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The purpose of this review paper is to provide information and guidance to those in the health care setting about why it is important to combat HIV‐related stigma and how to successfully address its causes and consequences within health facilities. Research shows that stigma and discrimination in the health care setting and elsewhere contributes to keeping people, including health workers, from accessing HIV prevention, care and treatment services and adopting key preventive behaviours.Studies from different parts of the world reveal that there are three main immediately actionable causes of HIV‐related stigma in health facilities: lack of awareness among health workers of what stigma looks like and why it is damaging; fear of casual contact stemming from incomplete knowledge about HIV transmission; and the association of HIV with improper or immoral behaviour.To combat stigma in health facilities, interventions must focus on the individual, environmental and policy levels. The paper argues that reducing stigma by working at all three levels is feasible and will likely result in long‐lasting benefits for both health workers and HIV‐positive patients. The existence of tested stigma‐reduction tools and approaches has moved the field forward. What is needed now is the political will and resources to support and scale up stigma‐reduction activities throughout health care settings globally.

Abstract The purpose of this review paper is to provide information and guidance to those in the health care setting about why it is important to combat HIV-related stigma and how to successfully address its causes and consequences within health facilities. Research shows that stigma and discrimination in the health care setting and elsewhere contributes to keeping people, including health workers, from accessing HIV prevention, care and treatment services and adopting key preventive behaviours. Studies from different parts of the world reveal that there are three main immediately actionable causes of HIV-related stigma in health facilities: lack of awareness among health workers of what stigma looks like and why it is damaging; fear of casual contact stemming from incomplete knowledge about HIV transmission; and the association of HIV with improper or immoral behaviour. To combat stigma in health facilities, interventions must focus on the individual, environmental and policy levels. The paper argues that reducing stigma by working at all three levels is feasible and will likely result in long-lasting benefits for both health workers and HIV-positive patients. The existence of tested stigma-reduction tools and approaches has moved the field forward. What is needed now is the political will and resources to support and scale up stigma-reduction activities throughout health care settings globally.

HIV-related stigma and discrimination (S&D) in healthcare settings represents a potent barrier to achieving global aims to end the HIV epidemic, particularly in Southeast Asia (Cambodia, Lao People's Democratic Republic, Thailand and Vietnam). Evidence-based approaches for measuring and reducing S&D in healthcare settings exist, but their incorporation into routine practice remains limited, in part due to a lack of attention to how unique organisational practices—beyond the knowledge and attitudes of individuals—may abet and reinforce S&D. Application of a quality improvement (QI) approach in which facilities leverage routine measurement of S&D among healthcare workers and people living with HIV, team-based learning, root cause analysis, and tests of change offers a novel means through which to address S&D in local contexts and develop interventions to address individual-level and organisation-level drivers of S&D. To support the adoption of a QI approach to S&D reduction, the Southeast Asia Stigma Reduction QI Learning Network was launched with Ministries of Health from Cambodia, Lao PDR, Thailand and Vietnam, to co-develop strategies for implementing QI activities in participating facilities. Since the inception of Network activities in 2017, Ministry-led QI activities to address S&D have been implemented in 83 facilities and 29 provinces across participating countries. Moreover, 27 strategies and interventions have been tested to date and are being evaluated for scale up by participating facilities, spanning multiple drivers and organisational domains. Lessons learned through Network activities offer national-level and facility-level HIV programmes best practices for implementing a QI approach to S&D reduction.

AbstractIntroductionStigma is a well‐known barrier to HIV testing and treatment and is an emerging barrier to pre‐exposure prophylaxis (PrEP) use. To guide future research, measurement and interventions, we developed a conceptual framework for PrEP stigma among adolescent girls and young women (AGYW) in sub‐Saharan Africa, a priority population for PrEP.MethodsA literature review, expert consultations and focus group discussions (FGDs) were conducted to adapt the Health Stigma and Discrimination Framework, describing the stigmatization process nested within the socio‐ecological framework. We reviewed all articles on PrEP stigma and on HIV, contraceptive or sexuality stigma among AGYW from 2009 to 2019. Expert consultations were conducted with 10 stigma or PrEP researchers and two Kenyan youth advisory boards to revise the framework. Finally, FGDs were conducted with AGYW PrEP users (4 FGDs; n = 20) and key influencers (14 FGDs; n = 72) in Kenya with the help of a Youth Research Team who aided in FGD conduct and results interpretation. Results from each phase were reviewed and the framework was updated to incorporate new and divergent findings. This was validated against an updated literature search from 2020 to 2023.ResultsThe conceptual framework identifies potential drivers, facilitators and manifestations of PrEP stigma, its outcomes and health impacts, and relevant intersecting stigmas. The main findings include: (1) PrEP stigma is driven by HIV, gender and sexuality stigmas, and low PrEP community awareness. (2) Stigma is facilitated by factors at multiple levels: policy (e.g. targeting of PrEP to high‐risk populations), health systems (e.g. youth‐friendly service availability), community (e.g. social capital) and individual (e.g. empowerment). (3) Similar to other stigmas, manifestations include labelling, violence and shame. (4) PrEP stigma results in decreased access to and acceptability of PrEP, limited social support and community resistance, which can impact mental health and decrease PrEP uptake and adherence. (5) Stigma may engender resilience by motivating AGYW to think of PrEP as an exercise in personal agency.ConclusionsOur PrEP stigma conceptual framework highlights potential intervention targets at multiple levels in the stigmatization process. Its adoption would enable researchers to develop standardized measures and compare stigma across timepoints and populations as well as design and evaluate interventions.

BACKGROUND: HIV stigma in health care settings acts as a significant barrier to health care. Stigma drivers among health professionals include transmission fears and misconceptions and pre-existing negative attitudes towards marginalized groups vulnerable to HIV. The DriSti intervention, consisted of two sessions with videos and interactive exercises on a computer tablet and one interactive skills-based face-to-face group session, mostly tablet administered, was designed to target key stigma drivers that included instrumental stigma, symbolic stigma, transmission misconceptions and blame to reduce HIV stigma and discrimination among nursing students and ward staff and tested in a cluster randomized trial. SETTING: This report focuses on second and third year nursing students (NS) recruited from a range of nursing schools that included private, non-profit, and government- run nursing schools from south India. RESULTS: Six hundred seventy nine NS received intervention and 813 NS were in the wait-list control group. Twelve months outcome analyses showed significant reduction among intervention participants in endorsement of coercive policies (p<.001) and in the number of situations in which NS intended to discriminate against PLWH (p<.001). Mediation analysis revealed that the effects of intervention on endorsement of coercive policies and intent to discriminate against PLWH were partially mediated by reductions in key stigma drivers that included instrumental stigma, blame, symbolic stigma and transmission misconceptions. CONCLUSION: This brief scalable stigma reduction intervention targeting key stigma drivers fills a critical gap in identifying the mechanistic pathways that aid in stigma reduction among health professionals.

The International Center for Research on Women, the Muhimbili University College of the Health Sciences, the Population Council, and Family Health International conducted an evaluation of a community-based effort to reduce stigma surrounding HIV infections in a peri-urban community in Tanzania. Results presented a mixed, but hopeful, picture for a way forward in tackling stigma at the community level. Tackling stigma requires that the individuals tasked with doing this undergo personal change. Programs can start by focusing stigma-reduction efforts on a smaller, more manageable geographical area and adding specific anti-stigma components to their portfolio of activities. Engaging community opinion leaders (e.g., political, religious, and youth leaders, and healthcare workers) is a promising way forward for scaling up stigma-reduction at the community level.

AbstractIntroduction: Young men who have sex with men (MSM) in Jamaica have the highest HIV prevalence in the Caribbean. There is little information about HIV among transgender women in Jamaica, who are also overrepresented in the Caribbean epidemic. HIV‐related stigma is a barrier to HIV testing among Jamaica's general population, yet little is known of MSM and transgender women's HIV testing experiences in Jamaica. We explored perceived barriers and facilitators to HIV testing among young MSM and transgender women in Kingston, Jamaica.Methods: We implemented a community‐based research project in collaboration with HIV and lesbian, gay, bisexual and transgender (LGBT) agencies in Kingston. We held two focus groups, one with young (aged 18–30 years) transgender women (n = 8) and one with young MSM (n = 10). We conducted 53 in‐depth individual semi‐structured interviews focused on HIV testing experiences with young MSM (n = 20), transgender women (n = 20), and community‐based key informants (n = 13). We conducted thematic analysis to identify, analyze, and report themes.Results: Participant narratives revealed social‐ecological barriers and facilitators to HIV testing. Barriers included healthcare provider mistreatment, confidentiality breaches, and HIV‐related stigma: these spanned interpersonal, community and structural levels. Healthcare provider discrimination and judgment in HIV testing provision presented barriers to accessing HIV services (e.g. treatment), and resulted in participants hiding their sexual orientation and/or gender identity. Confidentiality concerns included: clinic physical arrangements that segregated HIV testing from other health services, fear that healthcare providers would publicly disclose their status, and concerns at LGBT‐friendly clinics that peers would discover they were getting tested. HIV‐related stigma contributed to fear of testing HIV‐positive; this intersected with the stigma of HIV as a "gay" disease. Participants also anticipated healthcare provider mistreatment if they tested HIV positive. Participants identified individual (belief in benefits of knowing one's HIV status), social (social support) and structural (accessible testing) factors that can increase HIV testing uptake.Conclusions: Findings suggest the need for policy and practice changes to enhance confidentiality and reduce discrimination in Jamaica. Interventions to challenge HIV‐related and LGBT stigma in community and healthcare settings can enhance access to the HIV prevention cascade among MSM and transgender youth in Jamaica.

AbstractIntroductionStigma undermines all aspects of a comprehensive HIV response, as reflected in recent global initiatives for stigma‐reduction. Yet a commensurate response to systematically tackle stigma within country responses has not yet occurred, which may be due to the lack of sufficient evidence documenting evaluated stigma‐reduction interventions. With stigma present in all life spheres, health facilities offer a logical starting point for developing and expanding stigma reduction interventions. This study evaluates the impact of a "total facility" stigma‐reduction intervention on the drivers and manifestations of stigma and discrimination among health facility staff in Ghana.MethodsWe evaluated the impact of a total facility stigma‐reduction intervention by comparing five intervention to five comparable non‐intervention health facilities in Ghana. Interventions began in September 2017. Data collection was in June 2017 and April 2018. The primary outcomes were composite indicators for three stigma drivers, self‐reported stigmatizing avoidance behaviour, and observed discrimination. The principal intervention variable was whether the respondent worked at an intervention or comparison facility. We estimated intervention effects as differences‐in‐differences in each outcome, further adjusted using inverse probability of treatment weighting (IPTW).ResultsWe observed favourable intervention effects for all outcome domains except for stigmatizing attitudes. Preferring not to provide services to people living with HIV (PLHIV) or a key population member improved 11.1% more in intervention than comparison facility respondents (95% CI 3.2 to 19.0). Other significant improvements included knowledge of policies to protect against discrimination (difference‐in‐differences = 20.4%; 95% CI 12.7 to 28.0); belief that discrimination would be punished (11.2%; 95% CI 0.2 to 22.3); and knowledge of and belief in the adequacy of infection control policies (17.6%; 95% CI 8.3 to 26.9). Reported observation of stigma and discrimination incidents fell by 7.4 percentage points more among intervention than comparison facility respondents, though only marginally significant in the IPTW‐adjusted model (p = 0.06). Respondents at intervention facilities were 19.0% (95% CI 12.2 to 25.8) more likely to report that staff behaviour towards PLHIV had improved over the last year than those at comparison facilities.ConclusionsThese results provide a foundation for scaling up health facility stigma‐reduction within national HIV responses, though they should be accompanied by rigorous implementation science to ensure ongoing learning and adaptation for maximum effectiveness and long‐term impact.

IntroductionWithin healthcare settings, HIV‐related stigma is a recognized barrier to access of HIV prevention and treatment services and yet, few efforts have been made to scale‐up stigma reduction programs in service delivery. This is in part due to the lack of a brief, simple, standardized tool for measuring stigma among all levels of health facility staff that works across diverse HIV prevalence, language and healthcare settings. In response, an international consortium led by the Health Policy Project, has developed and field tested a stigma measurement tool for use with health facility staff.MethodsExperts participated in a content‐development workshop to review an item pool of existing measures, identify gaps and prioritize questions. The resulting questionnaire was field tested in six diverse sites (China, Dominica, Egypt, Kenya, Puerto Rico and St. Christopher & Nevis). Respondents included clinical and non‐clinical staff. Questionnaires were self‐ or interviewer‐administered. Analysis of item performance across sites examined both psychometric properties and contextual issues.ResultsThe key outcome of the process was a substantially reduced questionnaire. Eighteen core questions measure three programmatically actionable drivers of stigma within health facilities (worry about HIV transmission, attitudes towards people living with HIV (PLHIV), and health facility environment, including policies), and enacted stigma. The questionnaire also includes one short scale for attitudes towards PLHIV (5‐item scale, α = 0.78).ConclusionsStigma‐reduction programmes in healthcare facilities are urgently needed to improve the quality of care provided, uphold the human right to healthcare, increase access to health services, and maximize investments in HIV prevention and treatment. This brief, standardized tool will facilitate inclusion of stigma measurement in research studies and in routine facility data collection, allowing for the monitoring of stigma within healthcare facilities and evaluation of stigma‐reduction programmes. There is potential for wide use of the tool either as a stand‐alone survey or integrated within other studies of health facility staff.

AbstractIntroductionIn Ghana, men who have sex with men (MSM) are estimated to be 11 times more likely to be living with HIV than the general population. Stigmas at the intersection of HIV, same‐sex and gender non‐conformity are potential key drivers behind this outsized HIV disease burden. Healthcare workers (HCWs) are essential to HIV prevention, care and treatment and can also be sources of stigma for people living with HIV and MSM. This article describes the process and results of adapting an evidence‐based HIV stigma‐reduction HCW training curriculum to address HIV, same‐sex and gender non‐conformity stigma among HCWs in the Greater Accra and Ashanti regions, Ghana.MethodsSix steps were implemented from March 2020 to September 2021: formative research (in‐depth interviews with stigma‐reduction trainers [n = 8] and MSM living with HIV [n = 10], and focus group discussions with HCWs [n = 8] and MSM [n = 8]); rapid data analysis to inform a first‐draft adapted curriculum; a stakeholder adaptation workshop; triangulation of adaptation with HCW baseline survey data (N = 200) and deeper analysis of formative data; iterative discussions with partner organizations for further refinement; external expert review; and final adaptation with the teams of HCWs and MSM being trained to deliver the curriculum.ResultsKey themes emerging under four immediately actionable drivers of health facility intersectional stigma (awareness, fear, attitudes and facility environment) informed the adaptation of the HIV training curriculum. Based on the findings, existing curriculum exercises were placed in one of four categories: (1) Expand—existing exercises that needed modifications to incorporate deeper MSM and gender non‐conformity stigma content; (2) Generate—new exercises to fill gaps; (3) Maintain—exercises to keep with no modifications; and (4) Eliminate—exercises that could be dropped given training time constraints. New exercises were developed to address gender norms, the belief that being MSM is a mental illness and stigmatizing attitudes towards MSM.ConclusionsGetting to the "heart of stigma" requires understanding and responding to both HIV and other intersecting stigma targeting sexual and gender diversity. Findings from this study can inform health facility stigma reduction programming not only for MSM, but also for other populations affected by HIV‐related and intersectional stigma in Ghana and beyond.