Social Work in Health Care, 54:269–285, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0098-1389 print/1541-034X online DOI: 10.1080/00981389.2015.1005268

Experiences of Stigmatization and Discrimination in Accessing Health Services: Voices of Persons Living With HIV in Ghana MAVIS DAKO-GYEKE, PhD Department of Social Work, University of Ghana, Legon, Accra, Ghana

PHYLLIS DAKO-GYEKE, PhD and EMMANUEL ASAMPONG Department of Social and Behavioural Sciences, School of Public Health, College of Health Sciences, University of Ghana, Legon, Accra, Ghana

Drawing on Earnshaw and Chaudoir’s HIV stigma framework, this study explored the experiences of persons living with HIV and AIDS regarding stigmatization and discrimination in accessing health services. Using a qualitative research methodology, 42 participants were purposively recruited during support group meetings of persons living with HIV and AIDS (PLWHA) at Amasaman in Accra, Ghana. Four focus group discussions ( n = 22) and 10 in-depth interviews were conducted. Discussions and interviews were audio-taped, transcribed, and categorized based on the objectives of the study. The findings indicated that PLWHAs had knowledge of stigma that was experienced through enacted, anticipated, and internalized stigma mechanisms. Evidence showed that PLWHA did not experience stigma and discrimination when they accessed services at the Korle-Bu Teaching Hospital, the largest hospital in Ghana. However, the situation was different when they accessed services at other public health facilities. Based on the findings, implications are discussed for policy, social work, and public health practices. KEYWORDS HIV, AIDS, Ghana, health care providers, stigmatization, discrimination

Received February 21, 2014; accepted December 31, 2014. Address correspondence to Mavis Dako-Gyeke, Department of Social Work, University of Ghana, P. O. Box LG 419, Legon, Accra, Ghana. E-mail: [email protected]

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INTRODUCTION Globally, societies continue to grapple with HIV and AIDS because attitudes toward people living with the condition remain a major challenge. Unlike other chronic infections, HIV and AIDS have been associated with fear, ignorance and denial, leading to stigmatization and discrimination against infected and affected persons (International Center for Research on Women, 2002; Letamo, 2004). Everywhere HIV has been found, it is accompanied by stigma and discrimination and these are based on the cultural meanings of the disease (Mbonu, van den Borne and De Vries, 2009). Stigma isolates persons living with HIV and AIDS (PLWHA) from their families and communities and this could affect their overall quality of life (Rankin, Brennan, Schell, Laviwa, & Rankin, 2005; Campbell, Nair, Maimane, & Nicholson, 2007; Miller & Rubin, 2007). Stigma and discrimination nurture secrecy, which adversely affect prevention and treatment efforts and could intensify the impact of the epidemic (Rankin et al., 2005). At the onset of the HIV and AIDS pandemic, the disease was mainly found among groups (homosexuals, injection drug users, and sex workers) who were already socially marginalized and discriminated against (Letamo, 2004). PLWHA may become implicitly associated with stigmatized behaviors, regardless of how they actually became infected. Since stigma is often rooted in social attitudes, HIV-infected persons are habitually ostracized, rejected, shunned and may experience violence (Letamo, 2004). HIV and AIDS-related stigma can be described as a process of devaluing people who live with or are connected with the disease (UNAIDS, 2003). According to Earnshaw and Chaudoir (2009) discrimination is one of the mechanisms through which stigma is manifested and refers to discriminatory behaviors perpetuated by HIV-uninfected individuals toward HIV-infected persons. It is a type of enacted stigma that may be experienced by HIV-infected people in the form of job loss, social rejection, or physical violence (Earnshaw & Chaudoir, 2009). HIV-related stigma is particularly common in sub-Saharan Africa (Miller & Rubin, 2007). In Ghana, for example, many people feel that PLWHA are dangerous (Clottey-Sefa, 2001) and thus should be isolated from non-infected persons (Poku, Linn, Fife, Azar, & Kendrick, 2005). This arises from (a) the fear of HIV as an incurable and fatal infectious disease and (b) the fact that people have inaccurate and incomplete information about the ways in which HIV can be transmitted (Hong, Anh, & Ogden, 2004). PLWHA are usually stigmatized and discriminated against because of their actual or suspected status and this could deny them their basic rights and serve as a barrier to accessing HIV- and AIDS-related services. For fear of stigma and discrimination, people are averse to testing for HIV, revealing their HIV status, and seeking treatment for HIV and AIDS (Kalichman & Simbayi 2004; Lieber, Li, Wu, Rotheram-Borus, & Guan, 2006). Also, it negatively affects the quality of care given PLWHA and results in negative perceptions and

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treatment by their families and communities (Gerbert Sumser, & Maguire, 1991; Herek & Glunt, 1988; Kalichman & Simbaye, 2003). Despite the fact that the general adult prevalence for HIV has dropped by over 60% in 10 years, from 3.6% in 2003 to 1.37% in 2012 and new HIV infections have dropped from 26,000 per annum to fewer than 8000 in 2012 (El-Adas, 2013), it is important to note that these prevalence estimations represent a substantial proportion of the entire population of 24,658,823 Ghanaians (Ghana Statistical Service, 2013). Therefore, issues regarding access by PLWHA and use of health care facilities cannot be over looked. Persons living with HIV and AIDS may find it difficult to access health services due to stigmatization and discrimination. While HIV-related stigma and discrimination are major barriers, other barriers include cultural and religious values, understanding of the HIV (Churcher, 2013), denial, poor services, lack of money, dislike of health facility, and lack of confidentiality (Otieno et al., 2010). Given that in addition to medical problems, PLWHA also face social problems associated with the disease (Mbonu et al., 2009), previous studies in Ghana (e.g., Amo-Adjei & Darteh, 2013; Oduro & Otsin, 2013; Boateng, Kwapong, & Agyei-Baffour, 2013) have focused on prejudice and discrimination toward PLWHA. This study goes beyond extant research to investigate how PLWHA experience stigma and discrimination and how these influence access to health services. Many PLWHA do not patronize health services because people who deny or show negative feelings toward them may openly or secretly discriminate against them in different settings, including health care centers (Collymore, 2002; Letamo, 2005). While many prevention and care programs aim at reducing damaging attitudes, virtually none has a reliable way of measuring the harmful effects of stigma and discrimination (UNAIDS, 2003). It is therefore crucial to focus on PLWHA and explore their experiences of stigma and discrimination. The specific objectives of this article are to (a) explore PLWHA’s experiences of stigmatization and discrimination and (b) identify stigmatizing and discriminatory factors that serve as barriers to accessing health care facilities by PLWHA. Such information would assist health care professionals, social workers, and other professionals employed in HIV and AIDS service organizations to better understand stigma and discrimination. The information would also be useful for designing appropriate interventions to reduce stigma and discrimination while taking into consideration the setting, as stigma and discrimination are usually context-specific and should as such be carefully considered.

THEORETICAL BACKGROUND This study draws on Earnshaw and Chaudoir’s (2009) HIV stigma framework, which explains how the existence of HIV as a highly stigmatized attribute is

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manifested in individuals as stigma mechanisms that can impact outcomes. The framework is based on Goffman’s (1963) notion of spoiled identity and therefore proposes that HIV has a stigma or attribute that is socially devalued. According to the framework, stigma mechanisms are manifested in three main ways among HIV uninfected individuals and these are prejudice, stereotyping, and discrimination toward PLWHA. Prejudice is the negative emotions and feelings such as disgust, anger, and fear that HIV-uninfected people feel toward PLWHA (Allport, 1979; Brewer, 2007; Earnshaw & Chaudoir, 2009), stereotypes are group-based beliefs often applied to specific PLWHA (Earnshaw & Chaudoir, 2009; Kanahra, 2006), and discrimination is the behavioral expressions of prejudice by HIV-uninfected people directed at PLWHA (Allport, 1979; Earnshaw & Chaudoir, 2009). The framework further emphasizes that stigma impacts PLWHA because they possess a relative position of subordination based on the knowledge that their HIV status is a socially devalued attribute of the self and therefore may be subject to negative treatment by people, especially HIV-uninfected individuals. This knowledge is experienced through at least three essential stigma mechanisms and these are enacted stigma, anticipated stigma, and internalized stigma. Enacted stigma is the extent to which PLWHA believe they have actually experienced prejudice and discrimination from others in their community (Earnshaw & Chaudoir, 2009; Scambler & Hopkins, 1986). Anticipated stigma is related to the extent to which PLWHA expect that they will experience prejudice and discrimination from others in the future (Earnshaw & Chaudoir, 2009; Markowitz, 1998). Internalized stigma is the extent to which PLWHA endorse the negative beliefs and feelings associated with HIV and AIDS about themselves (Earnshaw & Chaudoir, 2009; Link, 1987). The stigma mechanisms are differentially related to psychological, behavioral, and health outcomes of PLWHA and these are usually harmful. While PLWHA who experience a high degree of enacted stigma may experience psychological distress and lowered well-being (Aggleton & Parker, 2002; Earnshaw & Chaudoir, 2009), persons who experience a high degree of anticipated stigma, such as PLWHA are less likely to disclose their HIV status due to fear of social rejection (Derlega, Winstead, Geene, Serovich, & Elwood, 2004; Earnshaw & Chaudoir, 2009). Moreover, PLWHA who experience a high degree of internalized stigma may suffer poor psychological wellbeing (Earnshaw & Chaudoir, 2009; Mak, Poon, Pun, & Cheung, 2007).

METHODS Study Design Due to the sensitivity of the research topic, a qualitative research design was deemed appropriate for this study. This research approach made it possible to obtain information about the values, opinions, behaviors, and social

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contexts of persons living with HIV and AIDS. The study participants were given the opportunity to share their experiences regarding stigmatization and discrimination and how it impacted their access to health services. Without situating them within the subjective experiences of the individual and the group (Hasdeu, 2009), it would be difficult to understand issues related to stigmatization, discrimination, and access to services.

Participants and Study Area The research sample included persons from the various regions in Ghana who were 18 years and above and had been diagnosed of HIV and living with the disease. A total of 42 (37 females and 5 males) living with HIV and AIDS were purposively selected. The researchers initially contacted the leader of the PLWHA support group and sought permission to visit the group. The researchers were subsequently invited by the leader to visit the group during their regular meetings. Following an information sharing session, the researchers paid visits to the support group during their meetings to build rapport. PLWHA who were attending regular meetings of the support group and were willing to participate in the study at the time of the researchers’ visits provided their contact details. Appointments were then scheduled for the focus group discussions (FGDs) and in-depth interviews (IDIs) at times convenient for participants. All participants chose the support group meeting days as suitable for the IDIs and FGDs. This selection procedure was appropriate because PLWHA are hard to reach or a hidden population. Locating PLWHA is complicated since it is difficult identifying and approaching individuals for interview (Awusabo-Asare, 1995). The support group meets in a peri-urban community in Accra, the capital city of Ghana. The group was made up of individuals from different administrative Regions in Ghana. Although the support group is located in Accra, it attracts members from other regions. This allowed the involvement of participants not only from the Greater Accra Region but also Eastern, Central, Brong-Ahafo, Upper East, and Northern Regions. All PLWHA included in this study accessed HIV-related services at the Fevers Unit of the Korle-Bu Teaching Hospital (KBTH), the largest hospital in Ghana. The hospital is located in Accra, the capital city of Ghana and is currently the third largest hospital in Africa and the leading national referral center in Ghana.

Data Collection and Analysis Procedures This study was conducted from July to December 2011. Data were gathered through FGDs and IDIs. The FGDs were used to gather information on collective views and the IDIs were used to collect individual information. Due to the sensitive nature of the topic, the IDIs provided opportunities for

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participants who preferred and were available to speak privately with the researchers. The use of these multiple data collection methods enhanced the credibility of the data gathered. Ethical approval for the study was sought from the Institutional Review Board at the Noguchi Memorial Institute for Medical Research, University of Ghana. During data collection, the purpose of the study was explained to all participants, and they were informed of their right to withdraw their participation at any point in time during the study. Participation in the study was voluntary and participants were assured confidentiality regarding the information they provided. Verbal consent was sought from each participant and this was followed by written informed consent. Participants were also asked to complete a short demographic questionnaire prior to commencement of the IDIs and FGDs. The IDIs and FGDs were conducted in Twi (the dominant Ghanaian local language) and English when necessary. Each IDI lasted approximately 40 minutes and each FGD lasted about two hours. With participants’ permission, both the IDI’s and FGDs were audio-taped. The FGDs included both males and females and were jointly led by a facilitator and co-facilitator who proceeded according to a set of open-ended guiding questions based on the objectives of the study. The use of two facilitators for each FGD allowed for tracking and managing group dynamics, such as turn taking, engaging and managing quiet and dominant participants, respectively (Gibson & Mykitiuk, 2012). The open-ended questions allowed participants to express themselves freely and in the process enabled the researchers and participants to discuss emerging issues in much detail. Additionally, the data collection method permitted the researchers to probe participants’ responses for elaboration and to explore key issues raised by participants, which were useful for the study. Furthermore, research assistants did note-taking during the interviews and focus group discussions. This was useful in elaborating on some of the key issues discussed. Subsequent to the data collection, the audio tape was replayed several times for the purpose of transcribing the data verbatim. The data was coded in order to conceal the identities of participants and was stored in a secure location. Transcriptions were augmented with the researchers’ field notes made during data collection. The data resulting from the transcriptions were evaluated, coded and analyzed thematically. All three researchers independently extracted and coded broad themes from the text. Themes coded considered statements of meaning that were present in most of the data. In an attempt to ensure the credibility of the results, sets of codes and themes individually developed by the researchers were discussed and consensus reached. Emerging themes and categories were used to address the objectives of this study.

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FINDINGS Demographic Characteristics of Study Participants Included in this study were 37 females and five males who had been diagnosed with HIV and had been living with the disease for periods between five months and 10 years at the time of the study. The fact that majority of participants are females is not surprising because generally, more women access HIV testing services than men. The Ghana Country AIDS Progress Report for January 2010 to December 2011 indicates that in 2011, out of the 1,151,034 individuals who were counseled and tested, 77% were females and 23% were males (Ghana AIDS Commission, 2012). For this study, the ages of the participants ranged between 22 and 71 years with majority of them between 30–50 years. In terms of educational background, the highest level attained by the participants was the Senior High School. Nineteen participants were without jobs while 22 had jobs. The most commonly held occupations at the time of interview were farming, trading, masonry, dressmaking, and hairdressing. For the participants who had no jobs, major reasons provided were physical inability, loss of job and loss of business capital. With regard to marital status, 16 participants were married and the rest were single, divorced or widowed. Participants resided in different Regions of Ghana and the majority of them had between one to seven children. Although majority of the participants were Christians, they belonged to different denominations and ethnic groups. Ghana has diverse ethnic and religious groups and HIV and AIDS is a disease that could infect anyone irrespective of their ethnic background or religious affiliation. While the participants attended the support group meetings in a periurban community in Accra, none of them resided in that community; they traveled from other locations, some from very far distances (e.g., BrongAhafo, Northern and Upper East Regions, covering a distance of between 250 km and 430 km to Accra). Although there are support groups and hospitals in the various communities, the main reason for the preference of the Accra group to those in their respective communities was the fear of their status being known and consequently being stigmatized and discriminated against by family, neighbors and community members. Moreover, even though the majority of participants were Christians and disclosed that they became very religious and prayed a lot when they became aware of their HIV status, for fear of stigma and discrimination, their status was not disclosed to their pastors or church members.

PLWHA’s Knowledge of Stigma and Discrimination Once a person is diagnosed with HIV, he or she experiences stigma and discrimination in one way or the other, especially if his or her status is disclosed. The participants in this study indicated that they had experienced stigma and

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discrimination in various forms. In terms of enacted stigma, PLWHA believed they had actually experienced prejudice and discrimination as they noted, “our spouses, children or even own mothers stigmatize against us by disowning or sacking us from home” and “even if people are quarrelling with my children, they would be calling them ‘the AIDS family’ and using the disease as basis for insults; this is a major issue that really bothers me.” A participant also said: “ . . . when a family issue is being discussed and you want to contribute, you’re ordered to sit down, think about yourself and your condition, this is stigma and discrimination and it is difficult for me” (Male, FGD). Similarly, another participant made the following statement: . . . even at my church, people say a lot of negative things about people who have HIV and AIDS, they think we go about sleeping with men . . . they think the only way a person can be infected is through sexual contact . . . . I want to continue going to church for God’s protection so I will not disclose my HIV status to any member of my church . . . (Female, IDI)

Also, other participants anticipated they would be stigmatized and discriminated against should they disclose their HIV status. According to the participants: Personally, I don’t inform others of my HIV status because if they hear about it I might lose my tenancy by ejection . . . . I was once going for my health insurance when I heard someone say, “God forbid that I should contract HIV . . . ” I think these experiences are stigmatizing. (Female, IDI) I lie to my family members that I am attending church service when I am going for PLWHA support group meetings. I once discussed issues about HIV and AIDS with my neighbours and I realised they had very weird perceptions about the disease. If people get to know I have HIV, they will avoid any close contact with me . . . they will even stop me from feeding my own child. I want to grow as old as 100 years . . . if I die one day and people get to know I died of HIV or AIDS, I don’t care because by then I would be gone from this world. (Female, FGD)

Apart from being stigmatized and discriminated against by HIV uninfected people, it was revealed that there were instances that PLWHA endorsed the negative beliefs and feelings associated with HIV and AIDS about them, as recounted by some participants: . . . even if I sell water, nobody will buy from me, yet people with sicknesses like tuberculosis are engaged in trading and people generally accept them and buy from them. To me, there is a lot of stigma attached

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to HIV and AIDS . . . honestly, but for the doctors and nurses at Korle-Bu Hospital, I would have been dead . . . (Female, FGD) My only worry now is that I cannot propose to a lady I love from my very heart. I don’t have a girlfriend now. I know if I conceal my status and I go ahead to have a girlfriend she will abandon me and marry someone else if she later gets to know . . . . I will not disclose my status to the lady at the initial stage because she will refuse to marry me . . . I will only tell her later. (Male, IDI)

The above statements suggest that PLWHA had knowledge about stigma and discrimination, which was manifested in diverse ways. Experiencing stigma and discrimination could be very challenging to the extent that some PLWHA may contemplate suicide as evidenced in the following remarks: . . . I considered suicide because of the shame associated with the disease. I felt I had lost respect from my friends and family . . . . I felt like killing myself since I couldn’t stand the shame and embarrassment. (Female, IDI) I really felt the urge to commit suicide, but because I was very weak, I could barely do anything without support. Though I feel better now the urge to commit suicide is still there, it comes and goes. (Male, FGD) It is very scary and stressful to keep this disease to myself . . . always making sure it is a secret is difficult and sometimes I feel like life should come to an end. (Female, FGD)

Stigmatization and Discrimination at the Fevers Unit, KBTH Beyond family, friends and neighbors, PLWHA are likely to be stigmatized and discriminated against by other persons, such as hospital staff. In this study, stigmatizing and discriminatory factors that served as barriers to accessing health care facilities by participants were explored. During the FGDs and IDIs, some participants noted: Discrimination and stigma exist but because the personnel at the Fevers Unit have been trained, they treat us very nicely . . . . I do not have any problems or concerns when I go there for medication and treatment. (Male, IDI) We feel comfortable with the staff at the Fevers Unit at the Korle-Bu hospital because they provide us with good services that make us happy. They make us feel human, do not discriminate against us or say things that would hurt us, this really makes us feel comfortable. (Female, FGD)

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. . . been in this group for 9yrs; sometime ago, the attitude of the nurses was very bad, they behaved as if they could contract the disease by touching us. We complained about it at our meetings, so they selected the elite among us, trained them and they were put at the front desk to attend to us. When they brought in our own people, things changed for the better, they have been respectful when dealing with us and we are happy. (Male, FGD) For me, no one stigmatizes or discriminates against me when I go to Korle-Bu. The workers are respectful and friendly . . . because I travel from outside Accra, I usually call them when I’m setting off from home so by the time I get to the hospital, my folder would be ready for me to see the doctor. (Female, IDI) . . . the staff at Korle-Bu do not stigmatize or discriminate against us, they always draw close to us because they said they would not be infected with the HIV by touching us . . . they do not reject us, they always make us happy; the doctors really have time for us because when we go to them they pamper us, they chat with us to find out our health condition, diet, etc., their style of conversation makes us very happy . . . (Female, FGD)

Evidently, the responses reveal that PLWHA included in this study were not stigmatized or discriminated against at the Fevers Unit of the KBTH. The major reason provided by the participants was that the health care personnel were trained on the adverse effects of stigma and discrimination on PLWHA. This notwithstanding, it was found that participants had concerns about the color and size of their hospital folders, as well as the days assigned to PLWHA for hospital attendance. Participants felt these served as identifiers, which could result in stigmatization and discrimination and therefore remarked: I personally did not know at first that patients with particular folders had HIV and AIDS infection, but many people now know that our folders are larger than that of other patients . . . . I was also informed that HIV and AIDS patients are those who visit the hospital on Wednesdays . . . the doctors have to change our folders and the day we visit the hospital since these create a lot of stigma and discrimination . . . (Female, FGD) The green paper in the folder and the big size of the folder make people easily detect that we have HIV . . . why should our folders be different from other people who visit the hospital? Maybe people who work in the hospital do not see anything wrong with it, but for us, it is an issue because sometimes we take the folder to the pharmacy for our medicine and don’t get things easy there, so our folders must be change . . . (Male, IDI)

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Stigmatization, Discrimination, and Access to Health Care Services Outside KBTH In spite of some PLWHA’s statements that they did not experience stigma and discrimination from health care providers at the Fevers Unit of the KBTH, the situation was different when they accessed services at other public health facilities. Participants who believed they were stigmatized and discriminated against disclosed: . . . after having been infected with the disease, I have visited other hospitals aside “Efikesemu” (this literally means big house, which refers to the Fevers Unit). It was very difficult to disclose my status to the medical staff . . . in one particular clinic as soon as I disclosed my HIV status, the nurse asked me to wait for a while . . . . I was there for a very long time . . . . I was the last patient to be attended to although I went there very early before the other patients, I felt very sad . . . (Female, IDI) When I was sick and visited a clinic it was very hard to disclose my HIV status to the doctor because it was my regular hospital before I became infected with HIV and the doctor was nice . . . when I disclosed my status, the doctor looked worried, he stared at me for a while and even found it difficult prescribing medicine for me . . . because of HIV, the doctor felt uncomfortable interacting with me, he was no longer nice to me. (Male, IDI)

Although, they had not yet been stigmatized and discriminated against by medical staff at other hospitals in their communities, some participants were reluctant to attend these hospitals as they recounted: I will not visit any hospital apart from the Fevers Unit because they are already aware of my status. If I visit another hospital and disclose my HIV status, the medical personnel will not treat me well since they do not have exposure to PLWHA and therefore do not understand the disease. They will refer me to the Fevers Unit anyway, so why should I waste my time? (Female, FGD) I do not want to be embarrassed by the medical staff in these hospitals . . . a lady in this support group disclosed to me that she visited a hospital in her community and she had a bad experience because the medical staff were not HIV-trained, they did not treat her well although she was very sick. I do not want to go through the same experience . . . we are all aware that Fevers Unit is overcrowded, but I prefer to go there when I am sick, even if it is just a headache. (Male, FGD)

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DISCUSSION OF FINDINGS The purpose of this study was to explore PLWHA’s experiences of stigma and discrimination in accessing health services. The findings of this research indicate that PLWHA have knowledge of stigma, which support the HIV stigma framework developed by Earnshaw and Chaudoir (2009). The framework suggests that PLWHA knowledge of stigma is experienced through enacted, anticipated, and internalized stigma mechanisms. For the reason that PLWHA experienced stigma and discrimination, they were reluctant to disclose their HIV status to their family members, friends, and even church members. Fear and secrecy associated with HIV infection may not only lead to stigmatization and discrimination against PLWHA, but could create the desire for suicide. This finding corroborates other studies that found relations between HIV stigma and mental strain (Green & Platt, 1997), feelings of self-loathing (Bennett, 1990; Herek, 1999), feelings of shame and guilt (Bennett, 1990; Laryea & Gien, 1993), or revenge (Oduro & Otsin, 2013). As suggested by Earnshaw and Chaudoir (2009), PLWHA who experience a high level of enacted stigma may experience psychological distress and lowered health. It is rather unfortunate that PLWHA included in this study were stigmatized and discriminated against by close family members because in many African countries like Ghana, the family is looked upon as a safe haven for family members, especially in times of ill-health. In the Ghanaian culture, the health of an individual is connected to the health of the corporate clan and therefore the responsibility of the kin group is to ensure that a family member suffering from a life-threatening disease is healed (Awusabo-Asare, 1995). However, PLWHA are often stigmatized because their illness is stained by religious beliefs regarding immorality and morally unsanctioned behaviors that symbolize a character blemish (Alonzo & Reynolds, 1995; Letamo, 2004). Compounding the issue is that stigmatizing views and discriminatory practices are rooted in superstition and supernatural beliefs, which are part of Ghanaian culture. Such behaviors and attitudes toward PLWHA are not surprising for the reason that some Ghanaians do not have much knowledge about the modes of HIV transmission (Boateng et al., 2013). Evidence also showed that PLWHA were hesitant in accessing services from health facilities outside the Fevers Unit due to stigma and discrimination. The fact that health personnel exhibited stigmatizing and discriminatory attitudes and behaviors toward PLWHA is worrying and this confirms findings from previous studies on HIV- and AIDS-related stigma and discrimination among health care providers. Reis et al. (2005) reported that discriminatory behaviors and attitudes toward PLWHA existed among a significant proportion of health care professionals in Nigeria. Similarly, Ullah (2011) found that 80% of the nurses and 90% of the physicians’ behavior toward HIV-positive individuals were discriminatory. Interestingly, Ullah (2011) also found that when talking to the patients, the health personnel stood far from

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them. As opined by Letamo (2005), usually health care personnel who have negative feelings toward persons with HIV may discriminate against them either overtly or covertly. The distinctive contribution of this study to the plethora of studies on health care providers’ behavior and attitudes toward PLWHA is the finding that participants were comfortable accessing services at the Fevers Unit of KBTH. The fact that participants did not experience stigma and discrimination at the Fevers Unit is noteworthy. This could enhance the quality of care provided them and consequently their compliance with treatment and their wellbeing. A vital element that influences the quality of life of all PLWHA is stigma (Emlet, 2005) because it could negatively impact on their health, working and family life, as well as their access to health services (dos Santos, Kruger, Mellors, Wolvaardt, & van der Ryst, 2014). Although, participants indicated that they were comfortable accessing services at the Fevers Unit, stigma and discrimination from family and friends could act as constraints on PLWHA to access HIV-related services. Additionally, participants had concerns about the color of folders and days assigned to PLWHA at the Fevers Unit. These are structural conditions that could lead to unintentional disclosure and discrimination (Emlet, 2008). Besides, the fact that many PLWHA access services at the Fevers Unit could lead to overcrowding and occasional shortages of HIV-related medications, which discourage PLWHA from accessing services at the facility. In Ghana, where there are gaps in health care provision between urban and rural settings, it is not surprising some participants traveled long distances to the Fevers Unit that is likely to be better equipped with clinical materials, drugs, and trained personnel. It is important to emphasize that the ability to provide services to PLWHA depend largely on institutional support in the form of availability of clinical materials like gloves, as well as policies and training on stigma and discrimination (Amosu, Degun, Makinde, Thomas, & Babalola, 2011; Reis et al., 2005). Institutional support received by health care providers reduces stigmatizing and discriminatory acts exhibited toward PLWHA (Feyissa, Abebe, Girma, & Woldie, 2012; Li et al., 2007).

CONCLUSIONS AND IMPLICATIONS Undoubtedly, the findings of this study revealed PLWHA’s understanding and personal experiences of stigma and discrimination. In view of the fact that HIV-related services have been decentralized in Ghana, participants were comfortable accessing these services at the Fevers Unit at the Korle-Bu Teaching Hospital. They appreciated the good interactions between them and health care providers who work at the Fevers Unit and attributed this to the fact that these health care providers had received training on how to manage PLWHA. This draws attention to the good work being done by the

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staff at the hospital and therefore should be given recognition, as well as commendation. Since stigma and discrimination are usually context-specific, it is suggested that other health care personnel outside the KBTH should be trained on the rights, as well as the negative effects of stigma and discrimination on the health and wellbeing of PLWHA. This would enable them feel comfortable providing professional health care for PLWHA and would also encourage persons living with the disease to patronize their community health facilities to complement the efforts of health care personnel at the KBTH. Additionally, given that stigma and discrimination by close associates can affect patients’ willingness to access health services, specific attention should be paid to issues related to stigma and discrimination, particularly among family members, friends of PLWHA, as well as health care professionals within the decentralized health care system. In order to eradicate HIV stigma and discrimination, social workers and public health professionals employed in HIV and AIDS service organizations, hospitals, medical clinics, and other organizations should consider both individual patient-related and structural processes when designing effective antistigma interventions. Specifically, campaigns aimed at educating people on the misconceptions associated with the modes of HIV transmission should be stepped up. Likewise, a better understanding of the psychosocial adjustment of infected and affected persons may help social workers adopt appropriate counseling approaches that would reduce HIV- and AIDSrelated stigma and discrimination and consequently enhance the wellbeing of PLWHA and their families. Moreover, the identification of the various forms of stigmatizing and discriminatory attitudes toward PLWHA should inform policy questions relating to issues of human rights and social justice. If these issues are properly addressed, a receptive environment would be created for people living with the disease, especially in terms of access to and use of health care and other facilities in Ghana. This is crucial because social workers’ ability to intervene and advocate for the rights of highly vulnerable populations like PLWHA would depend mainly on public concerns and opinions as well as policy discourses.

REFERENCES Aggleton, P., & Parker, R.A. (2002). Conceptual Framework and Basis for Action: HIV/AIDS Stigma and Discrimination. Geneva, Switzerland: Joint United Nations Programme on HIV/AIDS. Alonzo, A., & Reynolds, N. (1995). Stigma, HIV and AIDS: An exploration and elaboration of a stigma trajectory. Social Science and Medicine, 41(3), 303–315. Allport, G.W. (1979). The Nature of Prejudice. Cambridge, MA: Perseus Books.

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