection, proper awareness and education, reduction in complications related to treatment and healthcare seeking may be beneficial to reduce the transmission of STIs to a large extent. Socio-behavioural research to understand and estimate stigma and discrimination towards people suffering from STIs should be conducted to quantify the levels of stigma at various levels. Such studies will provide an opportunity for formulating guidelines which are more inclusive for individuals with STIs in order to destigmatize STIs in communities.

Introduction

Sexually transmitted infections (STIs) are defined as the infections predominantly spread through unsafe sexual contact. Some STIs may spread through non-sexual means by transfusion of infected person’s blood or bodily fluids to normal person or through contact with infected needles [1]. STIs such as chlamydia, gonorrhoea, hepatitis B, human immune-deficiency virus (HIV) and syphilis may transmit from infected mother to child during pregnancy and childbirth [2]. Globally, approximately 1 million STIs are acquired every day and there are about 300 million new infections of one of the four STIs viz. Chlamydia, gonorrhoea, syphilis and trichomoniasis [3, 4]. In India, about 6% of the adults have acquired one or more STIs which account for emergence of 30-35 million cases reported every year [5, 6]. The National AIDS Control Organization (NACO) (2017) reported that 0.26% of general population in India had acquired HIV, while the prevalence rate of HIV was estimated as 2.5% in STI clinics [7]. Till now, there is no defined cure available for three STIs (HIV, Herpes, Hepatitis B) but preventive and precautionary measures are vividly advertised to spread awareness. STIs are causing burden of mortality and morbidity and having additional psychosocial consequences on individual and at community levels due to the perceived stigma and discrimination against people having with STIs in a community [8].

Stigma is a kind of discriminatory status the society attaches to a certain anomaly or condition towards an individual who has that attribute [9]. Stigma is categorized into four domains viz. enacted stigma, vicarious, felt normative and internalized stigma based on the magnitude and involvement of individuals and communities in this discriminatory behavioural approach [8, 9]. Several studies have highlighted a negative association between stigma towards STI patients in India and their quality of life (QoL) [10, 11, 12, 13, 14, 15]. It is necessary to identify the barriers and challenges to mitigate proper clinical management of patients with STIs to enhance their QoL. In light of the available literature on associative nature of stigma and QoL, this mini review summarizes the effect of social stigma on people with STIs in India.

Methodology

The present review was conducted to assess effect of social stigma on people with STIs in India. This review will map the existing literature on stigma and QoL of STI patients in the country. It estimates the existence of stigma and its impact on patients with STIs and people living with HIV-AIDS (PLWHA). Furthermore, the current policies and actions for the welfare of PLWHA were also summarized to recognize the challenges which will provide ample scope for policy makers, and researchers to explore the research lacunae related to stigmatization among PLWHA and their QoL.

PubMed was used for literature search. The key words “Quality of life” AND “Stigma” AND “Sexually Transmitted Diseases” or “Sexually Transmitted Infections” OR “STI” OR “HIV-AIDS” OR “Human immune deficiency virus” OR “Acquired immunodeficiency syndrome” AND “India” were searched in PubMed database. This exercise provided us with 116 articles, after applying various inclusion and exclusion criteria about 59 articles fit into the criteria. Full text articles which discussed the stigma towards PLHWA and their QoL were included. Furthermore, unavailability of full text articles and those research publications which were out of the scope of the research objective of the current review were excluded. Most of them were discussed in relevance to their subjects in the current review. All articles were reviewed thoroughly for the articulate understanding effect of stigma on QoL of people with STIs in India.

Existence of Stigma towards People with STIs

People with STIs and their families often experience shame, anxiety, isolation, social boycott, rejection by the surrounding communities [16, 17]. They are often considered sexually undesirable, impure, dirty and face negative attitude which severely impacts their psychosocial health and QoL [18, 19]. Fear of isolation and prejudices in the society causes the sufferer to keep their disease status undisclosed even to their families because they are afraid of being socially boycotted [20]. The reluctancy and attitude of concealment of information regarding their health leads to complications in health seeking practices [19].

Impact of Stigma on People Having STIs

Stigma has severely negative impact on health outcomes of people living with HIV-AIDS (PLWHA) as it results in non-optimal adherence to medicines, low frequency of visits to health centres for treatment, greater depression, and resulting in overall decrease in the QoL [21]. Perceived community stigma towards PLWHA shows association with affective, cognitive as well as mental health factors, mediated by internalized stigma among STI patients [21, 22, 23, 24]. PLWHA are often shun from the society and workplaces upon disclosure of their status which causes unemployment among them at a significant level which also poses a financial burden on the patients.

Survirya, et al. in a study conducted at a Suraksha Clinic in Lucknow, Uttar Pradesh reported that single individuals felt significantly high amount of vicarious and felt normative stigma in comparison to married individuals [9]. It is possibly because single people might be able to indulge in talks on their experiences with people of same marital status [8]. The study also highlighted that the felt normative stigma scores were found to be significantly higher in homosexuals and bisexuals in comparison to heterosexual patients with STIs, because they bear the stigma in the society as it is due to their sexual and lifestyle preferences which increases discrimination and stigmatized attitude towards them if they have STIs [25]. Internalized stigma scores in association with biosocial, behavioural and clinical characteristics were not significant as STI patients did not consider stigma as valid and they do not want to be a target of stigma or discrimination in any form [9]. Hence, it is vital to curb stigmatized attitude towards PLWHA at individual, family and community levels so that the sociocultural barriers faced by patients in accessing treatment and care can be removed [24].

Consequences of Stigma on People Who Have Acquired STIs

The major consequence of stigma from the families and communities towards patients with STIs is concealment and late presentation of the patient to HIV care centres [19, 24]. HIV infected patients living with families showed late presentation to HIV care in other countries such as Ethiopia, Uganda and Switzerland, similar to India. The issues of confidentiality and fear of social isolation and boycott have been attributed as the reasons for concealment of HIV status among patients [24, 25, 26, 27, 28]. Mojumdar, et al. [29] reported 83.4% participants in a cohort study in India were late presenters, in which the factor association showed males aged 45 years who acquired STI through heterosexual contact were most likely to hide their HIV status or seek late healthcare for the infection.

Additionally, lack of information on government services related to treatment of STIs such as antiretroviral therapy (ART) among PLWHA poses adverse challenge in disease management [30]. Late presentations to HIV care are also associated with a perceived fear of possible side effects of ART in India along with other developing and under developed countries with high prevalence of STIs such as Mozambique, Uganda, Nepal and Ethiopia [24, 31, 32, 33, 34]. The associated stigma attached to PLWHA has a negative impact on the compliance rate of ART among patients which affects the course of overall treatment [30, 35].

Current Policies and Actions for Management and Treatment of STIs

In India, current policies and actions towards STI management and treatment by the NACO guarantees total confidentiality of patient during testing and treatment for safeguarding the well-being of patients with STIs [36]. Counselling and behavioural interventions such as introduction of comprehensive sexuality and adult education programmes in education system, pre- and post-testing counselling for STI patients, guidance on safer sex practices, creating awareness among vulnerable groups may lead to lowering of cases of STIs in India [30]. Unfortunately, lack of awareness related to the infection among masses, shortage of trained medical staff at remote locations, and rampant stigma in community towards patients with STI are the barrier to greater and effective utilization of such interventions and policies prepared by governmental and non-governmental organizations [37].

STI case management in developing countries such as India heavily depend on identification of easily observable and recognized symptoms which do not require laboratory testing. This diagnostic approach is known as syndromic management which relies on clinical algorithms which allow healthcare workers to diagnose the infections among patients through certain observable symptoms [38]. Syndromic approach in STI management is considered as a simple, rapid, time efficient and inexpensive diagnostic measure which has been widely practiced worldwide. However, syndromic management has a limitation in diagnosis where patient who do not show recognized symptoms associated with each kind of STIs [39]. Timely diagnosis and interventions by refining this approach may be useful in reducing the stigma attached with STIs in India, since, this very time effective approach to monitor the symptoms under medical guidance and confidentiality.

In several states of India, a pension scheme has been set up for PLWHA to enable them to meet their basic daily needs. “Madhu Babu Pension Yojana”, is one such scheme launched by the Government of Odisha for PLWHAs irrespective of their age, gender, economic status and caste. State Boards of AIDS control in several states and union territories also have similar provisions for providing financial aid to PLWHAs. Additionally, the Rajya Sabha passed the “Rights for Transgender Persons Bill” on April 24th 2014 which guaranteed rights and reservations for transgender people in education and jobs, with 2% reserved seats in government jobs, as well. Also, the bill entitled them for legal aid, pension policies, skill development programmes and unemployment allowances [40]. Furthermore, Pride Circle, a diversity and inclusion firm in Bengaluru has established a dedicated job consultancy wing for Lesbian, Gay, Bisexual and Transgender (LGBT) [41]. These initiatives to include vulnerable groups such as PLWHAs and LGBTs in mainstream will help in decreasing the stigma towards them which will be vital for improvisation of their QoL.

Prospective Approach for Destigmatising STIs for Improving QoL of People with STIs

Considerable efforts are being made towards proper identification and management of simple intervention techniques which can help in reduction of unsafe sexual behaviour, which is one of the prime contributors of STIs in people [42]. The behavioural changes observed among PLWHA poses to be a complex and consistent barrier in risk management, as the patients prefer to hide their infection status leading to delayed diagnosis and treatment. Positive coping strategies among HIV patients and stigma can help in improvisation of their overall QoL [43]. Some of the strategies which may be vital as individual, family and community level to lower the stigma towards people with STIs are as follow:

  • There is a need to develop a sense of belongingness among PLWHA which can be achieved through social support at family and community level and by participation in social groups at individual level.
  • Taboos associated with PLWHA can be overcome by increasing understanding and knowledge about the infection and its transmission.
  • There is a need to focus on defining vulnerable population groups, conducting extensive counselling sessions with the identified target groups and making them a part of socio-behavioural research programmes.
  • The narratives and experiences of target groups for designing, implementation and evaluation of research findings will provide a comprehensive emic approach in terms of research on STI patients. It will be beneficial in providing a robust and structure framework for the existing STI management programmes in India.
  • Inclusion of STI infected patients in research programmes will also provide opportunities for employment which will empower them financially and socially.
  • Usage of media to show AIDS has a human face to empower youth to prevent HIV infection through discussions related to stigma, discrimination and violence.

Conclusion

It may be understood that the stigma towards people with STIs may have significantly adverse effect on the QoL of these people. Concealment, late presentations at healthcare centres and reluctancy to treatment are certain actions which are sought by people with STIs to avoid discrimination in the society. Additionally, lack of awareness regarding the course of treatment often causes late presentations among the sufferers. Thus, proper awareness regarding prevention and early diagnosis to curb the spread of infection are necessary. In India, governmental and non-governmental agencies are making efforts to create awareness regarding STIs by providing free counselling and treatment in confidentiality to the patients who have acquired the infection. However, the compliance rate for proper health seeking behaviour among patients still remains a matter of grave concern as due to the existing stigma in the community towards them, very few patients complete the entire therapy. Therefore, socio- behavioural research to understand and estimate stigma and discrimination towards people suffering from STIs should be conducted to quantify the levels of stigma at various levels. Such studies will provide an opportunity for policy makers to prepare comprehensive and robust guidelines which are more inclusive for PLWHAs in order to destigmatize STIs in communities.

Conflict of Interest

Authors declare no conflict of interest

Funding Sources

No funding was sought for writing this review article.

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@article{aggarwal2020,
  title   = {Effect of Stigma on Quality of Life of People with Sexually
Transmitted Infections},
  author  = {Aggarwal S, Mahajan N and Singh T},
  journal = {Journal of Quality in Health Care & Economics},
  year    = {2020},
  volume  = {3},
  number  = {6},
  doi     = {10.23880/jqhe-16000186}
}
Aggarwal S, Mahajan N and Singh T (2020). Effect of Stigma on Quality of Life of People with Sexually
Transmitted Infections. Journal of Quality in Health Care & Economics, 3(6). https://doi.org/10.23880/jqhe-16000186
TY  - JOUR
TI  - Effect of Stigma on Quality of Life of People with Sexually
Transmitted Infections
AU  - Aggarwal S, Mahajan N and Singh T
JO  - Journal of Quality in Health Care & Economics
PY  - 2020
VL  - 3
IS  - 6
DO  - 10.23880/jqhe-16000186
ER  -