Module 5

1
Module 5

• Stigma and Discrimination Associated with HIV

2
Module Objectives

• Define correctly HIV-related stigma.
• Define correctly HIV-related discrimination.
• Describe current international rights related to
  HIV.
• Discuss stigma and discrimination against women
  in the context of HIV.
• Discuss examples of how stigma is expressed in
  professional and social settings.
• Discuss the consequences of stigma in PMTCT
  services.
• Discuss strategies to address stigma and
  discrimination.

3
Exercise 5.1

• Labels Interactive Game

4
Unit 1

• Introduction to the Concepts of Stigma and
  Discrimination and International Human Rights

5
Unit 1 Objectives

• Define correctly HIV-related stigma.
• Define correctly HIV-related discrimination.
• Describe current international rights related to
  HIV.

6
Introduction to Stigma Discrimination

• HIV poses human rights challenges
• HIV-related stigma is the single greatest
  challenge to slowing spread of the disease at
  global, national, and community level.
• HIV-related stigma can prevent a woman from
  seeking ANC services and HIV testing discourage
  her from disclosing her test results and agreeing
  to antiretroviral treatment and prophylaxis and
  keep her from adopting safer infant-feeding
  practices.
• Women may feel compelled to keep their HIV status
  secret.

7
What is stigma?

• Stigma refers to unfavourable attitudes and
  beliefs directed toward someone or something.
• Socially marginalized people bear heaviest burden
  of HIV-related stigma and discrimination.

8
What is stigma? (continued)

• HIV-related stigma
• Unfavourable attitudes and beliefs toward people
  living with HIV, those perceived to be infected,
  and their families, friends, social groups, and
  communities
• Stigma is greater when risk of contracting the
  disease is thought to be under the individuals
  control (e.g., commercial sex workers)

9
What is discrimination?

• Discrimination is the treatment of an individual
  or group with partiality or prejudice.

10
Examples of Discrimination

• HCW denies services to person with HIV
• Wife and children of a man who died of AIDS
  ostracized by community
• Individual loses his job when it is known he/she
  is HIV-infected
• Individual has difficulty getting a job when
  revealed he/she is HIV-infected
• Community ostracizes a woman who decides not to
  breastfeed because it is assumed she is
  HIV-infected

11
Stigmatization versus Discrimination

• Stigmatization reflects an attitude.
• Discrimination is an act or behaviour.
• Discrimination is a way of expressing
  stigmatizing thoughts, either on purpose or by
  accident.
• Stigmatized individuals may suffer discrimination
  and other human rights violations.

12
Stigma, HIV, and Women

• HIV epidemic spreading more rapidly among women
  than men.
• Women more vulnerable to HIV.
• Woman often first in a couple to be tested for
  HIV
• These reasons may compel a woman either not to be
  tested or to keep her HIV status a secret.
• Stigma and discrimination handicaps successful
  prevention, care, and support activities.

13
Human Rights HIV-related Stigma and
Discrimination

• Freedom from discrimination is a fundamental
  human right founded on the principles of natural
  justice.
• Discrimination against people living with HIV or
  people thought to be infected is a clear
  violation of human rights.

14
Human Rights HIV-related Stigma and
Discrimination Against Women

• Research in India and Uganda showed that women
  with HIV face stigma on many levels
• As women
• As people living with HIV
• As the spouse of an HIV-infected person
• As the widow of a person who died of AIDS
• Or as a woman who is HIV-infected and pregnant.

15
Protect, Respect, Fulfill Human Rights in
Relation to HIV

• Women and men have a right to determine the
  course of their sexual and reproductive lives.
• Children have a right to survival, development,
  and health.
• Women and girls have a right to information about
  HIV and access to a means of protecting
  themselves.

16
Protect, Respect, Fulfill Human Rights in
Relation to HIV (continued)

• Women have the right to access HIV testing and
  counselling and to know their HIV status.
• Women have a right to choose not to be tested or
  choose not to be told the result of an HIV test.
• Women have a right to make decisions about infant
  feeding and to receive support for the infant
  feeding method they choose.

17
Unit 2

• Social Context and the Impact of Stigma and
  Discrimination

18
Unit 2 Objectives

• Discuss examples of how stigma is expressed in
  professional and social settings.
• Discuss the consequences of stigma in PMTCT
  services.

19
The Face of Stigma

• People living with HIV, orphans and families
  affected by HIV, are highly stigmatized in many
  countries.
• Fear of stigmatization often the main reason why
  a person does not get tested.

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How Stigma Can be Expressed

• Attitudes and actions are stigmatizing
• Choice of language may express stigma
• Fear and lack of knowledge foster stigma
• Shame and blame are associated with HIV
• Stigma makes disclosure more difficult
• Stigma can exist even in typically supportive or
  caring environments

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Exercise 5.2

• Examples of
• Stigma Discrimination
• Large Group Discussion

22
Examples of Stigmatization and Discrimination

• In the media
• Suggestions that specific groups of people with
  HIV are at fault whereas others are innocent
• Depicting HIV/AIDS as a death sentence rather
  than a chronic disease that can be managed.
• Using stereotypical gender roles, which may
  perpetuate women's vulnerability to sexual
  coercion and HIV infection.

23
Examples of Stigmatization and Discrimination
(continued)

• In health services
• Violating patient confidentiality
• Providing HIV care in stand-alone settings (such
  as clinics for sexually transmitted infections)
  that further stigmatize and segregate PLHIV
• Requiring HIV test before surgery
• Using infection-control procedures (such as
  gloves) only with patients thought to be
  HIV-positive, rather than with all patients

24
Examples of Stigmatization and Discrimination
(continued)

• In the workplace
• Refusing to hire HIV-infected persons
• Violating confidentiality
• In the context of religion
• Denying participation in rituals (such as
  funerals) for PLHIV
• References to HIV as a punishment or test

25
Examples of Stigmatization and Discrimination
(continued)

• In the family and local community
• Discriminating against partners and children of
  PLHIV
• Using violence against an HIV-positive spouse or
  partner
• Denying support for bereaved family members

26
Effects of Stigma

• Stigma is disruptive and harmful at every stage
  of HIV care.
• People who fear stigma and discrimination are
  less likely to seek HIV testing.
• Persons testing HIV-positive may be afraid to
  seek necessary care and treatment.
• PLHIV may receive suboptimal care from
  discriminatory HCWs.
• Stigma may discourage those who are HIV-infected
  from discussing their HIV status with their sex
  partners.

27
Secondary Stigma

• Secondary stigma (stigma by association)
• Effects of stigma often extend beyond the
  infected individual to stigma by association.
• Women whose husbands died of AIDS can be
  stigmatized by their community.

28
Stigma PMTCT Services

• Consequences of stigma in PMTCT services
• Discourages women from accessing ANC
• Prevents people from receiving HIV testing
• Discourages women from discussing their HIV test
  results and disclosing results to partner(s)
• Prevents women from accepting PMTCT interventions
  
• Discourages women from accepting referrals to ARV
  Clinic
• Discourages safer infant-feeding practices
  (replacement feeding or early cessation of
  breastfeeding)

29
Unit 3

• Dealing with Stigma Discrimination in
  Healthcare Settings and Communities

30
Unit 3 Objective

• Discuss strategies to address stigma and
  discrimination.

31
Addressing Stigma in PMTCT Services

• To increase participation in PMTCT services,
  implement interventions that address HIV-related
  stigma.
• These efforts should occur at all levels
• National
• Community, social, and cultural
• PMTCT service
• Individual, HCW

32
National Level

• Examples of national initiatives and policies
  that HCWs can advocate
• Legislation that protects rights of PLHIV
• Legislation that protects legal rights of women
  in health care, education, and employment.
• Anti-discrimination policies
• Scale-up treatment of HIV with antiretroviral
  (ARV) medication.
• Quality treatment programmes for people with
  addictions.
• Involve consumers in national advocacy and
  programme and policy development.

33
National Level (continued)

• Advocate for sufficient funding for PMTCT
  services.
• Educate national leaders about the importance of
  PMTCT services

34
National Level (continued)

• Encourage national leaders to serve as role
  models in their professional and personal lives
• Encourage leaders to hire staff that are
  HIV-infected.
• Encourage leaders to praise the good work of
  PMTCT HCWs.
• Encourage leaders to speak out against emotional,
  verbal, and physical abuse directed at women
  infected with HIV.
• Remind leaders to promote funding of HIV care and
  treatment services.
• Suggest that leaders be tested for HIV.

35
Community Level

• Stigmatization is a social process that must be
  addressed on the community level.
• PMTCT service managers should collaborate with
  the community to address HIV-related stigma and
  discrimination.

36
HIV Education Training

• HCWs should participate in educational programmes
  that
• Increase knowledge about HIV
• Increase awareness of issues faced by PLHIV
• Increase awareness of domestic violence faced by
  some newly diagnosed women
• Include content that violence against women or
  men is not acceptable

37
HIV Education Training (continued)

• HCWs should participate in educational programmes
  that
• Encourage leaders to make workplaces
  HIV-friendly.
• Promote PMTCT activities as routine part of
  healthcare and HIV prevention/treatment
• Educate community about PMTCT interventions
• Increase referrals to/from PMTCT services

38
Community Awareness of PMTCT Interventions

• Community education and mobilization activities
  increase community awareness of PMTCT
  interventions
• Greater community awareness should strengthen
  social support for the partner, extended family,
  and community.
• People with social and family support cope with
  their HIV infection better.

39
Community Partnerships

• PMTCT HCWs and managers should build partnerships
  with churches, schools, and social or civic
  organizations when developing PMTCT services.
• Promoting PMTCT services among community
  organizations enhances sustainability
• Faith-based organizations (FBOs) and religious
  communities are important partners in efforts to
  eliminate stigma.

40
Ways to Facilitate Building of Community
Partnerships

• Maintain awareness of community health and
  development activities that benefit PMTCT
  clients.
• Understand the HCWs role as a liaison between
  community and the PMTCT service.
• Work to incorporate PMTCT messages and activities
  into existing MCH and BCI initiatives.
• Participate in community meetings with
  influential leaders to discuss HIV and PMTCT

41
Involve People Living with HIV (PLHIV)

• Invite PLHIV to become involved in national and
  local initiatives, as this will help them
• Gain and practise life skills to challenge
  HIV-related stigma and discrimination.
• Become actively involved in national and local
  activities to foster positive perceptions of
  PLHIV.
• Support establishment of organizations and
  networks for PLHIV.

42
Training Programmes for PLHIV

• Develop and implement training programmes for
  PLHIV to
• Advocate for their rights and take an active role
  in their own health care.
• Participate in interventions (such as PMTCT
  services or HIV prevention and care education) as
  volunteers, advisors, board members, or paid
  employees to demonstrate their ability to remain
  productive members of the community.

43
PMTCT Service Level

• Ensure that PMTCT services are integrated into
  existing health and social services
• Suggestions on how to do this follow in the next
  few slides

44
Integrate PMTCT Interventions into (ANC) services

• Offer routine HIV testing and education to all
  clinic attendees, regardless of HIV risk.
• Mainstream HIV services with routine ANC services
  helps normalize HIV.

45
Increase Participation of Partners

• Educate partners about PMTCT interventions and
  stress importance of partner testing and support
  for PMTCT.
• Examples where men were invited to visit
  reproductive clinics for testing, counselling and
  PMTCT education designed for a male audience have
  shown
• Improved spousal communication about PMTCT
• Increased HIV testing among male partners of
  PMTCT patients
• Increased rates of disclosure of HIV test results
  for both partners

46
Implement Educational Sessions

• Group or individual education sessions can draw
  attention to role of partners in HIV transmission
  and reduce stigmatization of women.
• Reach out to men in male-friendly settings, such
  as sports stadiums, taxi stands, and markets to
  increase awareness of PMTCT and encourage them to
  attend ANC with their pregnant partners.
• Couples counselling offers opportunity to reduce
  blame directed at women and emphasize couple's
  shared responsibility for PMTCT

47
Educate Train HCWs

• Success or failure of PMTCT service depends on
  attitudes, skills, and experience of its
  employees.
• Train HCWs and clinic staff at all levels
• Employee training should include
• Complete and accurate information about
  transmission of HIV and risk factors for
  infection
• Ongoing activities that address HIV-related stigma

48
Understand the Perspectives of PLHIV

• Training HCWs to reduce stigmatizing behaviour
  will address assumptions about the educational,
  social, economic, and class status of people
  living with HIV.
• During training activities, strive to increase
  awareness of language used to describe HIV and
  PLHIV.
• The training should include
• Exercises to encourage participants to explore
  personal attitudes and prejudices
• Summaries of confidentiality, anti-discrimination,
  and infection control policies as well as
  consequences of policy breaches

49
Adhere to Infection Control Patient
Confidentiality

• Infection control
• Provide all HCWs with the equipment and supplies
  needed to adhere to infection control policies
• Patient confidentiality
• Safeguard patient confidentiality by developing
  policies and procedures on
• Recording and storing patient information
• Ensuring patient interactions are private
• Disclosure of medical information and informed
  consent
• Disciplining workers who breach confidentiality
• Requirements for staff confidentiality training

50
Encourage PMTCT Staff to Serve as Role Models

• Encourage PMTCT staff to treat PLHIV the same as
  patients assumed to be HIV-negative.
• HCWs are role models, and their attitudes toward
  PLHIV are often imitated in the community.

51
Know the Local Community

• PMTCT staff should get to know people in the
  community.
• This will help them identify local HIV-related
  stereotypes.
• Staff can address stereotypes and correct
  misconceptions during PMTCT services.

52
Role of PMTCT Service Managers

• Ensure policies and procedures in place to
  protect individuals from discrimination and
  stigmatization
• Maintain policies against discriminatory
  recruitment and employment practices
• Support workers who are HIV-infected.
• Establish policies that all patients must receive
  equal treatment regardless of HIV status.
• Establish procedures and protocols for reporting
  discrimination and disciplining staff.

53
Role of PMTCT Service Managers (continued)

• Ensure that all staff follow standard
  precautions
• Update facility's infection control policy
• Ensure access to infection control supplies
  equipment
• Ensure staff members apply standard precautions
• Discipline employees who knowingly breach
  standard precautions policy
• Ensure post-exposure prophylaxis (PEP) accessible
  to staff

54
Exercise 5.3

• People Living with HIV Panel

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Exercise 5.4

• Stigma and Discrimination Case Study

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Module 5 Key Points

• While stigmatization reflects an attitude,
  discrimination is an act or behaviour.
• Stigma and discrimination are interconnected.
  Stigmatizing thoughts can lead to discriminating
  behaviours.
• PMTCT service staff have a responsibility to
  respect the rights of all women and men,
  regardless of their HIV status.
• Discrimination against people living with HIV is
  illegal in Malawi

57
Module 5 Key Points (continued)

• HIV/AIDS-related stigmatization and
  discrimination may discourage people living with
  HIV from accessing key HIV services. Stigma and
  discrimination may also
• Discourage disclosure of HIV status
• Reduce acceptance of safer infant-feeding
  practices
• Limit access to education, counselling, and
  treatment for people infected with HIV even when
  services are available and affordable

58
Module 5 Key Points (continued)

• PMTCT service staff can help reduce stigma and
  discrimination in the healthcare setting, in the
  community, and on the national level.
• Encourage PMTCT staff to serve as role models by
  treating people living with HIV as they would
  treat clients assumed to be HIV-negative.
• It is important for HCWs and staff to explore
  attitudes and behaviours that could be
  stigmatizing and discriminatory.