Stigma and Discrimination on People Living with HIV (PLHIV): a Systematic Review

Introduction: Human Immunodeficiency Virus (HIV) is a global health problem that is almost recorded in every country. The long-term and long-term negative impacts of HIV cases are stigma and discrimination in people with HIV (PLHIV). The purpose of this study is to find out the stigma and discrimination felt by PLHIV. Method: This study design of systematic review from 4 electronic databases namely Scopus ScienceDirect, Sage and ProQuest by using keywords tailored to Medical Subject Headings (MeSH) including "Stress", "covid", "nursing", "hospital". This study uses PICOS framework to prevent research bias and analysed using descriptive analysis. Results: The results of the analysis of the article showed from 761 articles have been identified title, abstract and full-text so that recorded 15 articles that can be reviewed. The article consists of various designs, namely RCT, cross sectional and qualitative studies. Analysis shows that stigma and discrimination are social phenomena that manifest in several social areas. Conclusion: Stigma and discrimination in people with HIV (PLHIV) is still common, stigma is carried out by the wider community to their own families. The family approach is necessary to improve well-being as well as improve the social community of the family.


INTRODUCTION
Nowadays HIV has become a major public health problem, globally almost all countries recorded as cases(1). People infected with HIV are often referred to as People Living with HIV (PLHIV) and often show a declining health condition (2). This decline in health is often associated with physical and psychological health conditions, such as poor medical care, adherence to antiretroviral drugs, stress due to lack of self-acceptance, stigma and discrimination from the family environment and society as well as other factors that aggravate the condition (3,4). In addition to the stigma and strict discrimination from the community, the health condition of people with HIV is decreasing with opportunistic infections that can suppress the immunity of sufferers, resulting in a decrease in well-being and quality of life (5,6).
In 2018, 37,968 people addressing HIV diagnosis in the United States and dependent regions (7). According to who, about 38 million people worldwide with HIV/AIDS in 2019, from the data of the number of cases, 36.2 million of them are adults and 1.8 million are children (< 15 years) (8).Data on deaths from HIV / AIDS is also growing, recorded since the start of the epidemic, an estimated 74.9 million people have been infected with HIV and 32 million people died from AIDS-related diseases. In 2018, a total of 770,000 people died from AIDS-related diseases. This number has decreased by more than 55% since a peak of 1.7 million in 2004 and 1.4 million in 2010(9). The development of the number of cases was also followed by the increasing stigma and discrimination that people give to people with HIV.
Stigma in particular regarding HIV has been cited as one of the most enduring barriers to ending the HIV problem in society (10). Stigma is a condition that becomes the main social measuring point of health that drives morbidity, death, and determines health inequality (11).
The stigma received by HIV sufferers is characterized by various cognitive, emotional, and behavioural components and can be reflected both in the attitude given. Stigma that is often felt is associated with experience, including an enforced or experienced stigma that affects a particular trait, among individuals (12).HIV-related stigma has been linked to poor health behaviour. This stigma is directly related to the reduction of voluntary counselling and testing (VCT) and the disclosure of cases of infection (13).So it is expected that through the application of a combination of effective stigma mitigation interventions on a large scale requires transdisciplinary longitudinal (14).The impact of stigma experienced by patients with HIV/AIDS is very diverse, often found patients experience low self-esteem, stress or decreased mental health, especially if followed by other diseases such as disability or other opportunistic infections (15).
Related to stigma and discrimination in people living with HIV / AIDS (PLHIV) has been conducted many studies, including the existence of self-stigma, stigma from the family to the community environment. However, it is still reported by various studies that there are still types and stigmas that have not been revealed as a whole in patients with HIV/AIDS. This systematic review aims to contribute to the knowledge of stigma by conducting an analysis of the type of stigma in HIV/AIDS, the impact of stigma and exploring whether and how the stigma framework occurs.

Search Strategy
We use literature reviews usingfour credible electronic databases namely Scopus, ScienceDirect, PubMed and ProQuest. The four databases we conducted selection based on the field of science, namely with the categories of medical sciences, Social Sciences, and nursing sciences. To extend the search range of articles, we use the Boolean operator AND, OR in each database. Keyword search has been adjusted with Medical Subject Headings (MeSH) to search for articles in the 4 electronic databases namely the search terms are "stigma", "discrimination", "HIV/AIDS". Keyword search information can be seen in table 1.

Inclusion and exclusion criteria
To determine the quality of the study, the researchers set the study criteria through PICOS, namely participants, interventions, comparators, outcomes and study types, with the following explanations:

RESULT
Based on the journal analysis that has been conducted, the spread of HIV cases is recorded in various countries both developed and developing countries. The distribution and progressivity of each country shows different numbers and patterns, several countries reveal this incident due to the high number of free-sex cases committed same-sex or different types.
In addition, quite a few other cases are the use of drugs and narcotics. From the journal analyse shows that the impacts received by people with HIV /AIDS are very diverse, ranging from short-term or long-term negative impacts during life in the community. In addition to the decrease in health conditions, such as decreased immunity of the body and reduced ability to do activities independently, as well as the emergence of some opportunistic infections that actually aggravate his health condition. On the other hand, the impact is the emergence of new stigma or strengthening of existing stigma and discrimination against PLHIV. This discrimination is directly felt by sufferers such as not accepted in the work environment and family, not involved in social activities and used as a talking point of others. The form of stigma obtained is a negative and bad image of the life of the sufferer before, this is very tangent to the norms and customs imposed in the community.

DISCUSSION
The results of the study analysis showed that the stigma that occurs in people with HIV (PLHIV) is very diverse, this diversity is influenced by several factors. This personal stigma has a significant association with age, education level, and disclosure of HIV status (25). This is in line with research that has been conducted in China that with age associated with lower stigma scores, this is possible with the views of individuals (31).A change of scenery in much older people due to social support and family support that is better able to adjust and understand the impact and prognosis of the problem of people with HIV (25).Family support is one of the key points of strengthening psychological conditions due to stigma and discrimination provided by society.
Factors that affectedon stigma in people with HIV is the lack of knowledge and understanding of society related to HIV infection, misinformation by word of mouth will give rise to different perceptions (24). The other research shows that greater knowledge of HIV transmission misconceptions is significantly associated with lower stigma towards people living with HIV. And among urban participants, the level of higher education (high school vs. elementary school or less) (32). In contrast to self-stigma, self stigma is giving a negative assessment of oneself due to something that is not accepted or considered inappropriate to others in general.Some efforts that can be made to respond to the stigma of society include by conducting self-testing of HIV but this strategy needs to be implemented as needed (30) (33).
The impact of stigma and discrimination received by PLHIV is very diverse some are not accepted in the community until the rejection of the core family. If the PLHIV does not have a good resilience then he will easily experience mental health. People with mental health problems consistently identify stigma, discrimination and social exclusion as major barriers to their health, well-being, and quality of life.

CONCLUSION
Stigma and discrimination are complex social problems that can directly affect psychological health conditions. This is exacerbated by a decrease in physical health conditions, such as the emergence of opportunistic infections in PLHIV. This stigma can arise from various parties, such as families, health workers as well as the public at large or who are in PLHIV. Forms of stigma and discrimination vary greatly from exclusion to not being involved in various community activities. The substantial factor of stigma and discrimination is the lack of knowledge and misinformation related to HIV/AIDS. So the stigma of perceived society and affective, cognitive, and mental health outcomes (selfesteem, depressive symptoms, avoiding coping, self-blame) need to be anticipated with a holistic family approach as well as good social support.