STIGMATISATION OF HIV-POSITIVE MEMBERS OF THE WORKFORCE

Die mikpunt met hierdie ondersoekende, kwalitatiewe navorsing was om vas te stel of daar in die Suid-Afrikaanse werkplek stigmatisering teenoor MIV positiewe lede van die werksmag bestaan of nie. Deur gebruik te maak van ’n selfopgestelde onderhoud, is telefoniese onderhoude gevoer met ’n steekproef van 20 MIV positiewe werknemers. Data ontleding deur middel van beskrywende statistiek en inhoudsontleding het gelei tot bewyse dat stigmatisering teenoor MIV positiewe werknemers in Suid-Afrika bestaan. Die bevindinge van hierdie navorsing dui daarop dat sulke stigmatisering spanning, angstigheid, depressie, vrees en voornemens tot arbeidsomset by MIV positiewe werknemers kan verhoog, terwyl dit motivering, hoop, werkstevredenheid en selfwaarde kan verlaag.


INTRODUCTION
The rate at which the Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) is spreading throughout the world, especially Africa, is alarming.Although Africa contains only about 12% of the world's population, it contains over 70% of HIV-infected individuals.It is estimated that over 10% of the South African population is HIV positive (Addison, 2001).This pandemic is a threat to the economy, individual workers and society in general (House, Eicken & Gray, 1995).Social implications of HIV/AIDS include fear, prejudice, discrimination, hysteria, stigmatisation and other irrational responses from members of society (Herek & Glunt, 1988;House et al., 1995).For the purpose of this study, "stigmatisation" refers to the irrational responses (including fear, attitudes and prejudicial behaviour) by co-workers and/or superiors within the work environment towards HIV positive individuals.

PHYSICAL IMPACT OF HIV/AIDS
People diagnosed with HIV do not usually exhibit symptoms of AIDS for many years (Miller, Backer & Rogers, 1997).HIV permanently attacks the immune system of the body, damaging nerve and brain cells, while weakening the body's defence against infection and disease.As the virus progresses, symptoms including fatigue, weight loss, diarrhoea, sores in the mouth, night sweats and swollen lymph nodes can occur (Kuzmits & Sussman, 1986).As the virus continues to weaken the immune system, high-risk diseases, such as cancer, pneumonia and tuberculosis can overwhelm the body and result in death (Jacana Education, 1998).
Physical side effects of the intense medication used to manage HIV/AIDS also impact on those sufferers who have access to or finance to obtain such medication.The medication is complex, with rigid and unique administration schedules (Breuer, 1995).The physical impact of HIV/AIDS on sufferers is an extremely important and continually researched aspect of the pandemic.The psychological impact, however, is of equal importance and has been given less research attention.

PSYCHOLOGICAL IMPACT OF HIV/AIDS
Psychological distress is a common occurrence in HIV-positive individuals.People may experience many forms of this distress from the time that they are diagnosed with HIV to the end of their lives, due to reasonable emotional reactions to this life-threatening disease (Tross & Hirsch, 1988).Many individuals interpret an HIV-positive diagnosis as a death sentence, which evokes violent emotional reactions, including shock, guilt, anger and denial (Crewe, 1992).
Dramatic changes in life style often occur as a result of HIV/AIDS.Confronting possible loss of one's job, social rejection, denial of insurance and exhausted financial resources due to health care are some of these distressing changes.Refraining from high-risk behaviour (for example, sexual activities) and the need to acquire coping skills for managing the virus are further life style changes facing most HIV-positive individuals (Tross & Hirsch, 1988).
Bereavement is another form of psychological distress experienced by many HIV-positive individuals.Sadness, depression and withdrawal are some of the reactions to experiencing friends or family members dying as a result of HIV/AIDS.Bereavement often forces HIV-positive individuals to face their own possible death (Tross & Hirsch, 1988).Loneliness also impacts psychologically on HIV-positive individuals.Jue (1994) stated that long-term survivors of AIDS express feelings of loneliness and isolation during their experience of living with AIDS.Respondents mentioned the stigma attached to AIDS causing them to be reluctant to disclose their HIV status to others in case of rejection or other negative reactions (Jue, 1994).
HIV-infected individuals have reported often feeling abandoned, rejected and helpless during the course of their illness.Family, friends and social acquaintances often abandon these persons on discovering their HIV status, contributing to these negative emotions and thoughts of suicide (Tross & Hirsch, 1988).Rejection and abandonment of HIV-infected individuals by those around them decreases their social support structure and thus their ability to cope with and manage the disease and subsequent illnesses.This isolation can result in further psychological reactions including depression and anxiety (Allers & Katrin, 1988, cited in House et al., 1995).
Job satisfaction, which can be defined as "our positive and negative feelings and attitudes about our jobs" (Schultz & Schultz, 1998:250), is also an aspect of psychological impact on HIVpositive individuals.The Perceptions of Fair Interpersonal Treatment (PFIT) Scale was developed to assess employees' perceptions of the interpersonal treatment by supervisors and co-workers, and the effect on job satisfaction and job withdrawal.As employees' perceptions of fair interpersonal treatment increase, so their job satisfaction will increase, while their work withdrawal and job withdrawal will decrease (Donovan, Drasgow & Munson, 1998).Tanzer (1990), cited in Donovan et al. (1998), stated that many injustices reported within the workplace relate to how people were treated in interpersonal encounters instead of relating to procedural or distributive injustices.The study by Donovan et al. (1998) also negatively correlated sexual harassment to the PFIT Scale and mentioned a hostile work environment as a further contributor to decreased perception of fair interpersonal treatment by employees.This implies that harassment experienced in other forms would have the same result.If, for example, an HIVpositive employee was stigmatised and harassed by supervisors or co-workers, his perception of fair interpersonal treatment would decrease, along with job satisfaction.Miller et al. (1997) list fear, prejudice and hatred towards HIV-infected employees by co-workers as having occurred in many businesses in the past.This would certainly constitute a hostile working environment.
Motivation is defined as "workplace factors and personal characteristics that explain why people behave the way they do on the job" (Schultz & Schultz, 1998:237).Research by Raghunathan and Pham (1999) empirically showed that mood (whether positive or negative) can impact on motivation and decision-making.Individuals, therefore, working under conditions causing them to be sad or anxious will be influenced by these negative affective states when making decisions.
Anxiety and depression are two of the principal psychological symptoms connected to HIV/AIDS, according to King (1990), cited in Vaughn andKinnier (1996).
As previously stated, HIV/AIDS is a disease which weakens the body's immune system.The immune system depends on hormones and involves both the nervous system and endocrine system in its functioning (Morris, 1996).Research has proven that stress disrupts the immune system, impacting on the health of an individual.Stress linked to depression has been connected to the impaired functioning of the human immune system (O' Leary, 1990;Oltmanns & Emery, 1994, cited in Morris, 1996).
The field of psycho-neuro-immunology (PNI) is defined as "a field of medicine that studies the interaction between stress on the one hand and the immune, endocrine, and nervous system activity on the other" (Morris, 1996:505).Gillian Gresak, a PNI counsellor, stated that "the simplest way of explaining PNI is to call it 'mind over matter'" (Vinassa, 2001:18).Gresak has worked with many HIV-infected South Africans and has stated that 80% of those that she has counselled are still alive.The effect of making a decision to live and developing the mind over matter approach appears to be one of prolonged survival of the disease (Vinassa, 2001).

Impact of HIV/AIDS on business organisations
HIV/AIDS impacts on the bottom line profits of businesses in many ways, including the loss of experienced employees, increased costs of replacing lost employees, legal costs of unfairly treated employees and heightened medical benefit costs (Kun, 1998;Addison, 2001).
HIV-positive employees may not initially exhibit illness or show a decrease in productivity, but due to numerous possible side-effects from the HIV medication taken by many HIV-positive employees, absenteeism may increase.Also, with the eventual progression of HIV into AIDS and the greater risk of illness in individuals with AIDS, increased absenteeism cannot be ignored as a further cost to the company (Bisseker, 1997).
An increased strain in labour relations is another possible cost of HIV/AIDS in the workplace (Schultz & Schultz, 1998).The climate within an organisation can also be adversely affected in terms of job satisfaction, motivation, turnover intentions and employee relations, if misinformed employees become afraid of contracting the virus, refuse to work side by side with HIV-positive employees, or threaten and stigmatise HIV-positive co-workers (Herek & Glunt, 1998;Schultz & Schultz, 1998).

METHOD Objectives
The objectives of this study were as follows: To utilise exploratory qualitative research methodology in the form of in-depth interviews to gain further insight into the topic of HIV/AIDS; To utilise the above-mentioned methodology to identify whether or not stigmatisation against HIV-positive members of the workforce occurs in the South African workplace; To establish whether or not any such stigmatisation impacts on HIV-positive employees in terms of job satisfaction, motivation, performance, general well-being and any other jobrelated attitudes or behaviours; To reach a conclusion based on the analysis of the findings of this study, to identify limitations of the study and to make recommendations (in the form of recommendations to management and for future research) from this conclusion.

Sample
A sample of 20 individuals was drawn using non-probability quota sampling as the main technique.The two control categories of the population elements were that respondents had to be HIV-positive and that respondents had to be currently employed.Some snowball sampling occurred when respondents offered referrals and contact details for further potential respondents.
Table 1 presents a description of the sample used in this study.Unfortunately, not all respondents were comfortable with revealing their biographical information.The focus of the study, however, made the missing information of little relevance to the importance of the findings of the interview.

Measuring instrument and procedure
In designing the interview, three experts in the field of counselling (two specialising in HIV/AIDS counselling) were consulted.A pilot interview was then conducted with an HIV-positive member of the workforce.These were attempts by the researchers to address issues of validity regarding the research instrument to be utilised in this study.The final interview consisted of 15 open-and close-ended questions.
Interviews were conducted telephonically, as only three potential respondents were willing to meet and participate in a personal interview.The interviews were conducted over eight weeks.All respondents were assured of their anonymity.The interviews lasted from 25 minutes to 45 minutes and were characterised by their conversational nature.The 15 structured questions led to related topics and many respondents offered free and lengthy dialogue on the topic and related issues from their personal experience.The interviews were transcribed verbatim.

Data analysis
Descriptive statistics were used to analyse the results of the close-ended (or yes/no) questions of the interview.Content analysis was utilised to analyse the responses to the open-ended questions.
Common themes, key words and patterns were identified and then summarised in the form of tables to illustrate the findings.From this analysis of the data the researchers were able to reach conclusions, identify limitations and offer recommendations for future research.

Length of employment
Of the 20 respondents interviewed, eight had been working for their current employer for less than five years, while 11 had worked for their current employer for between five and nine years.One respondent had been employed at his or her current organisation for over ten years.

Working environment
Respondents were asked to describe both the physical and social working environment at their place of employment.Of the 20 respondents, four worked on a factory floor, while 11 were employed in office buildings.Three respondents described their working space as small with few facilities, while five described their workplace as being large with many facilities.Of the 20 respondents, 10 described their overall physical work environment as "good", while six used the terms "hot" and "noisy" to describe their physical work environment.
In terms of the social work environment, seven of the 20 respondents replied using the words "good" and "friendly".Five respondents stated that there were "close working relationships" at their place of employment.Four of the 20 respondents mentioned a worker-management division in their organisations.The terms "unfriendly" and "cold" were used by four respondents to describe their social work environment.

Declaration of HIV status at work
It was found that 13 of the 20 respondents had declared their status to superiors and/or co-workers at work.In three cases where HIV-positive respondents had declared their HIV status to management but not to their co-workers, these co-workers had found out about their declaration or had subsequently developed a suspicion about their status leading to direct confrontation.
Of the 20 respondents, seven had not declared their HIV status at work at the time of this study.Fear of stigmatisation, ostracism, non-acceptance from co-workers and/or superiors and avoidance were cited as reasons behind the decision taken by these respondents to keep their HIV status a secret.Of these seven respondents, three believed their co-workers and superiors suspected their HIV status due to comments passed on their illness or weight loss.
Changes as a result of known HIV status

FIGURE 1 RESPONDENTS EXPERIENCING CHANGES IN ATTITUDE, PERCEPTION AND BEHAVIOUR DUE TO HIV STATUS
No change: 1 Attitude Change: 12 Figure 1 illustrates that of the 13 respondents who had declared their HIV status within the workplace at the time of this study 12 stated that attitudes, behaviours and perceptions of coworkers and/or superiors towards them had changed noticeably.Only one respondent denied experiencing such changes since declaration of his or her HIV status.All 12 respondents cited negative examples and instances of how these changes had occurred, whereas only five respondents cited positive examples of changes along with the negative examples."Accommodation, understanding…" 3 Table 2 summarises some of the changes in attitude, perception and behaviour of co-workers and/or superiors, as identified by respondents, once their HIV status was known in the workplace.
Respondents may be reflected more than once in Table 2, according to their responses.Negative changes cited by respondents included avoidance, fear, suspicion and abandonment.These were the exact reasons previously cited by those seven respondents who kept their HIV status a secret at work.Positive changes in terms of attitudes, behaviour and perceptions of co-workers and/or superiors included support and understanding.
All twelve respondents experiencing changes from co-workers and/or superiors since their HIV declaration stated that these changes had affected them.Negative changes affected respondents negatively.Levels of job satisfaction, motivation, well-being and esteem were said to decrease and levels of depression, anger, anxiety, stress and fear of rejection were said to increase by respondents with the occurrence of negative changes within the workplace.
Positive changes, on the other hand, were said to increase motivation, hope and strength, while decreasing stress.Positive changes, however, were only experienced by certain respondents, with the majority of them experiencing negative changes and subsequent negative effects.

Turnover intentions
Of the 20 respondents in this study, 12 stated that they had been motivated to leave their jobs in the past due to attitudes, perceptions and behaviours directed towards them or another HIVpositive employee on the basis of their HIV status.The need for income was the reason cited by these individuals for remaining in their jobs, despite motivation to leave.In the past three of the 12 respondents had acted on this motivation and left previous jobs in search of better working environments.

Productivity and absenteeism
In terms of productivity, only three of the 20 respondents believed their productivity to be decreased by their HIV-related health issues, while 17 believed their productivity to remain unchanged by their HIV status.Of the 20 respondents, six stated that they were absent more than their co-workers.HIV-related illness, as well as regular visits to the doctor or clinic to maintain good medical care were cited as the main reasons for increased absenteeism by these respondents.
The majority ( 14) of the respondents believed that they were not absent more than their coworkers.

Workplace HIV/AIDS education
Of the 20 respondents, 17 stated that their employer offered some form of HIV/AIDS awareness and/or education programme.Seven respondents named this programme to be an AIDS Forum.
Other types of programmes mentioned by respondents included awareness campaigns through brochures and pamphlets, talks by AIDS organisations and a wellness programme based on voluntary membership.
Seven of the 20 respondents were actively involved in the HIV/AIDS programme at their place of employment.The remaining respondents cited fear of negative attitudes or behaviour towards them as the reason for not involving themselves in such programmes.The seven respondents who had not declared their HIV status in the workplace were not involved in any HIV/AIDS programmes offered by their employer due to their fearing that their HIV status would become known through any such involvement.

Discrimination and protection by law
Of the 20 respondents, 14 believed that they had not been the victim of unfair discrimination at work due to their HIV status, while four believed that they had suffered in terms of job loss, promotions and opportunities in general at work due to their HIV status.
Only four of the 20 respondents believed the provisions of the South African Constitution and legislation afforded them the protection and rights that they deserve within the workplace.The majority ( 16) respondents stated that they were not granted the protection and rights that they deserve at work.Reasons for this response included the fact that HIV-positive employees can still get fired or receive early retirement due to incapacity as a result of HIV-related illness.Another reason for this response was that little protection is offered to HIV-positive employees in terms of social discrimination and stigmatisation.The law does not extend to this ethical, social area of HIV/AIDS in the workplace, according to 13 respondents, and leaves these rights unprotected.

Solutions
Respondents were asked to offer possible solutions to the problem of accommodating both HIVpositive and HIV-negative employees in the workplace, if they believed such a problem to exist.All 20 respondents believed such a problem to exist and offered a number of possible solutions, including increased awareness through pamphlets and other literature, educational programmes compulsory for all employees (including management) on HIV/AIDS, and offering medical treatment in the workplace.
Further solutions offered by respondents were the development of a comprehensive AIDS policy within the organisation outlining all aspects of accommodation, management and treatment of HIV-positive employees and the encouragement of community involvement from employees in the combat of HIV/AIDS.Psychological counselling for employees and their families, ensuring a safe and healthy working environment for all employees and offering sensitivity and attitudinal training courses for all employees on the topic of HIV/AIDS in the workplace were other potential solutions cited by respondents.

DISCUSSION
Thirteen of the 20 respondents had declared their status publicly at work (to their superiors and/or co-workers), indicating that these employees were willing to be open and honest about their HIV infection.An issue of concern, however, is the question of privacy and confidentiality.In three cases where HIV-positive respondents had declared their HIV status to management, but not to their co-workers, these co-workers had found out about their declaration or had subsequently developed a suspicion about their status leading to direct confrontation.
The implications of this are that employeesand perhaps managementwere involved in informal discussions about the respondents in question and their state of health.This is unprofessional and a clear invasion of privacy, as HIV-positive employees are under no obligation to volunteer such information if they prefer to keep it confidential.Discussing a co-worker behind his or her back and speculating about his or her health is not only work unrelated, but can contribute to a social environment of distrust, stigmatism and avoidance of the person in question.
The fact that seven respondents had not declared their HIV status at work at the time of this study is another point of concern.Fear of stigmatisation, ostracism, non-acceptance from co-workers and/or superiors and avoidance were all cited as reasons behind the decision taken by these respondents to keep their HIV status a secret.This type of fear and the constant concern over whether co-workers or superiors will find out your HIV status undoubtedly create additional stress for HIV-positive employees within the workplace.This fear has been learned from previous experience or from vicarious learning through the experiences of others and has led to the respondents in question expending additional effort on preventing others in the workplace from finding out about their HIV status.
Negative changes cited by respondents included avoidance, fear, suspicion and abandonment, which offers confirmation of the fear expressed by the seven respondents who had not declared their HIV status at work.These were the exact reasons cited by those seven respondents for keeping their HIV status a secret.Positive changes in terms of attitudes, behaviour and perceptions of co-workers and/or superiors included support and understanding.These changes, however, were cited by comparably fewer respondents, leaving the overall changes identified as negative ones.These findings imply the existence of stigmatisation of HIV-positive employees in the workplace.
All 12 respondents experiencing changes from co-workers and/or superiors since the declaration of their HIV status stated that these changes had affected them.Negative changes affected respondents negatively.Levels of job satisfaction, motivation, well-being and esteem were said to decrease and levels of depression, anger, anxiety, stress and fear of rejection were said to increase with the occurrence of negative changes within the workplace.These negative effects on HIVpositive employees due to actual or feared stigmatisation are not only costly in terms of the welfare of the individuals affected, but also in terms of the wellbeing of the organisation itself due to decreased motivation and job satisfaction.Robbins (1998) stated supportive colleagues and supportive working conditions to be two vital aspects of job satisfaction.From the findings of the interviews, in many cases these two conditions were not being met for HIV-positive employees.
Positive changes, however, were said by respondents to increase motivation, hope and strength, while decreasing stress.These positive effects are, once again, of importance for both the individual's welfare and that of the organisation.Stress, as previously discussed, has a negative impact on the immune system and can prove to be a key factor in increasing the progression of the HIV virus in sufferers, causing more health complications than necessary.Unfortunately, these positive changes were only experienced by a few respondents, with the majority of respondents experiencing negative changes and subsequent negative effects.Therefore, only a few respondents could benefit from the positive effects on motivation, stress and strength, while most respondents had to deal with the negative impacts on motivation, job satisfaction, stress and general wellbeing.
The fact that more work environments had a negative reaction to the HIV-positive status of a coworker instead of a positive reaction reinforces the notion of the presence of stigmatisation of HIV-positive members of the workforce.Of great importance, in addition to identifying the presence of such a stigma, is establishing the impact that this problem has on HIV-positive members of the workforce as well as on the organisations for which they work.These findings show that such stigmatisation could be affecting motivation, stress levels, hope, job satisfaction and the general well-being of HIV-positive employees, which in turn can effect the well-being and success of the organisation.Although a consistent correlation between job satisfaction and productivity has yet to be confirmed by research, a negative correlation between job satisfaction and absenteeism as well as job satisfaction and labour turnover has been confirmed by research (Robbins, 1998).Motivation affects performance because it has a bearing on the amount of effort exerted by the individual in his or her job (Robbins, 1998).
Of the 20 respondents in this study, 12 stated that they had been motivated to leave their jobs in the past due to attitudes, perceptions and behaviours directed towards them or another HIVpositive employee because of their HIV status.A further point of concern is the fact that the need for income was the reason cited by these individuals for remaining in their jobs, despite motivation to leave.This implies that the situation prompting their motivation to leave has not been entirely resolved, but their financial situation does not allow them to leave their jobs in search of more favourable conditions.
The fact that only seven of the 20 respondents were involved in HIV/AIDS programmes offered by their employer is very troubling.This lack of involvement reveals that participation in HIV/AIDS programmes is voluntary and not compulsory to all employees, regardless of their HIV status.The threat posed by HIV/AIDS is so great that not making participation in awareness and educational programmes compulsory is dangerously negligent on the part of employers.
Respondents not involved in these programmes at work cited fear of negative reactions from their co-workers and stigmatisation as reasons for their choice.This fear of involvement could once again confirm the possible presence of stigmatisation of HIV-positive employees in the workplace.

Limitations
The absence of prior empirical research on stigmatisation of HIV-positive employees in the South African context limited the availability of resources to be used as background for or guidelines in this study.The small sample size, although deemed sufficient for this exploratory qualitative study, did not allow for validity and reliability to be ascertained through complex statistical analysis.The willingness of potential respondents to participate freely in this study and the high rate of attrition of potential respondents due to fear of their participation becoming publicly known were further limitations.The sensitivity of the topic may have served to limit the study due to the emotional content and subjectivity of responses.

Recommendations for future research
Research of this topic using a sample size large enough to undergo more complex statistical analysis to ascertain the validity and reliability of the research instrument -and hence its findingsshould be undertaken to confirm the evidence suggested by this exploratory study.Research into the causes of stigmatisation of HIV-positive individuals should be undertaken in order to try and overcome such stigmatisation.Although previous research has identified certain causes of this stigmatisation of HIV positive individuals, the South African context could prove to hold additional and unique causes.

SUMMARY
The rate at which HIV/AIDS is spreading in South Africa, despite media campaigns on HIV/AIDS and the formation of HIV/AIDS associations throughout the country, is cause for great alarm.
HIV/AIDS poses a huge threat to business organisations, communities and the economy of South Africa.
HIV/AIDS is not a short-term illness.An individual can be HIV-positive for many years without showing any physical symptoms of his or her infection.An HIV-positive employee, therefore, can make a worthwhile and valuable contribution to the organisation and is not necessarily disabled in any way by the virus.Even if preventative measures presently being taken in this country could lower the transmission rate of HIV to zero, many South Africans are already infected with the virus and hence it still threatens business and the economy in terms of costs, including loss of skilled employees, increased benefit schemes and decreased employee morale.
Previous research on stigmatisation attached to HIV/AIDS has shown this stigmatisation to result from ignorance, fear, misinformation and irrational responses to the disease and topics related to this disease, including promiscuity, drug use and death.In South Africa research has shown the presence of stigmatisation.Although no previous empirical research on stigmatisation of HIVpositive employees in the South African context was found, published literature offers support for the presence of stigmatisation.Documented accounts by HIV-positive employees, describing their treatment within the workplace by co-workers and superiors and cases of legal action taken by HIV-positive employees against their employer due to unfair treatment within the workplace confirm that the problem of stigmatisation of HIV-positive employees exists in South Africa.
On the basis of published literature, as well as this qualitative study, it can be concluded that stigmatisation of HIV-positive employees, based on their HIV status, occurs in South Africa.This stigmatisation impacts negatively on HIV-positive employees' job satisfaction and motivation, while increasing turnover intentions.Stigmatisation, therefore, threatens the welfare of HIVpositive employees, organisational climate and bottom-line profits of businesses in terms of labour costs.Such stigmatisation against HIV-positive employees should be addressed and steps taken to eliminate this threatening phenomenon.