A focus on the individual, environmental and policy levels
Although stigma is a pervasive and daunting problem in the health care setting, much can be done to address its causes and consequences. A key lesson that has emerged from recent research and field experiences is that to combat stigma in the health care setting, interventions must focus on the individual, environmental and policy levels [3
At the individual level, increasing awareness among health workers of what stigma is and the benefits of reducing it is critical. Raising awareness about stigma and allowing for critical reflection on the negative consequences of stigma for patients, such as reduced quality of care and patients' unwillingness to disclose their HIV status and adhere to treatment regimens, are important first steps in any stigma-reduction programme. A better understanding of what stigma is, how it manifests and what the negative consequences are can help reduce stigma and discrimination and improve patient-provider interactions.
Health workers' fears and misconceptions about HIV transmission must also be addressed. Fear of acquiring HIV through everyday contact leads people to take unnecessary, often stigmatising actions. Thus programmes need to provide health workers with complete information about how HIV is and is not transmitted and how practicing universal precautions can allay their fears. In addition to basic HIV epidemiology, health workers must be able to understand the occupational risk of HIV infection relative to other infectious diseases that are more highly transmissable and commonly found in heath care settings.
Understanding the association of HIV and AIDS with assumed immoral and improper behaviours is essential to confronting perceptions that promote stigmatizing attitudes toward individuals living with HIV. Programmes need to address the shame and blame directed at people with HIV by providing health providers with a safe space to reflect on the underlying values that lead to the shame and blame. It is important for health care workers to disassociate persons living with HIV from the behaviours considered improper or immoral that are often associated with HIV infection.
In the physical environment, programmes need to ensure that health workers have the information, supplies and equipment necessary to practice universal precautions and prevent occupational transmission of HIV. This includes gloves for invasive procedures, sharps containers, adequate water and soap or disinfectant for handwashing, and post-exposure prophylaxis in case of work-related, potential exposure to HIV. Posting relevant policies, handwashing procedures or other critical information in key areas in the health care setting enables health workers to maintain better quality of patient care.
The lack of specific policies or clear guidance related to the care of patients with HIV reinforces discriminatory behaviour among health workers. Health facilities need to enact policies that protect the safety and health of patients, as well as health workers, to prevent discrimination against people living with HIV. Such policies are most successful when developed in a participatory manner, clearly communicated to staff, and routinely monitored after implementation.
Several studies have shown that stigma reduction activities in hospitals, based on the principles we have outlined, have led to positive changes in health providers' knowledge, attitudes and behaviours, and better quality of care for HIV-positive patients [3
For example, following a stigma-reduction intervention in four Vietnamese hospitals [51
], the mean score on both a fear-based and a value-based stigma index decreased significantly among hospital workers (p < 0.05). Additionally, there was a significant reduction in reporting of discriminatory behaviours and practices by hospital workers. For example, the percentage of hospital workers reporting the existence of labels indicating HIV status on files declined from 56% to 31% (p < 0.001) in one hospital, and from 31% to 17% in another (p < 0.002). During monitoring visits, various positive changes were observed (e.g., improvements in the use of universal precautions, increased voluntary HIV testing of patients and informing patients of their HIV status, and a reduction in the marking of files and beds with the patient's HIV status).
The intervention accomplished this reduction in stigma and discrimination within six months through the following programmatic steps:
1) Implementation of a brief survey to document the need for action to reduce stigma and guide the design of the intervention
2) Establishment of a steering committee to plan the intervention
3) A flexibly scheduled 2 1/2 day participatory training for all hospital staff (from cleaners to clerks to doctors), which focused on increasing knowledge and awareness of HIV, universal precautions, and fear-based and value-based stigma, including what stigma looks like in the health care setting
4) Participatory drafting and negotiation by all staff of a hospital policy to foster staff safety and a stigma-free atmosphere
5) Provision of materials and supplies to facilitate the practice of universal precautions.
This and other intervention studies in hospitals [3
] suggest a number of promising pathways and approaches for tackling the problem at the individual, environmental and policy levels. Stigma reduction fundamentals for the hospital setting, outlined below, are also applicable in other health care settings, such as primary care clinics and health posts.
Involve all staff members, not just health professionals, in training and in crafting policy
Reaching everyone with whom a patient comes in contact (e.g., doctors, nurses, guards, cleaners and administrative staff) helps ensure ownership of the stigma-reduction process and a unified response by the health care facility.
Use participatory methods
Participatory methods such as games, role plays, exercises and group discussions create a non-judgemental environment that allows participants to explore personal values and behaviours, while improving their knowledge and awareness. It also creates a sense of ownership in the process of developing stigma-reduction strategies in the health care setting.
A variety of tested tools exist from which to find participatory exercises on stigma reduction to build your programme. They include: Understanding and Challenging HIV Stigma: A Toolkit for Action [53
], a general tool that has worked well in health facilities, as well as two participatory tools focused specifically on the health care setting: Safe and Friendly Health Facility Trainers Guide [54
], and Reducing HIV Stigma and Gender-Based Violence: Toolkit for Health Care Providers in India [55
Provide training on both stigma and universal precautions
Equipping health workers with the knowledge and skills necessary to protect themselves from occupational transmission of HIV is a key step in addressing fear-based stigma. But health workers also must be provided with the supplies necessary (e.g., gloves, gowns, water and disinfectant solution) so that they can take appropriate steps to ensure staff and patient safety.
Involve individuals living with HIV
Showing that HIV has a "human face" helps health workers to better understand stigma and its insidious impact on individuals and families. Involving members of socially marginalized groups who are HIV positive, such as men who have sex with men, sex workers, and injecting drug users, also helps to address the additional social stigmas they face on top of HIV-related stigma.
When designing a training programme, it is important to tap into existing networks of people living with HIV to identify individuals to take part in training activities, as well as to provide adequate preparation and training to these individuals to equip them for the role they will play in training (e.g., testimonials and co-facilitation). An important group to have represented, if possible, is health care workers living with HIV.
Periodically monitor stigma among health workers
One way to ensure that this happens is by enacting health care setting regulations that mandate the monitoring of health worker attitudes and behaviours to assess progress. It is also important to establish anti-stigma policies and benchmarks that health facilities can use for assessing their efforts. For example, the government of Vietnam is currently updating its national hospital regulations to include stigma reduction, and is developing a tool that hospitals can use to determine the extent to which they are in compliance.
Take advantage of existing tools
We have described two participatory resources that have been tested and shown to be effective in different contexts for training health workers, as well as one for other groups. With regard to programme planning and monitoring, a hospital-based intervention in India produced a tool that health workers can use to assess the extent to which a facility complies with anti-stigma and discrimination standards. This is the PLHA-friendly checklist [56
], which can be used to catalyze action in a given facility and also as an evaluation tool. Another tool for training health care workers is: Reducing Stigma and Discrimination Related to HIV and AIDS: Training for Health Care Workers [57
Address the needs of HIV-infected health workers
Health facilities should respond in a multi-faceted way to address HIV-positive health workers' fear of stigma and loss of confidentiality. The response should include private and confidential counselling and testing services, access to antiretroviral therapy, and professional and emotional support, either on the premises or at a convenient location. Also important are the enactment and enforcement of anti-discrimination policies to protect health workers living with HIV [36