Reducing Stigma and Discrimination

A study and intervention in two communities in Vietnam found that project interventions led to a significant increase in awareness of stigma, reduction in fear of becoming infected with HIV through casual contact with HIV-positive people and stigma and intentions concerning stigmatizing behavior. Better, more complete knowledge of how HIV was not transmitted translated into a greater degree of acceptance of people living with HIV and their family members. Stigma was so strong in these communities that no one was open about their HIV-positive serostatus. The intervention consisted of a workshop with community leaders to sensitize leaders on the impact of stigma and to provide knowledge on HIV and to meet people living with HIV. Each community designed activities to reduce stigma: distributing an HIV and stigma fact sheet; meetings; posters; drama; school sessions for students and teacher; and support groups for people living with HIV. 35 focus group discussions and 97 in-depth interviews were conducted with people living with HIV, family members and community members. 700 in each community were sampled at prior to the intervention and at the end of the project, fourteen months later. Prior to the project, people living with HIV reported not accessing health services due to fear of disclosure of their serostatus. Exposure to multiple activities led to greater increases in stigma reduction. However, the intervention was less effective in reducing blame toward HIV-positive people, especially sex workers and IDUs.

Between 2004 and 2006, a project in Thailand that paired HIV-positive with an HIV-negative partner to receive loans to create a small business found that HIV-negative partners reported greater willingness to participate in activities with HIV-positive people. Within a few months, the percent of people involved in the project who said they would be comfortable visiting a house of an HIV-positive person increased from 20% to 90%. HIV-positive partners reported they no longer felt they had to accept discrimination. People living with HIV who participated in the project reported improvements in quality of life, as well as in their economic, social, physical and mental well being between 2004 and 2006. In addition, 91% of the loans have been repaid on time. Both partners needed training in basic business skills. Women comprise the majority of the participants. More than 42% of all participants paired two women and 39% were composed of one man and one woman.

An intervention from 2005 to 2007 with 2,800 school children ages 12 to 15 in rural schools in Bosnia and Herzegovina that increased knowledge on HIV transmission via bodily fluids decreased the fear of socializing with HIV- positive people from 46% at baseline to under 13% by the end of project surveys. 150 pupils, aged 13 to 14, 62% girls and 38% boys were surveyed at the beginning of the project and at the end.

A study in Vietnam that provided training to 975 hospital workers who received a one and a half day training on HIV and universal precautions, along with testimonials from people living with HIV and training to 617 hospital workers who received the same training with an additional half day training on social stigma co-facilitated by people living with HIV found that both interventions were successful in reducing discriminatory behaviors and hospital practices, with the additional half day training on stigma resulting in a greater impact on reducing discrimination and stigma. For example, hospital workers who felt that HIV/AIDS is a punishment for bad behavior declined in one hospital form 44% before the intervention to 19%. The hospital workers who had additional stigma training were 2.3 times less likely to report placing signs on beds indicating HIV status than hospital workers without the stigma training. Training also used the resource “Understanding and Challenging HIV Stigma: A Toolkit for Action” . The intervention also provided sharps containers for safe needle disposal as well as providing hospital workers with a manual on the “safe and friendly hospital worker in the presence of HIV/AIDS”. Guidelines for testing for HIV were created and having hospital policies in place reduced stigma. Approximately 70% of hospital workers were women. (Oanh et al., 2008).

Training for service providers in county hospitals Yunnan, China resulted in a stronger belief in patient confidentiality, reduced fear of people living with HIV and better knowledge and practice of universal precautions. 13 providers were assigned to an intervention or control group and followed for six months.

A training of trainers for 45 nurse leaders in Vietnam from 2005 to 2007 with three-week training workshops including practice resulted in increased willingness to care for HIV-positive patients according to pre- and post-test evaluations. Between 2006 and 2007 the nurse trainers trained an additional 20,488 additional health care providers.

A pre-post test study in India of training for health workers in a hospital in India with a survey for 885 health workers resulted in less stigmatizing attitudes and practices by health workers. Based on interviews with health workers and HIV-positive patients, the project developed a “PLHA Friendly Checklist” (http://www.popcouncil.org/pdfs/horizons/pfechklst.pdf) and trained health workers. When presented with data from their hospital, managers instituted hospital-wide initiatives to combat stigma and discrimination. The number of ward staff who reported that HIV cannot be transmitted by touching someone with HIV increased significantly from 80% to 96%. After the intervention, doctors were more likely to agree that patients should not be tested for HIV without consent, increasing from 37% to 67%. Following training, a significantly greater proportion of doctors reported that they always arranged pre-test counseling (from 31% to 46%) and post-test counseling (56% to 69%). Following training, more doctors wore gloves (64% to 93%) and more ward staff wore gloves to carry blood samples (29% to 93%).

YRGCare in Chennai, India, a nonprofit HIV counseling, testing and treatment center found that HIV-positive individuals reported that couple and family counseling was beneficial in addition to individual counseling for reducing stigma within the household. Thirteen thousand patients have received counseling. Five thousand six hundred sixty-seven patients living with HIV/AIDS have been followed longitudinally since 1993 with medical and psychosocial care. Seven hundred fifty-four couples accessed couples counseling and 698 accessed family counseling. Disclosure, pressure to have children by family members unaware of their serostatus, discrimination, and hiding medication, which can alert others to their serostatus, were issues addressed.

With the technical support of the International Labor Organization (ILO), ten enterprises in six sectors of the economy of Nepal implemented HIV/AIDS workplace policies. While only 73% of workers were willing to work with an HIV-positive co-worker prior to workplace policies, following implementation of workplace policies this increased significantly to over 94%. Worker’s views that employers should not fire HIV-positive workers increased from 61% to 81%.

A program established in 2003 in Thailand to create formal company HIV/AIDS policies and implement awareness and education for managers and employees found that acceptance in working with HIV-positive colleagues, such as sharing a meal, increased from 40% in 2005 to 95% after implementation (no dates given). Employees’ reported condom use in casual sexual encounters also increased from 16% to 49%.

A cluster-randomized behavioral intervention trial conducted in 14 villages in Anhui province, China found that recruited opinion leaders reduced the prevalence of stigmatizing behaviors observed and reported by community members. Seven villages were randomized to receive the intervention which consisted of four weeks of training for 742 opinion leaders followed by monthly reunion sessions, as well as eight weeks of skills training and monthly reunions for 150 people living with HIV. 330 people living with HIV were followed for one year in both control and intervention villages. Three cross-sectional surveys were carried out among 950 randomly selected villagers. At 12 months, the prevalence of stigmatizing behaviors observed and reported by community members was significantly lower in intervention villages at fewer than 42% compared to 56% in control villages. The intervention achieved a reduction in reported stigma of 27%. Reports from people living with HIV indicated corresponding decreased in perceived stigma, with significantly reduced perception of stigmatizing behaviors.

Following violence in Kenya, VCT services were established, with counseling and access to antiretroviral therapy for those who tested HIV- positive. Support groups for 100 women and 45 men living with HIV had reduced stigma. Along with ART, nutrition is key to supplement relief efforts.

A study carried out from 1999 to 2001 in Thailand, with 329 HIV-positive women found that HIV-positive women who reported that they could disclose their HIV serostatus gained increased acceptance and support from family and community, accessed support groups that increased their ability to cope with the disease, and increased their access to treatment regimens. Of the 329 women, 57% participated in one or more HIV-positive support groups. One woman stated: “At that time, when I knew I was HIV-positive, I thought, how could I live! Then, I had a chance to learn about a support group. I joined this group. I feel good cause I can meet others who’re the same as me...” (p. 37). Another stated: “I can get more knowledge from others who have had the same experiences. I feel that there are many people living with HIV, not only me. I feel warm when I join in the group” (p. 37-38) One woman stated: “In the village, everybody knew my HIV status. At first, they did not accept me, but now they have a good relationship with me. I can eat and talk with them. I think that I can live well in the village” (p. 37). The women were interviewed using a structured questionnaire. In-depth interviews were conducted among 60 HIV-positive women. Four participatory workshops were held on data analysis and report writing. A week long counseling training session was held for the women conducting interviews. Women interviewed were selected non-randomly from support groups, clinics, ANC clinics, NGOs, and communities using dimensional sampling method. The dimensions used were ages 15-25, 26-35, or 36-49, and number of years from diagnosis. Women who met the criteria for both dimensions were selected based on convenient or snowball sampling techniques. Six focus group discussions were held with six to eight men.

A qualitative study of interviews with 75 HIV-positive people (43 females, 32 males) from 20 countries, including Australia, Botswana, India, Kenya, South Africa, Thailand, Uganda, Zambia, and Zimbabwe, conducted between 1997 and 1999, found that immediately following diagnosis, most respondents felt shame and a sense of worthlessness. Most carefully guarded the secret of their serostatus for fear of negative repercussions. The average time between diagnosis and public disclosure was 2.6 years, as most people needed to time to talk through their fears with peers or a counselor. Motivation for disclosure was to prevent further infections, challenge stigma, or both. Contributing to community AIDS prevention provides a sense of purpose for many of those interviewed: “It makes you feel like you’ve done something worthwhile”.