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. Author manuscript; available in PMC: 2026 Apr 7.
Published before final editing as: Stigma Health. 2025 Apr 7:10.1037/sah0000635. doi: 10.1037/sah0000635

Association between HIV knowledge and stigma among HIV healthcare workers in the Dominican Republic: The role of empathy and social distance

Ibrahim Yigit 1,*, Robert Paulino-Ramírez 2, John Waters 3, Dustin M Long 4, Janet M Turan 5,6, Henna Budhwani 1
PMCID: PMC12463302  NIHMSID: NIHMS2063798  PMID: 41020093

Abstract

Out-of-date HIV knowledge among healthcare workers (HCW) can hinder the quality of care for people with HIV (PWH) and contribute to stigmatizing attitudes and behaviors. However, the role of HIV knowledge on stigma and mechanisms underlying HCWs’ attitudes and behaviors remain understudied. This study examined empathy and social distance as mediators in the relationship between HIV knowledge and stigma toward PWH among HCWs. Cross-sectional data from 219 HCWs were collected at two clinics in the Dominican Republic. Serial mediation analyses examined the indirect effects of HIV knowledge on stigmas (i.e., worry related to contracting HIV, taking additional infection precautions, and moralizing opinions about PWH’s behaviors) through empathy and social distance, adjusting for age and sexual orientation. Mean age was 42.16 years (SD=11.97). Most participants identified as female (79.9%), heterosexual 68.9%, and multi-racial (71.7%). The serial mediation models revealed significant indirect effects, suggesting that insufficient HIV knowledge was associated with less empathy toward PWH (B=1.92, β=.33, SE=.37, p<.001). Lower empathy, in turn, was associated with greater desire for social distance (B=.15, β=.18, SE=.06, p=.009). Greater social distance was subsequently linked to increased worry related to contracting HIV (B=.13, β=.21, SE=.04, p=.001), taking additional infection precautions (B=.06, β=.14, SE=.03, p=.035), and more moralizing opinions about PWH (B=.11, β=.13, SE=.05, p=.027). Interventions that improve HIV knowledge and foster empathy, thereby possibly reducing the desire for social distance from PWH among HCWs, should be explored to test their potential to mitigate HIV stigma and enhance care outcomes for PWH.

Keywords: HIV knowledge, stigma toward people with HIV, healthcare workers, empathy, social distance

Introduction

HIV-related stigma, a psychosocial phenomenon where people with HIV (PWH) face negative attitudes, beliefs, and behaviors from others because of their HIV status, remains a significant barrier to optimal HIV treatment and care (Earnshaw & Chaudoir, 2009; Link & Phelan, 2001; Sweeney & Vanable, 2016; Turan, Hatcher, et al., 2017). Prior evidence indicates that various dimensions of HIV-related stigma—such as experienced (actual experiences of discrimination), anticipated (the expectation of stigma in the future), perceived community (the belief that others in the community hold negative attitudes toward PWH), and internalized stigma (the internalization of societal stigma by individuals themselves) (Earnshaw & Chaudoir, 2009; Turan, Budhwani, et al., 2017; Turan, Hatcher, et al., 2017)—are linked to a variety of adverse HIV health outcomes and behaviors (Katz et al., 2013; Rueda et al., 2016; Sweeney & Vanable, 2016). These include suboptimal medication adherence, failure to achieve viral load suppression, missed clinic appointments, reduced access to medical care, and poor physical and mental health (Rueda et al., 2016; Turan, Budhwani, et al., 2017; Turan, Hatcher, et al., 2017; Yigit et al., 2020; Yigit et al., 2024). PWH may face stigma across different environments (e.g., community, healthcare, religious settings) and from a range of individuals, including family members, friends, romantic partners, and healthcare workers (HCW) (Crockett et al., 2022; Turan, Hatcher, et al., 2017). Stigma in healthcare settings can be especially harmful (Kay et al., 2018; Rice et al., 2019; Turan, Budhwani, et al., 2017), given that PWH frequently interact with healthcare staff and need support and quality care. Research has suggested that stigma and discrimination within healthcare environments can negatively impact health outcomes and behaviors for PWH, including fostering low trust in physicians (Kay et al., 2018), poorer antiretroviral treatment (ART) adherence (Rice et al., 2019; Turan, Rogers, et al., 2017; Yigit et al., 2024), and mental health problems (e.g., depressive symptoms) (Rueda et al., 2016; Turan, Rogers, et al., 2017). Therefore, understanding the factors among HCWs in HIV clinics that contribute to stigma toward PWH is crucial for preventing stigma development and improving efforts in HIV prevention and treatment.

One potential precipitating factor that triggers stigmatizing attitudes and behaviors toward PWH can be insufficient or out-of-date knowledge related to HIV. Social science theories propose that stigma stems from the inherent human tendency to classify objects and people based on pre-existing knowledge structures, such as schemas and prototypes, which help organize and simplify complex social information encountered in daily life (Goffman, 2009; Jones, 1984; Major & O’brien, 2005). Although these knowledge structures may be useful for making quick judgments with minimal effort, they can also have negative consequences, including the formation of stereotypes, which form the basis of stigmatizing attitudes (Earnshaw & Chaudoir, 2009; Goffman, 2009; Jones, 1984; Link & Phelan, 2001). For example, in qualitative and quantitative studies conducted with general populations, out-of-date HIV knowledge has emerged as a significant determinant of stigmatizing and discriminatory attitudes toward PWH (Beaulieu et al., 2014; Bozkurt & Bayırlı Turan, 2020; Fauk et al., 2021; James & Ryan, 2018; Letshwenyo-Maruatona et al., 2019; Lifson et al., 2012; Mahamboro et al., 2020).

Furthermore, even HCWs working in HIV clinics can have inadequate HIV knowledge, harboring myths and misconceptions about HIV transmission and the disease itself, which can serve as the root of stereotypes and, consequently, stigma (Feyissa et al., 2019; Rutledge et al., 2011). HCWs with lower levels of HIV knowledge may overestimate the risk of casual transmission, leading to avoidance behaviors, unwarranted fears, or discriminatory practices, such as maintaining excessive physical distance, using judgmental language, or providing suboptimal care—all of which are stigmatizing behaviors toward PWH (Crockett et al., 2022; Fauk et al., 2021; Geter et al., 2018; Rice et al., 2019; Rintamaki et al., 2007; Sayles et al., 2007). Studies (Davtyan et al., 2017; Harapan et al., 2013; Vorasane et al., 2017) have suggested that insufficient HIV knowledge among HCWs in both the US and other countries is a precipitating and perpetuating factor of stigmatizing attitudes toward PWH. Additionally, a review study (Nyblade et al., 2009) suggests that three primary causes of HIV stigma in healthcare settings are limited awareness among healthcare workers about the manifestations and harms of stigma, fear of casual contact due to incomplete knowledge about HIV transmission, and the association of HIV with inappropriate or immoral behavior. On the other hand, there is evidence suggesting that having in-depth knowledge of HIV was associated with lower levels of stigma and discrimination toward PWH (Delobelle et al., 2009; Feyissa et al., 2012). Thus, elucidating how HCWs’ level of HIV knowledge contributes to the development of their stigmatizing attitudes and behaviors toward PWH is crucial for informing targeted interventions aimed at reducing stigma in healthcare settings, thereby ultimately improving the quality of care for PWH. This need is particularly stark in the Dominican Republic (DR), which has a conservative cultural orientation (Arregui, 2007; Malta et al., 2019), where stigmatizing and discriminatory behaviors against PWH and sexual and gender minorities (SGM) are widespread, and HCWs are likely to exhibit stigmatizing attitudes and behaviors toward PWH who identify as SGMs (Budhwani et al., 2022; Figueroa, 2014; Geibel et al., 2020; Kerr et al., 2024; Rojas et al., 2011; Yam et al., 2020; Yigit et al., 2024).

Understanding the relationship between HIV knowledge and stigma among HCWs is essential, as stigma can impact health outcomes and behaviors for PWH and exacerbate health disparities. However, HIV knowledge alone may not fully explain the drivers of stigma in healthcare settings; identifying the underlying mechanisms through which insufficient HIV knowledge leads to stigmatizing attitudes and behaviors is necessary. Among various mechanisms, empathy (or lack thereof) and the desire for social distance (avoidance) from PWH can play significant roles in shaping HCWs’ attitudes and behaviors. Existing studies conducted with both healthcare staff and community samples have found that higher levels of empathy are linked to less stigma and discrimination toward PWH (Olapegba, 2010; Özakgül et al., 2014; Sianturi et al., 2022) as well as less avoidance (Lin et al., 2012). This suggests that empathy may act as a buffer against stigma, reducing stigmatizing attitudes and discriminatory practices among HCWs, as empathy fosters a more person-centered approach to care and encourages HCWs to view PWH holistically. Similarly, negative perceptions and stigmatizing practices toward PWH among HCWs can also be manifested in a desire for social or physical distancing—reflecting a lack of closeness or willingness to engage with individuals from different social groups (Kalichman et al., 2017; Link & Phelan, 2001; Nyblade, 2006; Rintamaki et al., 2007; Von Collani et al., 2010)—creating barriers to effective and respectful healthcare. Reasons for HCWs to exhibit social or physical distancing toward PWH may include out-of-date knowledge about HIV (e.g., viewing PWH as “high-risk” or “contagious”), low empathy, fear of stigmatization by others, and cultural and institutional norms. Despite existing knowledge, a systematic understanding of how lack of empathy and the desire for social distance, alongside insufficient HIV knowledge, influence stigmatizing and discriminatory attitudes and behaviors toward PWH among HCWs remains lacking.

To address gaps in this knowledge area, we examined whether HIV knowledge is associated with various dimensions of stigma in healthcare settings (i.e., worry related to contracting HIV, taking additional infection precautions, and moralizing opinions about PWH’s behaviors), mediated through empathy and desire for social distance, among HCWs in the DR. More specifically, we hypothesize that HCWs with insufficient HIV knowledge may have less empathy for PWH, which subsequently results in greater desire for social distance. Desire for social distance, in turn, leads to greater stigmatizing and discriminatory attitudes toward PWH. Findings from this study will contribute to our understanding of the psychological and social mechanisms that shape stigmatizing attitudes and behaviors among HCWs in the DR, where cultural and societal norms may compound stigma against certain populations (e.g., PWH). These insights can inform strategies to reduce stigma in healthcare settings, thereby creating an environment where PWH can receive optimal treatment and care.

Methods

Participants & Procedures

Survey respondents were HCWs from two clinics in the DR during 2021–2022 (ClinicalTrials.gov ID: NCT04491539). The details of this pilot trial can be found elsewhere (Batey et al., 2016; Budhwani et al., 2022). Inclusion criteria were being 18 years or older, having exposure to PWH for at least four hours per week, and fluency in Spanish. Surveys were anonymous, and therefore informed consent was not collected. Data were collected at four different time points at clinics that had a one-time stigma-reduction workshop (including a limited number of HCWs) as a part of the pilot trial during the study period. The study was approved by the Institutional Review Boards at the University of Alabama at Birmingham (IRB-300005657), Universidad Iberoamericana (UNIBE, CEI2020–32), and Florida State University (STUDY00003459) and signed informed consent was obtained from all participants.

Measures

HIV knowledge

HCWs’ HIV knowledge was assessed using 13 yes-no items (e.g., “Can HIV/AIDS be cured?”) developed within this study for local context benefitting from the existing scales (e.g., HIV Knowledge Questionnaire [Carey and Schroder, 2002]). The questionnaire assigns one point for each correct answer and zero points for incorrect answers or responses such as “don’t know” or “prefer not to answer.” In this study, we reversed the mean score to reflect insufficient knowledge, making interpretation easier. Cronbach’s alpha was .59.

Stigmatizing attitudes and behaviors among healthcare providers

We used Nyblade et al.’s (2013) brief scales to measure stigmatizing attitudes and behaviors among healthcare staff, focusing on three stigma dimensions: worry related to contracting HIV measured with 4 items (e.g., “Dressing the wounds of a client living with HIV”; Cronbach’s α=.60) rated on a 3-point Likert scale (1=Not worried, 3=Very worried); taking additional infection precautions measured with 4 yes-no items (e.g., “Wear double gloves”; Cronbach’s α=.76); and moralizing opinions about PWH’s behaviors measured with 5 items (e.g., “People living with HIV should feel ashamed of themselves”; Cronbach’s α=.78) rated on a 4-point Likert scale (1=Strongly agree, 4=Strongly disagree). Higher scores on these dimensions indicate higher stigmatizing attitudes and behaviors.

Empathy

To measure empathy in healthcare professionals, we used 11 items adapted from the Jefferson Scale of Physician Empathy (JSPE) (Hojat et al., 2002; Lin et al., 2012), tailored to the context of HIV care. Items (e.g., “Clients with HIV feel better when I understand their feelings”) were rated on a 5-point Likert scale (1=Strongly Agree, 5=Strongly Disagree), with higher scores indicating less empathy. Cronbach’s alpha was .84 in this study.

Desire for social distance

The desire for social distance from PWH was assessed using the Bogardus Social Distance Scale (Bogardus, 1933), consisting of 7 items adapted to measure level of interpersonal contact of HCWs with PWH. Items (e.g., “How would you feel about introducing someone with HIV to your friends?) were rated on a 4-point Likert scale ranging from “definitely willing” to “definitely unwilling”, with higher scores indicating greater desire for social distance (less engagement). In this study, Cronbach’s alpha was .66

Data analysis

We calculated descriptive statistics for participants. We conducted serial mediation models where insufficient HIV knowledge is associated with stigma dimensions (i.e., worry related to contracting HIV, taking additional infection precautions, and moralizing opinions about PWH’s behaviors) through first lack of empathy and then desire for social distance. Covariates included age and sexual orientation. For the serial mediation models, we used SPSS PROCESS macro (Model 6), employing 5,000 bootstrapping resamples with 95% percentile confidence intervals (CI). According to this procedure, if CIs don’t have a zero, this is a significant mediation (indirect) effect (Hayes, 2017). All of the analyses were cross-sectional, using the mean scores for each variable. We reported both unstandardized and standardized coefficients for the paths in the serial mediation models. Data were analyzed via SPSS (Version 29).

Data availability statement

The data used in this study are available from the corresponding author upon reasonable request.

Results

Descriptive statistics are presented in Table 1. HCWs who participated in the survey included: nurse, physician, psychologist, social worker, pharmacist/pharmacy technician, laboratory technician, health educator, dentist, administrator, clinical aide, administrative support (reception, clerical, financial services), disease intervention specialist, investigator, and other (e.g., customer service, bioanalyst, security officer, archivist). Among 219 HCWs, the mean age was 42.16 years (SD=11.97; range=18–75). Most participants (79.9%) identified as female, 68.9% identified as heterosexual, and 71.7% as multi-racial.

Table 1.

Descriptive Statistics

Variable N(%)
HCW Category
 Nurse 32(14.6)
 Physician 20(9.1)
 Psychologist 12(5.5)
 Social worker 5(2.3)
 Pharmacist/pharmacy technician 7(3.2)
 Laboratory technician 3(1.4)
 Health educator 4(1.8)
 Dentist 3(1.4)
 Administrator 6(2.7)
 Clinical aide 6(2.7)
 Administrative support (reception, clerical, financial services) 43(19.6)
 Disease intervention specialist 1(.50)
 Investigator 1(.50)
 Other (e.g., customer service, bioanalyst, security officer, archivist) 76(34.7)
Gender
 Male 44(20.1)
 Female 175(79.9)
Sexual Orientation
 Heterosexual 151(68.9)
 Same gender attracted 60(27.4)
 Bisexual 5(2.3)
 Prefer not to respond 3(1.4)
Race
 Black 24(11.0)
 Multi-racial 157(71.7)
 White 29(13.2)
Education
 < High school 51(23.3)
 ≥ High school 168(76.7)
Migrant
 Yes 6(2.7)
 No 213(97.3)
M(SD, range)
Age 42.16(11.97, 18–75)
Insufficient HIV knowledge .19(.13, 0–.77)
Empathy 2.14(.77, 1–3.5)
Desire for social distance .63(.64, 0–3)
Worry related to contracting HIV .83(.40, 0.3–2.3)
Taking additional infection precautions .16(.25, 0–1)
Moralizing opinions about PWH’s behaviors 1.90(.54, 1–4)
Open in a new tab

First, we tested the serial mediation model from insufficient HIV knowledge to worry related to contracting HIV, mediated through empathy and desire for social distance. The total effect of insufficient HIV knowledge on worry related to contracting HIV was significant when empathy and desire for social distance were not in the model (B=.85, β=.28, SE=.20, p<.001). The serial indirect effect was also significant (B=.04, SE=.02, 95% CI[.005, .093]; see Figure 1), suggesting that insufficient HIV knowledge was significantly associated with less empathy (B=1.92, β=.33, SE=.37, p<.001), which in turn was associated with higher desire for social distance (B=.15, β=.18, SE=.06, p=.009), subsequently resulting in greater worry related to contracting HIV (B=.13, β=.21, SE=.04, p=.001).

Figure 1.

Figure 1.

Open in a new tab

Serial mediation model of HIV knowledge on worry related to contracting HIV through empathy and social distance. *p<.05, **p<.01, ***p<.001. B=Unstandardized coefficient, β=Standardized coefficient (beta). aDirect effect when the mediators are in the model.

On the other hand, the total effect of insufficient HIV knowledge on taking additional infection precautions was not significant (B=.22, β=.12, SE=.12, p=.073). The serial indirect effect of insufficient HIV knowledge on taking additional infection precautions first through less empathy and then through desire for social distance was significant (B=.02, SE=.01, 95% CI[.001, .045]; see Figure 2). Finally, the total effect of insufficient HIV knowledge on moralizing opinions about PWH’s behaviors was significant (B=1.20, β=.30, SE=.26, p<.001). The serial indirect effect of insufficient HIV knowledge on moralizing opinions about PWH’s behaviors first through less empathy and then through desire for social distance was also significant (B=.03, SE=.02, 95% CI[.002, .080]; see Figure 3).

Figure 2.

Figure 2.

Open in a new tab

Serial mediation model of HIV knowledge on taking additional infection precautions through empathy and social distance. *p<.05, **p<.01, ***p<.001. B=Unstandardized coefficient, β=Standardized coefficient (beta). aDirect effect when the mediators are in the model.

Figure 3.

Figure 3.

Open in a new tab

Serial mediation model of HIV knowledge on moralizing opinions about PWH’s behaviors through empathy and social distance. *p<.05, **p<.01, ***p<.001. B=Unstandardized coefficient, β=Standardized coefficient (beta). aDirect effect when the mediators are in the model.

Discussion

A growing body of research indicates that PWH experience stigma and discrimination in healthcare settings, which contributes to suboptimal HIV health outcomes and behaviors for PWH, such as poorer ART adherence, failure to achieve viral load suppression, and compromised psychological and physical health (Kay et al., 2018; Nyblade et al., 2013; Rice et al., 2019; Turan, Rogers, et al., 2017; Yigit et al., 2024). Thus, this study aims to explore factors associated with stigmatizing attitudes and behaviors toward PWH among HCWs in the DR. Consistent with previous studies (Davtyan et al., 2017; Vorasane et al., 2017), our findings suggest that limited or outdated HIV knowledge among HCWs is associated with greater worry about contracting HIV while providing care to PWH, as well as with judgmental or moralizing opinions about the behaviors of PWH. In other words, inadequate knowledge appears to lead to or reinforce stigmatizing attitudes, possibly through ignorance, fear, and perpetuation of myths related to HIV.

However, stigma in healthcare settings is not driven solely by knowledge gaps; it is also shaped by broader structural and institutional factors, including power imbalances that allow stigmatizing behaviors to persist. For example, while limited knowledge may lead to excessive physical distancing (e.g., avoiding contact with the clothing or bedding of a person with HIV), the use of judgmental language and moralizing attitudes likely reflects not only ignorance but also systemic issues (e.g., entrenched hierarchies) within healthcare institutions (Chambers et al., 2015; Pantelic, Sprague, & Stangl, 2019). These hierarchies may normalize discrimination and reinforce negative attitudes toward PWH, particularly in settings where accountability for stigma-reducing practices is weak As a result, HCWs with inadequate training or exposure to updated information about HIV transmission, progression, and treatment may engage in discriminatory practices, such as maintaining excessive physical distance (e.g., worrying about touching the clothing or bedding of an individual with HIV) and moralizing their behaviors (e.g., believing that HIV is punishment for immoral behavior or that they should feel ashamed of their HIV status) (Naughton & Vanable, 2013). These practices are reinforced by institutional norms, which may lead to the provision of suboptimal health care.

Conversely, it can be concluded that adequate HIV knowledge may equip HCWs with the confidence to effectively engage with PWH without relying on outdated information or misconceptions. HCWs who feel knowledgeable and competent in delivering care can likely treat PWH with dignity and respect, thereby decreasing stigmatizing behaviors towards PWH. However, given the multifaceted nature of stigma, interventions must go beyond knowledge improvement alone (Ikeda et al., 2019). While training and education are essential components of stigma reduction, evidence suggests that education-only approaches have suggested limited success in fully eliminating stigma (Pantelic, Sprague, & Stangl, 2019; Pantelic, Steinert, et al., 2019). Thus, stigma-reduction interventions must also address structural determinants, including power dynamics within healthcare institutions, policies that reinforce discrimination, and the need for accountability in promoting equitable and nonjudgmental care (Pantelic, Sprague, & Stangl, 2019; Stangl et al., 2013). Our finding underscores the importance of developing HCW-centered stigma-reduction interventions that focus not only on improving knowledge and training in HIV care but also on addressing the institutional and systemic factors that perpetuate stigma. These interventions should include a range of HCWs, not simply clinical providers, as stigma manifests across multiple levels of care. Such efforts could play a pivotal role in advancing national HIV prevention and care goals by minimizing stigma and promoting equitable healthcare for PWH, especially in the Latin American and Caribbean (LAC) region, including the DR, which has one of the highest HIV prevalence rates in the region (Coelho et al., 2021).

Another important finding is that empathy and desire for social distance mediate the relationship between HIV knowledge and stigmatizing attitudes and behaviors of HCWs. Specifically, insufficient HIV knowledge is associated with reduced empathy (greater apathy), which in turn is associated with a stronger desire for social distance. This cascade ultimately results in increased worry about contracting HIV, the adoption of excessive infection precautions, and more moralizing opinions about PWH. Our findings suggest that HCWs who are not well-informed about the medical and psychosocial complexities of HIV may develop lower levels of empathy (more apathy) toward PWH, overlooking the real-life impacts of HIV on individuals. This can lead to dehumanizing perspectives, wherein PWH are viewed primarily through the lens of disease, behavior, and stigma. Such attitudes are linked to a less accepting, supportive, and understanding stance toward PWH. In turn, a lack of empathy is likely to increase social distance—desire to keep social or physical distance from PWH—which contributes to avoidance behaviors and reluctance to engage closely with PWH, ultimately decreasing compassionate care and increasing the likelihood of stigmatizing attitudes and behaviors. These findings suggest that increasing HIV knowledge alone may not be sufficient to counteract negative stereotypes, biases, and stigma among HCWs. Efforts must also focus on addressing affective factors and behavioral tendencies that sustain stigma, such as fostering empathy and reducing desires for social distance, leading to higher-quality interactions with PWH and contributing to more equitable healthcare, where PWH feel safe, respected, and understood.

The study has limitations which should be considered when interpreting the findings. While the findings provide valuable insights, they may not be generalized to the broader population of HCWs or HIV care providers and to countries or regions with different cultural, social, and healthcare contexts. Second, factors such as personal experiences with HIV, prior knowledge, training about HIV, or exposure to PWH could not be accounted for and may have influenced the relationships between HIV knowledge, empathy, social distance, and stigma. Third, there are other potential determinants of stigma, such as institutional policies, workload pressures, and cultural attitudes toward HIV, which were not examined and but might also play significant roles. Fourth, data from four time points were utilized, acknowledging the potential for non-independent observations, which should be taken into consideration when interpreting the results. Finally, we used a cross-sectional design, which limits the ability to establish causality and changes over time among the examined relationships, and alternative explanations must be considered. While our mediation model suggests that insufficient HIV knowledge leads to lower empathy, which subsequently increases social distancing and stigmatizing behaviors, the directionality of these associations may not be strictly unidirectional. For instance, concerns about HIV transmission may drive distancing behaviors rather than vice versa, and broader institutional norms that reinforce stigma could shape these interactions in complex ways. Additionally, while our model posits that knowledge deficits contribute to reduced empathy, prior research suggests that empathy itself may influence knowledge acquisition, as more empathetic healthcare providers are often more motivated to engage with and retain patient-centered information (Decety & Fotopoulou, 2015). It is also possible that individuals with lower empathy are less inclined to seek out or integrate updated HIV-related knowledge, thereby reinforcing stigmatizing attitudes. Beyond a simple lack of access to information, willful ignorance may also contribute to persistent stigma in healthcare settings. Some HCWs may actively avoid HIV-related knowledge that challenges their beliefs or requires behavior change (Vu et al., 2023). This avoidance may be driven by discomfort, institutional norms, or moralizing attitudes toward PWH, reinforcing the very stigma that education-based interventions seek to reduce. Given these potential bidirectional relationships, future research employing longitudinal or experimental designs is needed to clarify the temporal sequencing of these variables and determine the most effective points of intervention for reducing HIV-related stigma among healthcare workers.

Overall, this study suggests the importance of addressing both cognitive and affective factors to reduce stigmatizing attitudes and behaviors toward PWH among HCWs. Tailored interventions that enhance HIV knowledge and foster empathy, while simultaneously reducing desires for social distance, could play a critical role in improving HCW-patient interactions. By targeting these components, such interventions may not only mitigate stigma but also improve treatment outcomes and care behaviors for PWH, ultimately contributing to better health equity in HIV care. Additionally, our findings emphasize the value of examining the stigma process from the perspectives of potential stigmatizers (e.g., healthcare staff). Such an approach is vital for understanding stigma’s detrimental effects and for designing effective stigma-reduction strategies.

Positionality Statement.

The following positionality statements regarding our research team’s professional and personal identities may influence how our study findings are interpreted. Our team included researchers with MD and PhD degrees, as well as MPH-trained research staff based in the United States and the Dominican Republic. All team members identified as cisgender, with some identifying as sexual minorities. The three Principal Investigators had prior experience working with transgender and sexual minority populations. All members of the research team were dedicated to upholding ethical and equitable research practices and were committed to presenting findings that authentically capture the complexities of our participants’ experiences.

Clinical impact statement.

Healthcare workers with outdated HIV knowledge may unintentionally contribute to stigma, which can negatively impact care for people with HIV (PWH). This study suggests that improving HIV knowledge among healthcare workers is associated with empathy, reduces social distance, and diminish stigmatizing attitudes and behaviors toward PWH. These findings suggest the importance of educational interventions that focus on both accurate HIV information and empathy-building to enhance care quality and reduce stigma in healthcare settings. By addressing these factors, healthcare organizations can create a more supportive environment for PWH and improve health outcomes.

Acknowledgements

We thank Katelin Adams, Ingrid Ruiz De León, and Analía Henríquez Cross for their early work supporting this project. We acknowledge the contributions of our intervention facilitators, data collectors, and community advocates: Dr. Rosa Mayra Rodriguez-Lauzurique, Mr. Elias Ramos, and Ms. Nairovi Castillo. We also want to express our gratitude to our partner SGM community-based organizations in the Dominican Republic for all their support. Our team recognizes the valuable insights provided through their participation. We also acknowledge the political support and encouragement of the Servicio Nacional de Salud (SNS) authorities.

Funding and Support

Research reported in this publication was supported by the National Institute of Mental Health (NIMHD) and the Fogarty International Center (FIC) of the National Institutes of Health (NIH) under Award Numbers R21MH124083 and R21TW011761.

Footnotes

Conflict of Interest

None.

Data availability statement

The data used in this study are available from the corresponding author upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data used in this study are available from the corresponding author upon reasonable request.

The data used in this study are available from the corresponding author upon reasonable request.

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