IJTID Vol 8 No 2 May-Agustus 2020_NEWfromSARAH.indd Vol. 8 No. 2 May–August 2020 Copyright © 2020, IJTID, p-ISSN 2085-1103, e-ISSN 2356-0991 Available online at IJTID Website: https://e-journal.unair.ac.id/IJTID/ Research Article Lower Perceived-Stigmatization by Health Workers Among HIV-AIDS Patients of Key Population Backgrounds Jihan Qonitatillah1, Samsriyaningsih Handayani2a, Ernawati3, Musofa Rusli4 1Faculty of Medicine, Universitas Airlangga, Surabaya, East Java, Indonesia 2Department of Public Health and Preventive Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya, East Java, Indonesia 3Department Obstetrics and Gynecology, Faculty of Medicine, Dr. Soetomo Hospital, Surabaya, East Java, Indonesia 4Department of Internal Medicine, Division of Infectious and Tropical Disease, Dr. Soetomo Hospital, Surabaya, East Java, Indonesia Received: 22nd January 2019; Revised: 29th October 2019; Accepted: 25th February 2020 ABSTRACT The stigma of people living with HIV-AIDS (PLWHA) by health workers may have a broad impact, so it is necessary to identify the factors that infl uence the occurrence of stigma. Identifi cation of factors that cause a decrease in stigmatization by health workers will have an impact on improving the quality of life of people with HIV, increasing compliance with medication, and ultimately reducing the incidence of HIV infection itself. The purpose of this study was to analyze factors related to PLWHA’s perception of stigma among health workers in the community health center. This research applied a cross-sectional design using interviews. Ninety-four patients from the Infectious Disease Intermediate Care of Dr. Soetomo Hospital Surabaya, a tertiary level hospital, were interviewed. The stigma perception was assessed using a questionnaire modifi ed from the Standardized Brief Questionnaire by Health Policy Project with Cronbach’s Alpha of 0.786. The data were simultaneously analyzed with binary multiple regressions on IBM SPSS Statistics 22.0 for Windows software. There were 30 out of 94 patients with key population backgrounds, and most population was injecting drug users (IDUs) and female sex workers (FSWs). PLWHA perceived most stigmatized community health workers when they drew blood, provided care, and considered they were involved in irresponsible behavior. There were relationships between age (p=0.008), marital status (p=0.013), and the history of key population (p=0.006)to people living with HIV-AIDS (PLWHA)’s perception of stigma among health workers in East Java community health center. Future research on factors infl uencing HIV-related stigma is needed to improve patients’ quality of life. Keywords: Health workers, HIV-AIDS, key population, stigma ABSTRAK Stigma terhadap orang dengan HIV-AIDS (ODHA) oleh tenaga kesehatan dapat berdampak luas, maka perlu dilakukan identifi kasi faktor-faktor yang memengaruhi terjadinya stigma. Identifi kasi faktor-faktor yang menyebabkan penurunan stigmatisasi oleh tenaga kesehatan akan berdampak terhadap peningkatan quality of life orang dengan HIV, meningkatnya kepatuhan minum obat, dan akhirnya akan mengurangi angka kejadian infeksi HIV itu sendiri. Tujuan dari penelitian ini yaitu untuk menganalisis faktor-faktor yang berhubungan terhadap persepsi orang dengan HIV-AIDS (ODHA) atas stigma oleh tenaga kesehatan puskesmas. Penelitian ini menggunakan rancangan penelitian cross-sectional dengan metode wawancara. Sembilan puluh empat pasien dari Poli Rawat Jalan Instalasi PIPI RSUD Dr. Soetomo, yang merupakan rumah sakit tersier diwawancarai. Persepsi stigma pasien dinilai menggunakan kuesioner standar oleh Health Policy Project dengan nilai Cronbachs Alpha 0,786. Data dianalisis dengan uji regresi logistic berganda dengan perangkat lunak IBM SPSS Statistics 22.0 for Windows. Didapatkan 30 dari 94 pasien yang memiliki riwayat kelompok risiko, dengan kelompok risiko terbanyak adalah Penasun dan WPS. Gambaran stigmatisasi oleh tenaga kesehatan terhadap ODHA yaitu khawatir ketika mengambil darah, a Corresponding author: samsri.handayani@gmail.com 91Jihan Qonitatillah, et al.: Lower Perceived-Stigmatization by Health Workers Copyright © 2020, IJTID, p-ISSN 2085-1103, e-ISSN 2356-0991 memberikan perawatan berkualitas rendah, dan menganggap seseorang terinfeksi HIV karena mereka terlibat perilaku yang tidak bertanggung jawab. Terdapat hubungan antara usia (p=0,008), status perkawinan (p=0,013), dan ODHA beriwayat kelompok risiko (p=0,006) dengan persepsi ODHA atas stigma oleh tenaga kesehatan puskesmas. Usia yang muda, menikah, dan memiliki riwayat kelopok risiko merupakan faktor-faktor yang signifi kan terhadap rendahnya persepsi ODHA atas stigma oleh tenaga kesehatan puskesmas Jawa Timur. Penelitian terkait faktor-faktor yang berhubungan dengan stigma HIV dibutuhkan untuk meningkatkan kualitas hidup ODHA. Kata kunci: Tenaga kesehatan, HIV-AIDS, kelompok risiko, stigma How to Cite: Qonitatillah, Jihan. Handayani, Samsriyaningsih. Ernawati, Ernawati. Rusli, Musofa. Lower Perceived- Stigmatization by Health Workers Among HIV-AIDS Patients of Key Population Backgrounds. Indonesian Journal of Tropical and Infectious Disease, 8(2), 1–8 INTRODUCTION The stigma against PLWHA, which arises from the mind of an individual or society who believes that AIDS is a result of immoral behavior that cannot be accepted by society, is refl ected in cynical attitudes, feelings of excessive fear, and negative experiences to PLWHA1. Stigma and discrimination are not only carried out by commoners who do not have enough knowledge about HIV and AIDS but can also be carried out by health workers2. The opinion that states AIDS is a curse because of immoral behavior also greatly aff ects how people comport themselves and behave towards PLWHA3. In 2014, UNAIDS established a program in accordance with Millennial Developmental Goals (MDGs) namely 3 Zeros, which includes Zero new infections, Zero AIDS-related deaths, and Zero stigma and discrimination4. This program is a human- centered HIV prevention and treatment service to end the AIDS epidemic by 20305. However, this has not been in contrary to the reality in the fi eld. Research by Stringer involving 651 health workers found that almost 90% of health workers gave at least one stigma to PLWHA. 18.9% of health workers agreed that PLWHA had a large number of sexual partners, 33.3% agreed that PLWHA could avoid HIV infection if they wanted to, and 35.3% thought that suff erers could become infected with HIV due to irresponsible sexual behavior6. Research in Indonesia in 2014 also found stigma by health workers, including landfi lls that are diff erentiated and labeled HIV, feeding under the door, not changing patient’s bedsheets, excessive use of protective equipment, isolation, and taking action without informed consent7. Stigma by health workers towards people with HIV certainly still has a strong impact. Eventually, this will impact how others perceive a person, social rejection, decreased acceptance of social interaction, increased discrimination, and adding family burden8. The impact of this stigma is not good and can be fatal for HIV patients, as mentioned in the study conducted by Ardani9. Drug-addict-PLWHA who feel stigmatized will reduce the possibility of seeking treatment, for those who have undergone treatment may choose to end the treatment. Furthermore, stigma aff ects the lives of PLWHA by causing depression and anxiety, sadness, guilt, and feelings of worthlessness. Besides, stigma can reduce the quality of life and limit access and use of health services9. Labeling and discrimination against people living with HIV-AIDS are the foremost eff ective barriers in preventing HIV and also in providing drugs, care, and support10. Because of the stigma of people with HIV can have a wide-ranging impact, it is necessary to identify the factors that infl uence stigma to PLWHA by health workers. Identification of factors that cause a decrease in stigmatization by primary health center workers will have an impact on improving the quality of life of people with HIV, improving medication adherence, so the incidence rate of HIV itself will be reduced. Therefore, this study was aimed to identify the correlating factors between PLWHA and stigmatization by community health center’s workers using subjects of people with HIV 92 Copyright © 2020, IJTID, p-ISSN 2085-1103, e-ISSN 2356-0991 Indonesian Journal of Tropical and Infectious Disease, Vol. 8 No. 2 May–August 2020: 90–100 in the Outpatient Care Clinic of Intermediate and Infectious Disease Care Unit (Perawatan Intermediet Penyakit Infeksi - PIPI) Dr. Soetomo Hospital Surabaya. It is hoped that the results of this study can provide input to policymakers to initiate a stigma reduction program for people with HIV that can be started from PLWHA who has the highest stigma, to make it easier for PLWHA to disclose their status and treatment. Also, it is hoped that the prevention of HIV transmission to the community will be more controlled and help improve the quality of life with HIV-AIDS (PLWHA). MATERIALS AND METHODS This study used an observational analytic study with cross-sectional study design. The sample of this study was 94 HIV positive patients in the Outpatient Care Clinic of Intermediate and Infectious Disease Care Unit Dr. Soetomo Hospital Surabaya from October to December 2018 who were referral patients from a community health center or had received health services at a community health center in East Java after being diagnosed with HIV. The sampling technique used was consecutive. Respondents were interviewed using a modifi ed questionnaire by the Health Policy Project available at www.stigmaindex. com, which has been tested for reliability and validity with a Cronbach’s Alpha coeffi cient of 0.786. The Standardized Brief Questionnaire by the Health Policy Project was developed and verifi ed through a calculated collaborative process that involved experts from various countries. There are four areas which are pertinent to stigma and discrimination in health care environment that the experts are complied to focus on: 1) fear of HIV infection among health facility staff ; 2) stereotypes and prejudice related to people living with or thought to be living with HIV; 3) observed and secondary stigma and discrimination; and 4) policy and work environment11. In the questionnaire by the Health Policy Project, the health workers’ point of view is used as the object. What is new in this study is using the perspective of people living with HIV-AIDS. The questionnaire was about socio-demographic data and HIV-related questions that illustrate the understanding, awareness, and experience of attitudes by health center workers towards PLWHA. This questionnaire was divided into four sections. The fi rst section was background information containing questions about sex, age, marital status, duration of HIV diagnosis, the origin of residence, occupation, and history of key population. The second section, infection control, contained questions about the stigma that has been experienced related to HIV infection control at the time of examination. The third section, Health Facilities’ Environment, contained questions related to stigma in the health facility environment. The fourth section, Opinion about People Living with HIV, contained statements related to the opinion of health workers towards people living with HIV-AIDS. The choice of answers to each question was how often the stigma occurred so that it would describe which stigma is most often obtained. RESULTS AND DISCUSSION Sociodemographic Characteristics The sample in this study was varies based on the gender, age, marital status, occupation, duration of patient diagnosed with HIV, HIV control/check-up, residence, and history of key population as described in Table 1. Patients from Surabaya were grouped according to the sub-district of residence. The distribution of patients from Surabaya is shown in Table 2. The number of females infected with HIV-AIDS was higher than males, in contrast to data released by the Ministry of Health in 2017. The higher number of infected females is because females are vulnerable to HIV due to biological factors, reduced sexual autonomy, and it is explained that women want to prevent HIV but do not have enough strength to against12. Prospective studies of serodiscordant couples and male contact with FSW show that women are twice as likely to be infected if exposed to HIV13. The age classifi cation in Table 1 is based on the Indonesian Ministry of Health in the annual HIV-AIDS disease progress 93Jihan Qonitatillah, et al.: Lower Perceived-Stigmatization by Health Workers Copyright © 2020, IJTID, p-ISSN 2085-1103, e-ISSN 2356-0991 report, which used the same age classifi cation so that the comparison of results is appropriate. The age of most PLWHA obtained from this study was 25-49 years because it is the age of sexually active. The same data is issued by the Indonesian Ministry of Health in the Report on the Development of HIV-AIDS & Sexually Transmitted Infectious Diseases for the First Quarter 2017, that is 69.6% is the 25-49 years age group, 17.6% is the 20-24 years age group and 6.7% is the age group of >50 years14. Most marital status was marriage, which could be a clue that sexual contact was the most cause. The longest HIV diagnosis was one year or less, which could be understood because Dr. Soetomo Hospital Surabaya is a third-level health facility that accepts referral cases and cannot be resolved at a fi rst or second level health facility. ARVs were taken at the Dr. Soetomo so that many new patients immediately went to the Dr. Soetomo Hospital Surabaya to get treatment. The most times of having HIV control to health services was once in a month at Dr. Soetomo Hospital Surabaya due to the rules of taking antiretroviral drugs. Table 1. Sociodemographic Characteristics Sociodemographic Characteristics Frequency Percentage (%) Gender Male 45 47.9 Female 49 52.1 Age 20-24 years old 2 2.1 25-49 years old 84 89.3 >50 years old 8 8.6 Marital Status Married 58 61.7 Single 23 24.5 Widowed 13 13.8 Occupation Housewife 25 26.6 Female Sex Worker 45 47.9 Health Worker 1 1.1 Others 23 24.6 Duration of patient diagnosed with HIV 1 year 26 27.7 2 years 7 7.4 3 years 17 18.1 4 years 9 9.6 5 years 8 8.5 6 years 8 8.5 7 years 4 4.3 8 years 2 2.1 9 years 3 3.2 >10 years 10 10.7 HIV Control/Check-up Twice or more in a month 11 11.7 Once in a month 79 84 Once in three months 2 2.1 Once in 4-6 months 2 2.1 Residence Blitar 2 2.1 Bondowoso 1 1.1 Gresik 3 3.2 Jombang 1 1.1 Mojokerto 1 1.1 Ngawi 1 1.1 Pasuruan 3 3.2 Sidoarjo 9 9.6 Sumenep 2 2.1 Surabaya 71 74.3 Trenggalek 1 1.1 History of Key Population Yes 30 33.9 No 64 68.1 Table 2. Distributions of patients from Surabaya Sub-districts Frequency Percentage (%) Benowo 2 2.9 Bubutan 1 1.4 Genteng 1 1.4 Gubeng 6 8.6 Karang Pilang 1 1.4 Kenjeran 1 1.4 Krembangan 7 10 Mulyorejo 3 4.3 Pabean Cantian 2 2.9 Rungkut 2 2.9 Sawahan 10 14.3 Semampir 2 2.9 Sukolilo 3 4.3 Sukomanunggal 1 1.4 Simokerto 1 1.4 Tambaksari 12 17.1 Tegalsari 7 10 Wiyung 3 4.3 Wonocolo 1 1.4 Wonokromo 4 5.7 94 Copyright © 2020, IJTID, p-ISSN 2085-1103, e-ISSN 2356-0991 Indonesian Journal of Tropical and Infectious Disease, Vol. 8 No. 2 May–August 2020: 90–100 Most patients lived in Surabaya, precisely in Tambaksari District. This can be understood because it is located near to Dr. Soetomo Hospital Surabaya, which is about 2 km measured using the Google Maps application. There are four community health centers in this district, namely Pacarkeling Health Center, TambakRejo Health Center, Rangkah Health Center, and Gading Health Center. The second most was from Sawahan District. This is consistent with data from the Ministry of Health of the Republic of Indonesia, which is as many as 139 patients tested positive for HIV in the fi rst quarter of 2017, the most after Health Center of Putat Jaya Surabaya14. The number of patients who did not have a history of key population was greater than those who had a history of key population, which is as much as 68.1%. The Distribution of Key Population Background of People Living with HIV-AIDS (PLWHA) History of key population was obtained through interviewing the patients using questionnaires. The data obtained is displayed in Table 3. The results have been obtained that patients with the most history of key population are injected-type drug users (IDUs) and prostitute (FSW) as many as nine people. The same data issued by the Ministry of Health of the Republic of Indonesia shows the data of IDU has the highest prevalence of 41% compared to other key populations15. HIV prevalence in the IDU group is high because they inject drugs more than once a day and more than 60% of them using needles that are not sterilized. While risky sexual behavior that causes HIV prevalence among FSWs remains high, because of unprotected sex. MSM groups of 7 people followed this. It was reported that condom use in MSM consistently lower than FSW, despite the higher level of HIV prevention knowledge16. D e s c r i p t i o n o f P LW H A’ s P e r c e i v e d Stigmatization by Health Center Workers The description of stigmatization by health workers at the community health center perceived by PLWHA was obtained from interviewing the patients using questionnaires. The data obtained is displayed in Table 4, 5, 6, and 7. In section 2: Infection Control, was divided into two parts. Part 1 was health center workers’ concern when examining people living with HIV- AIDS since part 2 was exclusive protection in treating people living with HIV-AIDS. From 13 questions on the questionnaire that describe stigmatization by health workers at the health center, the stigmatization of health workers was taken which was often obtained from the number of subjects who have been stigmatized, the answers to that are least worried, worried, very worried in section Infection Control. Also, the answer once or twice, several times, and almost every time in section health Facilities’ Environment and Health Workers Opinion about People Living with HIV-AIDS. In section infection Control, the most stigmatization was obtained when health workers were worried when they did blood sampling. A study by Sismulyanto17 conducted at a hospital in Banyuwangi shows that from 96 nurses, as many as 7.5% of the nurses were afraid to take laboratory samples, such as blood and urine. According to Sismulyanto17, this is because they were afraid of contracting HIV when in direct contact with the patient’s blood. In section Health Facility’s Environment, the most stigmatization was obtained when health care workers provide low-quality care to HIV Table 3. Distribution of key population background of PLWHA Category Frequency Percentage (%) Patient with History of Key Population Female Sex Workers (FSW) 9 9.6 Injecting Drug User 9 9.6 FSW sex partner 4 4.3 Men Who Have Sex With Men (MSM) 7 7.4 Transvestite Homosexual 1 1.1 Patient without History of Key Population Housewife 28 29.8 Private Sector Worker 20 21.3 Others 16 17.0 95Jihan Qonitatillah, et al.: Lower Perceived-Stigmatization by Health Workers Copyright © 2020, IJTID, p-ISSN 2085-1103, e-ISSN 2356-0991 patients compared to other patients, including rejecting patients with HIV-AIDS because they consider HIV-AIDS patients are people who have a great risk if direct contact with patients7. A study in Aceh, Indonesia, shows that some doctors treat PLWHA with disrespect, push other patients away from them, and keep them away from care services18. It was also found that most stigmatization was obtained when health workers talk badly about HIV patients. This was due to the high stigma in the community and health workers which causes health workers to stay away from them, so they tended to provide low-quality care. In section Health Workers’ Opinions of People Living with HIV-AIDS, the most stigmatization was obtained when health care workers assume that someone who is infected with HIV because of irresponsible behavior. This was because the community thinks that “bad” behavior is seen from free sex and blames PLWHA as a source of AIDS transmission7. Table 4. Description of PLWHA’s Perceived Stigmatization on Infection Control: Part 1 Form of Stigma Not worried A little worried Worried Very worried Never experienced n % n % N % n % n % Worried when touching the clothes 82 87.2 3 3.2 1 1.1 0 0 8 8.5 Worried when dressing wounds 47 50.0 21 22.3 3 3.2 1 1.1 22 23.4 Worried when drawing blood 66 70.2 19 20.2 7 7.4 0 0 2 2.1 Worried when taking the temperature 81 86.2 7 7.4 1 1.1 0 0 5 5.3 Table 6. Description of PLWHA’s Perceived Stigmatizationon-Health Facilities’ Environment Form of Stigma Never Once or twice Several times Almost every time n % n % n % n % Health workers unwilling to care for you 91 96.8 2 2.1 1 1.1 0 0 Health workers providing poorer quality of care to relative to other patients 87 92.6 4 43 2 2.1 1 1.1 Health workers talking badly about you 87 92.6 6 6.4 1 1.1 0 0 Health workers do not want to do blood sampling 92 97.9 1 1.1 1 1.1 0 0 Health workers treat in a place that is not closed 91 96.8 3 3.2 0 0 0 0 Disclose the status of HIV patients to others without consent 93 98.9 0 0 1 1.1 0 0 Using an HIV-related name when calling you when waiting in sequence number 93 98.9 0 0 1 1.1 0 0 During the examination, health workers call improperly 93 98.9 0 0 0 0 1 1.1 During examinations or other activities at the health center, health workers say that you are HIV patient with a loud tone 93 98.9 0 0 1 1.1 0 0 Table 5. Description of PLWHA’s Perceived Stigmatization on Infection Control: Part 2 Form of Stigma Never Rarely Often Always n % N % n % n % Avoid physical contact 83 88.3 9 9.6 2 2.1 0 0 Wear double gloves 87 92.6 3 3.2 2 2.1 2 2.1 Wear gloves during all treatments 78 83.0 4 4.3 4 4.3 8 8.5 Use any special infection-control that are not used while examining other patients 78 83.0 4 4.3 4 4.3 8 8.5 96 Copyright © 2020, IJTID, p-ISSN 2085-1103, e-ISSN 2356-0991 Indonesian Journal of Tropical and Infectious Disease, Vol. 8 No. 2 May–August 2020: 90–100 Relationship Analysis Relationships between variables were tested using IBM SPSS Statistics 22.0. All data about age, sex, marital status, occupation, place of residence, history of risk groups, and duration of HIV diagnosis were transformed into binomial Table 7. Description of PLWHA’s Perception of health Workers’ Opinions of People Living with HIV-AIDS Form of Stigma Never Once or twice Several times Almost every time Not know n % n % n % n % n % Hearing health workers say most of PLWHA do not care if they infect other people 88 93.6 2 2.1 1 1.1 1 1.1 2 2.1 Hearing health workers say HIV patients should feel ashamed of themselves 88 93.6 4 4.3 0 0 0 0 2 2.1 Hearing health workers say most HIV patients have multiple sexual partners 81 86.2 6 6.4 2 2.1 0 0 5 5.3 Hearing health workers say someone infected with HIV because they engage in irresponsible behavior 78 83.0 12 12.8 1 1.1 0 0 3 3.2 Hearing health workers say HIV is punishment for bad behavior 85 90.4 6 6.4 2 21 0 0 1 1.1 forms for analysis. The statistical test used is the binary logistic multiple regression test. Relationship of stigmatization data by health center’s workers with age, sex, marital status, occupation, residence, history of risk groups, and duration of HIV diagnosis are shown in Table 8 Table 8. Bivariate analysis of stigmatization variables on independent variables Dependent Variables Stigma Signifi cance (Chi-square test)Low Stigma Greater Stigma n % N % Age <37 25 52,1 23 47,9 P = 0.019 >37 13 28,3 33 71,7 Gender Male 14 31,1 13 68,9 P = 0.078 Female 24 49 25 51 Marital status Married 29 50 29 50 P = 0.016 Single 9 25 27 75 Occupation Low risk 36 40 54 60 P = 0.690 High risk 2 50 2 50 Duration of HIV diagnosis >5 years 15 42,9 20 57,1 P = 0.711 < 5 years 23 39 36 61 Residence Surabaya 8 34,8 15 65,2 P = 0.526 Outside of Surabaya 30 42,3 41 57,7 History of key population Do not have any history 32 50 32 50 P = 0.006 Have history 6 20 24 80 97Jihan Qonitatillah, et al.: Lower Perceived-Stigmatization by Health Workers Copyright © 2020, IJTID, p-ISSN 2085-1103, e-ISSN 2356-0991 Table 9. Multivariate logistic regression analysis of stigmatization variables against independent variables Dependent Variables Independent Variables P Exp (B) Signifi cance Stigma perception Age 0.008 0.249 Signifi cant Gender 0.950 1.033 Not signifi cant Marital status 0.013 0.251 Signifi cant Occupation 0.339 3.174 Not signifi cant Duration of HIV diagnosis 0.140 0.444 Not signifi cant Residence 0.092 2.713 Not signifi cant History of key population 0.006 0.180 Signifi cant using the chi-square test and again tested using the binary logistic multiple regressions test in Table 9. The binary logistic multiple regressions test was carried out to eliminate confounding variables, fi nd out which groups received greater stigma, and get an exponential rate of PLWHA perceptions of stigma by health center workers. The history of key population was divided into two groups. Having a history of key population was one of the FSWs, FSW’s sex partners, MSMs, transvestites, and injecting drug users (IDUs). Choices other than FSWs, FSW’s sex partners, MSMs, transvestites, and IDUs were included as do not have a history of key population. The chosen cut-off for the stigma was 24. It was a high stigma if greater or equal to 24, while smaller than 24 was a low stigma. The score of 24 indicates that the respondent answered never or not worried, which is score 1, in all of the 24 questions, which means that the respondent never got any form of stigma from the health center workers. Once or twice, got 2 on the score. Score 3 for worried, often, and several times. If the answer was very worried, always, and almost every time got score 4. The score of each respondent was obtained from the sum of each question. The cut-off for age was the mean of them, which was 37.46 rounded to 37. If greater or equal to 37 years old, it was said to be old age. While it was said to be young if smaller than 37 years old. Jobs were categorized into 2, high and low-risk jobs. High- risk jobs were health workers, doctors, nurses, security, ward attendants, sex workers, and fl ight attendants. Meanwhile, choices other than those mentioned were low-risk jobs. The cut-off chosen residence was Surabaya, where patients from the city of Surabaya were said to live near and outside Surabaya said to be distant. The cut-off time for HIV diagnosis was its mean, which was 4.29. If greater or equal to 4.29 years, it was old patients. While it is new patients if smaller than 4.29 years. Analysis of the relationship between age, sex, marital status, occupation, residence, history of key population, and duration of HIV diagnosis with stigmatization by health workers in East Java community health centers on patients in Outpatient Care Clinic of Intermediate and Infectious Disease Care Unit (Perawatan Intermediet Penyakit Infeksi - PIPI) provided signifi cant results on the variables of age, marital status, and key population history. Whereas sex, occupation, residence, and duration of HIV diagnosis variables provided insignifi cant results. The history of key population had Exp (B) of 0.18, which means PLWHA who have the history of key population get a stigma 0.18 times compared to those without a history of key population. So, it showed a protective factor of stigmatization by health workers. PLWHA who have the history of key population got a lower stigma than PLWHA who did not have. This was because PLWHA who have the history of key population have a psychological mentality that is accustomed to being stigmatized in the community. Pala, Villano, and Clinton19 explained that HIV stigma is not because someone is HIV- positive but also because of other conditions of social stigmatization, such as having same-sex partners with other people, female sex workers, and her partner/s, and Injecting drug users 98 Copyright © 2020, IJTID, p-ISSN 2085-1103, e-ISSN 2356-0991 Indonesian Journal of Tropical and Infectious Disease, Vol. 8 No. 2 May–August 2020: 90–100 (IDUs). Both female sex workers (prostitute) and PLWHA face the same type of stigma, which is seen as “unclean”, a danger to public health, and making decisions that are detrimental to their families and communities. For FSW living with HIV, they get these two stigmas. Sex workers living with HIV are regularly exposed to negative stereotypes about themselves and consider them ‘worthy’ to become HIV positive20. Due to the frequent exposure to negative stereotypes from the community, PLWHA’s psychological state who have a history of key population is more vulnerable to stigma. PLWHA who do not have a history of key population, have a different mentality than PLWHA who have a history of key population because they are not accustomed to experiencing stigma from the community. HIV-AIDS brings an unprecedented problem for that person, regardless of background. A person suff ering from HIV- AIDS experiences severe psychological distress and feels hopeless about the future, including work, family life, health, and self-esteem21. Old age, above 37 years old, gets a higher stigma compared to the age below 37 years old. This is because older adults are at a signifi cant risk of experiencing HIV stigma22. Research has shown that older PLWHA may experience greater stigma due to the double stigma of being HIV positive plus age discrimination, which is usually referred to as layering23. Emlet has stated that layering or co-occurring stigmas of ageism and HIV stigma had been experienced by about 68% of older HIV positive adults in Washington DC. Internalized stigma has a negative impact on the self-esteem and psychological well-being of older adults living with HIV24. PLWHA who were married got lower stigma compared to PLWHA who were not currently married, which was 0.251 times. In this case, the factor of being married is associated with social support. PLWHA who are married has higher social support compared to PLWHA who are single. Research conducted by Emlet explains that social support is associated with lower levels of HIV stigma25. A signifi cant relationship had been proven found between the participation of peer groups and the improvement of the quality of life of PLWHA26,27. Reducing the impact of stigma and perceived behavior of PLWHA can be done by changing individual and community perceptions about HIV-AIDS by using peer support and counseling approaches28. It was also explained that social support aff ects lower levels of depression and anger29. Sex, occupation, residence, and duration of HIV diagnosis variables gave insignifi cant results related to stigmatization by health workers. Some factors that are thought to cause this result include the research method in the form of interviews so that there could be biased information. The cut-off values that do not have standard rules yet in categorizing continuous variables can affect the relationship and interpretations of the research results. Also, it will randomize the research fi ndings30,31. Categorizing variable will make some information loss, so the statistical power to know the relation between variables will be lower32. This is well understood because if the threshold for the defi nition of “exposure” changes, the magnitude of the estimated eff ect such as the odd ratio (OR), will vary too30. CONCLUSIONS Stigma against people living with HIV-AIDS (PLWHA) by health workers is still often found in the community health center in East Java. The stigma could have a wide impact, so it is necessary to identify the factors that infl uence the occurrence of stigma, which is expected to reduce stigmatization by health workers. Factors related to PLWHA’s perception of stigma among health workers found in this research were the history of key population, age, and marital status. PLWHA who have a history of key population, got a lower stigma than PLWHA who do not have because PLWHA who have a history of key population have a psychological mentality that The score to being stigmatized in the community. Old age got higher stigma compared to the young age, because of having the double stigma of being HIV positive and age discrimination. PLWHA who were married, got lower stigma compared to PLWHA who were not currently married because they have higher social support compared to PLWHA 99Jihan Qonitatillah, et al.: Lower Perceived-Stigmatization by Health Workers Copyright © 2020, IJTID, p-ISSN 2085-1103, e-ISSN 2356-0991 who are single. It is hoped that the results of this study can provide input to policymakers to initiate a stigma reduction program for people with HIV that can be started from PLWHA who has the highest stigma, to make it easier for PLWHA to disclose their status and treatment. Besides, it is hoped that the prevention of HIV transmission to the community will be more controlled and to help improve the quality of life people living with HIV-AIDS (PLWHA). 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