For this assignment, provide a synopsis of the review of the research literature. Using the "Literature Evaluation Table," determine the level and strength of the evidence for each of the eight research articles you have selected. The articles should be c

Services, Stigma, and Discrimination: Perceptions of African Descendant Men Living with HIV/AIDS in Brazil and in the United States Aparecida de Fatima Cordeiro Dutraa, Wilma Cordovab, and Freddie Avantb

aCenter for Regional Heritage Research, Stephen F. Austin State University, Nacogdoches, Texas, USA; bSchool of Social Work, Stephen F. Austin State University, Nacogdoches, Texas, USA

ABSTRACT This study aimed to give voice to 13 men of African descent from Salvador, Brazil, and East Texas, United States, living with HIV/AIDS regarding their perceptions on accessibility of services, and the stigma and discrimination they experience. Phenomenological research using in-depth interviews was used as methodology. Five themes emerged from the data analysis: percep- tion of positive health, services and accessibility, not disclosing HIV status is a way to be protected, health professionals untrained in treating people living with HIV/AIDS, being of African descent increases discrimination in both countries, education would decrease stigma and discrimination. This study addresses how stigma and discrimination experienced by these men violate their human rights, and the need of policies to mitigate these practices.

KEYWORDS Afro-descendant population; discrimination; HIV/AIDS; human rights; stigma

Introduction

People living with HIV/AIDS (PLWHA) have benefited from advances in treatment across the globe. Some countries have taken a more proactive approach in treating PLHWA. For instance, Brazil has been internationally recognized for its progressive way to face HIV/AIDS for over a decade (Berkman, Garcia, Muñoz-Laboy, Paiva, & Parker, 2005; Gomez, 2010). Brazil has a public health system known as Sistema Único de Saúde/SUS (Unified Health System) developed under the premise that health is a right of all individuals and must be provided by the government (Law 8080/90 Law 8080/90 – Brasil, 2003). Through the SUS, antiretroviral therapy (ART) has been available at no cost for PLWHA since 1996 (Gomez, 2010). The wide availability of the medication has contributed to a decrease of the mortality rate related to AIDS. UNAIDs estimates that at least one half of the population living with HIV/AIDS in Brazil receive ART, which is a monumental accomplishment when compared to the global average, which is less than 47% (Unaids, 2016). However, it is important to mention that due to the current political and economic instability in Brazil, it is difficult to predict the amount of financial resources that will continue being allocated to HIV/AIDS programs (Basthi, Parker, & Terto, 2016).

The health care system in the United States functions differently from Brazil, in that there is no universal health care, and individuals are required to supplement, at least a portion of their treatment. In 2011, 37% of people living with HIV/AIDS in the United States were receiving ART (Avert, 2016). PLWHA may have free medication through nonprofit government organizations (NGOs), which are funded by grants and the Ryan White Act (Gallant et al., 2011). However, once the grant money is depleted and the act is no longer funded, the patients may be left on they

CONTACT Aparecida de Fatima Cordeiro Dutra [email protected]. Center for Regional Heritage Research, Stephen F. Austin State University Room G 75, Ferguson Building PO Box 13028, SFA, Station Nacogdoches, Texas 75962, USA. © 2018 Taylor & Francis

SOCIAL WORK IN PUBLIC HEALTH 2018, VOL. 33, NO. 4, 226–236 https://doi.org/10.1080/19371918.2018.1454868

own. This would constitute a challenge taking into consideration that prevention, treatment, and medication are expensive and not all PLWHA would be able to afford the costs.

Although the health care system differs between Brazil and United States, they share a common concern. Stigma and discrimination are experienced by PLWHA in both countries. “As a trait, stigma is defined as an attribute or characteristic that is viewed negatively by the culture or society. As an outcome, stigma occurs when the negative meanings attached to the discrediting attribute become linked to the individual” (Greeff et al., 2008, p. 312). Discrimination is related to prejudgments and negative attitudes toward PLWHA. These discriminatory practices may result in psychological and physical abuse for anyone living with the disease. Interestingly enough, in both countries, stigma and discrimination are similar in its impact on the individual, society, and in the healthcare system.

Many studies have been conducted about stigma and discrimination (Cordova, Cooper, & Avant, 2011; Feigin, Sapir, Patinkin, & Turner, 2013; Garcia & Koyama, 2008; Vanable, Carey, Blair, & Littlewood, 2006), but none was found regarding men of African descent (this term refers to Afro- Brazilians [Brazil’s term] and African Americans) living with HIV/AIDS in rural East Texas, United States, and Salvador Brazil. This study offers voice to this population to state their feelings and perceptions about the accessibility of services, stigma, and discrimination. In doing so, we were able to much more fully understand their experiences of living with HIV/AIDS, as we became more aware of the compound difficulties caused by constantly dealing with an incurable disease. Thus, this study brings contributions to the field, as it supports the need for continued education to address the discrimination PLWHA endure and to address stigma as a “social phenomenon.”

Moreover, there is an urgent need to promote awareness that the disease does not affect only a specific population, but it has a broader impact on the community and health care system. Policymakers in health, health professionals, and society must take a stand to promote mindfulness about the negative effect of oppression toward individuals living with HIV/AIDS and the potential global impact of these practices.

Literature review

HIV/AIDS is a chronic disease and may affect any human being regardless of their background. Nevertheless, studies have revealed that Afro-descendant people have been disproportionately affected by this epidemic, and little attention has been given to understand the structural causes that contributes to the vulnerability and disparities in HIV infection among this population (Buseh & Stevens, 2007; Rowe, 2007; Sengupta et al., 2000; Stevens & Hull, 2013). In fact, Buseh and Stevens (2007) highlight that race/ethnicity do not constitute in a predisposing factor for the disease, nevertheless race is associated with social and economic aspects that continueto deprive this population to fully access their human rights. In both countries, Brazil and United States, lack of access to basic needs have contributed to the social inequality and exclusion of African descendants. In a context of social exclusion, African- descendant men living with HIV/AIDS may face even more challenges concerning the disease and the stigma and discrimination related to it.

Data from HIV Surveillance Report (2013) indicates that more than 42% of African Americans live with HIV/AIDS in the United States, this is an alarming number, considering that African Americans represents only 12% of the entire population. In the state of Texas, the number of people of color affected by HIV is also startling. There were 38% of people identified as Black living with HIV/AIDS in 2010, whereas they represented only 11% of the Black population in the state (Texas Integrated Epidemiologic Profile for HIV/AIDS, 2010).

In Brazil, the global AIDS narrative report from 2015 identified that there was 21.4% of black skin people infected with HIV/AIDS. In Brazil, individuals self-identify their race/color; they are given the choice of white, black, yellow, brown, and indigenous (The Brazilian response to HIV and AIDS, 2015). In the state of Bahia, in 2016 there were 20,893 adults infected by HIV/AIDS, and people identified as cor preta (black color) accounted for 3,833 of the cases, which represents more than 18% of the cases in that state, though people identified as pardo (brown) accounted for 10,912 of all

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cases, accounting for almost one half of all cases (The Brazilian response to HIV and AIDS, 2015). According to the AIDS global narrative report (2015) there was a significant number of people that identified themselves as brown and white, instead of black, so they may fall in a different race/color category of PLWHA, therefore disguising the real numbers of Afro-Brazilians affected by HIV/AIDS in Brazil. It is important to note that racism and racial inequality persists in the Brazilian society (Beato, 2004). There is a tendency to see no white races as inferior; the white supremacy may lead non-White people to contradict their own race (de Jesus Ferreira & Camargo, 2014).

Moreover, scholars have pointed out a variety of historical, social, political, and economical reasons for such a disproportionality of HIV/AIDS within the African-descendant population (Buseh & Stevens, 2007; Garcia, Abrao, Lima, Silva, & Andrade, 2013; Feigin et al., 2013; Peltzer, Domian, & Teel, 2014). They are the group that due to the historical oppression has had less access to education and qualified health services. Lack of information may result in sexual practices without protection increasing the risk to be infected. Scarcity or absence of access to health services makes African-descendant community more vulnerable and less likely to be diagnosed and treated. Aggravating the situation, African descendants are also the ones more likely to be discriminated in health agencies.

Furthermore, HIV is a disease that continues to be stigmatized across the globe mostly due to the lack of knowledge. A study conducted by Gańczak and colleagues (2007) in a university setting in United Arab Emirates, demonstrated that most of the respondents lack information about HIV/ AIDS, and as a consequence, they tend to react negatively toward PLWHA. Similar results were found by Norman, Abreu, Candelaria, and Sala (2009) in a study conducted in Puerto Rico. Most of the participants hold intolerant attitudes toward PLWHA because they believe that people infected by HIV/AIDS had a dissolute lifestyle. Both studies support the fact that negatives attitudes toward PLWHA are the result of lack of information about the subject.

As shown, PLWHA continue to be the target of stigmatization and discrimination. Such practices discourage individuals to access prevention tools, and this contributes to the decline in demand for medical prevention and care (Bogart et al., 2015). The stigma and discriminatory practices associated to HIV/AIDS are harmful and detrimental to the entire society. Recent studies (Hatzenbuehler, Phelan, & Link, 2013; Monteiro, Villela, & Soares, 2013) have shown the social functions of stigma and how stigma is used to justify the power of a particular social group over other. These authors point out that though there are not effective policies to address stigma as a social issue, it is likely that the perverse effects of stigma will continue to jeopardize peoples’ health. It is crucial to empower PLWHA, promoting their health, well-being, and social inclusion to reduce social inequality.

Method

The methodology of this research was based on phenomenological research, which is a research that aims to identify what individuals facing the same situation have to share about their feelings and experiences (Creswell, 2013). Using phenomenological research, we aimed to answer the following research questions:

(1) How do African -descendant men living with HIV/AIDS describe the services offered to them in Salvador, Bahia, Brazil, and East Texas, Texas, USA?

(2) How do African-descendant men living with HIV/AIDS in Salvador, Bahia, Brazil, and East Texas, Texas, USA, perceive stigma and discrimination toward them?

Sample

Thirteen men of African descent participated in this study. Participation was completely voluntary and all participants signed an informed consent form. The proposal of this research was approved by the Institutional Review Board (IRB) of an East Texas university and by the Research Ethnics

228 A. D. F. DUTRA ET AL.

committee in Brazil through the Brazil Platform (Plataforma Brasil), “a database that requires the registration of research involving human subjects” (De Castro, 2013, p. 1). In addition, a local and an international health agency involved in the study provided approval letters formally accepting to work in a collaborative research. Upon approval of the two committees and the health agencies we were able to work on recruiting participants.

Participants were recruited through the health agencies where they were receiving treatment. In both agencies, Salvador and East Texas, health professionals facilitated the recruitment. In Brazil a health professional in charge of the support group for PLWHA, a group that meets every week to share their stories to encourage and support each other, talked to PLWHA about the purpose of the present study. Participants met with the researcher after the process was explained and they agreed to volunteer. The researcher spent the month of June 2016 in Brazil to complete the interviews. Most of the participants in Salvador chose to be interviewed on the same day they had the support meeting group or any other appointment to avoid multiple trips to the agency. Seven participants were interviewed in Brazil in June 2016 by one of the researchers of the present study, who is Brazilian and native speaker of Brazilian Portuguese. In East Texas, six African American men were inter- viewed between June and August 2016. A health professional from a local health agency located in a small city in East Texas identified participants that met the requirements of the present study. Participants were also recruited through flyers, which were posted in the waiting area. Those willing to participate informed their social workers/case managers, and an appointment was scheduled with the researchers. The participants in both countries self-identified as African descendent and to be HIV/AIDS positive. This particular group was selected because of the limited research on men of African descent. The researchers did not require disclosure of sexual orientation. The researchers also identified the two countries based on the fact that Brazil implements a universal health care system and the United States does not. Although a comparison was not the main focus of this study, it was important to identify any differences in regard to services and individuals unique experiences with stigma and discrimination.

Data collection and data analysis

In-depth interviews were conducted using semistructured interviews to gather participants’ informa- tion about services they access, as well as their perceptions about stigma and discrimination. Two sets of five open-ended questions were asked, one set regarding the services and the other set regarding participants’ perceptions addressing stigma and discrimination. In addition, 10 questions were asked to collect specific demographics. To preserve participants’ identity, they were identified in this research by pseudonyms and random numbers chose by themselves. Anticipating any psychological risk in that some of the questions would make participants uncomfortable, it was emphasized that if they became uncomfortable they should not have to proceed or answer any of the questions. Participants were initially asked information about their background (see Tables 1 and 2) and the next step was proceeding to the questions that would enable us to understand their experiences as PLWHA and respond to the proposed research questions of the present study. Interviews were recorded and lasted anywhere from 30 to 105 minutes, although the researchers implemented the technique of probing for interviewing, some participants were brief and reserved in their responses, especially those from the United States. In East Texas, one of the participants did not want to be recorded but did allow the researcher to take notes. All interviews were translated literally, and those in Portuguese were translated and transcribed into English. The audio files resulting from the interviews were kept in a password-protected computer and only the researchers had access to the data.

The researchers read the data multiple times for interpretation and meaningful analysis during and after the process of transcribing the data. Data were codified into themes by ranking status, which is an important aspect of qualitative research. Another important concept is the common utterances by the participants that define the themes (Burnard, 1994; Ryan & Bernard, 2003). Five themes emerged from data analysis. Demographic information and themes are discussed in the Results section.

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Results

Demographically, one can see that there is a vast difference in the amount of income from one country to the other. Brazil is inflicted with poverty whereas the U.S. participants were not as economically challenged. Education differs in some ways but not in others. Public elementary and secondary education is free in the United States with the option of private education for those who can afford it. A university education is at a cost for U.S. citizens. In Brazil higher education is free but remains a privilege for those who can afford quality elementary and secondary schools that offer leverage in scoring high on entry-level exams. Brazilians must pass a test to enter college, and those who attend public elementary and secondary schools are not always prepared to achieve the required scores and get accepted into a public university (De Carvalho & Barreto, 2007). The process to attain higher education is beginning to change with the enforcement of Affirmative Action laws but remains unequal (Da Cruz & Van Kan, 2012; Rowe, 2007). According to the website blackdemo- graphics, in the United States only 16% of Black men earned a college degree in 2011, thus making the United States similar to the Brazilian experience as it relates to higher education Education is important in the well-being of individuals as it leads to a life of economic stability. One can see these results resonate with the participants in their responses to education and income.

Of the 13 men interviewed, three have lived with HIV/AIDS 20 years or more; two of the men live in Brazil. The youngest to be interviewed was age 28 years and was from Brazil. Two men were age 64 years, one from Brazil and one from the United States and were the oldest participants.

Themes

Five themes emerged from participants’ interview; they were consolidated and categorized pertaining to perceptions of services, stigma, and discrimination. The themes are categorized as follows:Perception of positive health services and accessibilityAll participants indicated that services in both countries were good to excellent. Participants stated, “The service for me is great, I have nothing to complain about, and they serve well”and “They are the best.” All participants resonated the same sentiments in both countries. This is certainly hopeful for those suffering from the disease. This supports the fact that Brazil and the United States are improving their services to provide for PLWHA.

Table 1. Demographics (Brazil).

N = 7

Age Range 28–64

Mean 46

Years living w/HIV/AIDS 4–26 14.14 Number of children 0–5 01.57 Educational level 7 years–12 years 10.14 Monthly income $233-$500 $408.28 Marital status (4 single, 3 married)

Table 2. Demographics (United States).

N = 6

Age Range 42–65

Mean 50

Years living w/HIV/AIDS 1–20 10.83 Number of children 1–5 3 Educational level 12 years–15 years 13 Monthly income $0-$2,500 $833.16 Marital status (5 single, 1 married)

230 A. D. F. DUTRA ET AL.

In East Texas, USA, 50% of the participants indicated that transportation to services is a concern, which is often a challenge in many rural communities. In Salvador, Brazil, there is a public transport system, and none of the participants identified getting to services as a problem.Not disclosing HIV status is a way to protect themselves in a society that already rejects them

Stigma and discrimination are the major challenges inhibiting PLWHA to disclose their status. The literature has shown that disclosing HIV status has advantages and disadvantages. Among the advantages is the support from family and friends, more freedom to get tested and seek treatment, decrease of physical symptoms, and chances to become more aware and involved in issues about HIV/AIDS (Kalichman, DiMarco, Austin, Luke, & DiFonzo, 2003). On the other hand, however, disclosing status may affect relationships with family and friends if there is no empathy and understanding. Disclosure in situations where there is most likely to be restrictions for international traveling and employment opportunity may increase anxiety levels (Paxton, 2002; Sandelowski, Lambe, & Barroso, 2004). In the present study 69% of the participants did not share their status as indicated in the quotes:

My family does not know, nobody of my family knows, when I . . . it was alone (crying). I went through this. . .. I get emotional because it was by myself, I did not have the support of anybody. I did not tell my family because it was a difficult time.. . . My relationship with my family is ok because they think I don’t have anything.

I have no interest that they know. Actually, I am the oldest of a family of eleven siblings, I need to give good examples, not that have AIDS is a bad example, but I am sick, it is a chronic disease. Maybe if I shared, they would not react in a different manner, but the way it is nobody is losing, me neither. It is just to take care of me in order not to need their help.

Although there is no agreement from scholars about the benefits of disclosure HIV status, some studies (Edwards, 2006; Sandelowski et al., 2004) have shown that disclosing HIV status helps PLWHA to decrease the stressor that individuals with a chronic disease experience, increase social network and the chances to find support. In addition, more recent studies have also shown that disclosing HIV status appears to be crucial to cope and accept the disease (Feigin et al., 2013).

Thirty-one percent revealed their status to families, health professionals outside the HIV/AIDS agency providing care, and friends to share the burden and to seek support. Nevertheless, the support they sought was not always guaranteed resulting in the continuation of social isolation in their daily lives:

My friends walked away. I’m sure they walked away because I have HIV. Before, they slept there, ate there, I helped everyone, some called me father. Suddenly, everybody disappeared. Discrimination happened when I returned there (at work), I sat in a place and a person said that he could not sit there because he/she would get AIDS, or a time to offer me something to eat, after that, they throw away the dish and the glass. Sometimes I am in a place that is hot as hell, and a person does not want to turn on the fan saying that if the wind hits me and hits them, they will get AIDS.

“Sometimes when I am visiting family . . . and I go to the bathroom . . . you know . . . they tell themselves (meant each other). Don’t go in there . . . cause you know he has that . . . disease . . . he is dirty.”

Even though being stigmatized and ostracized, those participants that disclose HIV status believed that it would be the only way to promote social changes:

When the society knows a person has HIV, or even in the community, so . . . they spread for everybody, and everybody gets a little different with that person. The black man suffers more in several aspects because he is black. There is more discrimination against black. I feel better because my family supports me . . . you know. When you keep this secret . . . it is worse.

Before, we used to hide ourselves to die; now we show ourselves to live. If we hide ourselves, the depression comes, but if we raise our head, go ahead, heads up . . . it is what we all should do. Also, be involved in the public policy, which has already been implemented. If people accept themselves more, it would decrease stigma and discrimination.

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The choice to whom, how, and when to disclose HIV status is a difficult one for PLWHA, sharing or concealing their status may set them up for social isolation, rejection, and fear. It is a personal decision to disclose HIV status; however, it is important to be aware of the issues that disclosure can bring. In addition, the literature has presented that health professionals should be the ones well prepared to talk about the benefits and concerns of disclosing HIV status (Serovich, 2000).

Health professionals who were untrained in treating PLWHA< >

Some participants from both countries complained about unprofessional treatment received by health professionals at non-AIDS/HIV agency, “While receiving services in an emergency room, one nurse screamed at me ‘What . . . you are HIV positive . . . and didn’t tell me!’”

I went to another doctor at non-AIDS/HIV agency. The doctor simply didn’t measure my blood pressure; didn’t see my heartbeat, nothing. He was looking at my records and continued without looking at me, and gave me a prescription. I got up from there, when I got to the door I tore the prescription. I am not going to take a medicine from a doctor that doesn’t know who I am. That doctor doesn’t know the color of my skin. I will not trust in a professional like that, there is no way.

There was a woman that worked at the hospital I was and I trusted her. I could not leave, and my mother was busy. I trusted that woman and let her get the result, I gave her consent. She got the results; she opened the envelope, saw it and she did not go to deliver it to me. That woman, who took the results, spread to the whole city (I have AIDS). (He was bullied into leaving his home and rural town).

Many studies (Gee, 2002; Hammond, 2010) have denounced the unequal treatment that people of color frequently receive at healthy agencies due to racial discrimination, and how it contributes to impoverish their health. In Brazil, complaints about precarious treatment at public health agencies have become common. Clinics and hospitals overcrowded and professionals overloaded are a daily routine of a public service where the demand is usually greater than the supply. However, these factors cannot justify mistreatment to patients. Previous studies have shown that doctors that have racist behavior tend to deliver inferior care for people of color (Lopes, 2004). Regarding PLWHA, a study guided by Earnshaw, Bogart, Dovidio and Williams (2013) showed that doctors that have unconscious racial biases are inclined to delay ART prescription because they suspect that a person of color will not follow the treatment correctly. This is important to emphasize due to possible injustices, based on preconceived stereotypes toward African-descent men inflicted with HIV/AIDS.

Being African descendant increases discrimination in both countries< >

Of 13 participants, 77% stated that their skin color increases discrimination against them, “There is more discrimination against black people,” “With HIV or not, they treat you different. I have felt this difference in treatment at various places, not only in relation to HIV, but only for being black,” and “Being a black man in the U.S., whether having HIV/AIDS or not, one is always discriminated against.”

It is complicated to say you have HIV, for any race. If you have HIV, society will mistreat you. Now, the fact of being black you have another prejudice, by being black and having HIV, you can be sure that society discriminates you, for sure.

African-descendant populations have been historically targets of discriminatory practices. African- descendant population living with HIV/AIDS have to face even more challenges including poverty and unemployment, as it has been pointed out in several studies (Earnshaw et al., 2013; Woods- Giscombé, 2010).

Poverty levels for African descendants in both countries are high due to lack of education, single- household families, incarceration, and discrimination (Lopes, 2004; Monteiro & Cardoso, 2013; U.S. Census, 2010). According to Lopes (2004, p. 57) “poverty in Brazil has race, color, and ethnicity” and in 2001 46.9% of the black population were living in poverty. Regarding higher education, the

232 A. D. F. DUTRA ET AL.

percentage of those earning college degrees is deceptive due to the skin classification in Brazil, which groups black and yellow populations together at a rate of 45.5%. In the job market the black population has lower incomes in comparison to other races. Concerning incarceration, in 2011, the black population represented 60% of the inmates in Brazilian jails (Monteiro & Cardoso, 2013).

These numbers are similar in characteristics to the U.S. Black population. As previously men- tioned, in the United States only 16% of Black males earn college degrees, while, according to the U. S. Census Bureau (2017), 20.2% of Black families live in poverty with the Black male population being over-represented in jails.

Education would decrease stigma and discrimination< >

Seventy-seven percent of the participants stated that more information and education about HIV/ AIDS would decrease stigma and discrimination against PLWHA. Participants stated, “Through the media I guess, it is one way; always talking about HIV/AIDs, I think it is the only way nowadays to spread this, about HIV. There is a need of more information, more information to end prejudice.”

Like my grandmother said: Sweep your own front door. Education . . . more so we can find solutions. As long as there is hate in the world . . . things will still be the same between black and white. No one should judge and others need to look in their own closets.

More education would help to decrease ways of discrimination, develop the intellectual to fight these things that affect the chronic patient, not only HIV but also any chronic disease. Only information will solve this.

Lack of education about HIV/AIDS can contribute to an increase in the numbers of infection; and for the prevalence of stigma and discrimination (Gańczak et al., 2007; Stevens & Hull, 2013). Education would be an important tool to decrease the stigma and discrimination faced by PLWHA. The need for education and awareness resonated with participants’ responses from both countries in various forms.

Discussion

This study aimed to understand about the accessibility of services, stigma, and discrimination from participants’ perceptions in Brazil and in the United States. Both countries have come a long way in their development of services for PLWHA with Brazil leading the way to preven- tion and treatment. Brazil has adopted legislation providing PLWHA the luxury of medication at no cost and an acceptance of more realistic attitudes about sexual behavior. Hopefully the current crisis that Brazil is experiencing will not have a major effect on policies addressing HIV/AIDS.

As it can be seen from participants’ statements, the services offered for PLWHA are good, which represents hope for people infected by HIV/AIDS. However, the real challenge is the continued stigma and discrimination men of African descent face. An important fact to note is that stigma and discrimination needs to be seen not only as an individual experience, but also as an insidious issue that affects families, societies, and the health care system. Stigma needs to be seen as a social issue to be addressed, and close attention should be given to those that face multiple oppressions (i.e., poverty, homophobia, racism).

In both countries having HIV/AIDS is seen as deviant and immoral, and anyone with the disease has “gotten what they deserve” due to their inability to control their sexual desires. These kinds of attitudes are oppressive and contribute to the inequality prevalent in societies.

In rural areas there are specific beliefs and customs regarding HIV/AIDS, especially in areas where fundamental religious beliefs are inherent in the culture. PLWHA tend not to seek medical care or other services because of what they experience in the community or their perceived discrimination.

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Limitations

This study contributes to the field of social work and health care and provides cutting-edge research for future studies. However, we should acknowledge its limitations. Interviews were conducted in the health agencies that participants were receiving treatment, so it may have influenced participant responses about services offered to them. Moreover, though the sample size can be considered sufficient in a qualitative research, where more participants would not bring new information, a greater number of participants would give more generalized results about the issue studied. In addition, all respondents of this study were receiving treatment in health agencies. Future studies should try to reach PLWHA not engaged in treatment to hear about their experiences. It would also be important to ascertain whether gender influences perceptions about stigma and discrimination and the decision to disclose HIV/AIDS status.

Conclusion

Death is no longer imminent for PLWHA, as more people die from cancer than AIDS. Still some countries are resistant to learn about a disease that continues to be associated with immoral behavior. Education and information are important in overcoming unnecessary fear and resistance to learn about HIV/AIDS and the complex issues that come with the disease.

Political and powerful spiritual leaders need to take the lead in promoting acceptance and the desire to learn more about HIV/AIDS. Under political and spiritual leaders, society’s attitudes of hatred and repulsiveness can change and eradicate the pain inflicted on those suffering from HIV/ AIDS.

Although the participants for the study are from two different social, economic, and political contexts, they have similar experiences with stigma and discrimination. Furthermore, most of the participants identify being of African descendent as the common denominator for experiencing even more discrimination. The unfortunate truth is that those inflicted with HIV/AIDS carry a heavy burden enthralled with guilt and at times depression. However, their plight should be one of support and empathy. It is a matter of social justice and the demand for all human rights that HIV/AIDS, and the stigma and discrimination associated to this disease should become a fight for all.

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