HIV discrimination: integrating the results from a six-country situational analysis in the Asia Pacific

HIV stigma intervention in a low-HIV prevalence setting: a pilot study in an Egyptian healthcare facility

This pilot study is the first to evaluate stigma-reduction intervention in a healthcare setting in Egypt and in the Middle East and North Africa region. It also contributes to knowledge on how to address stigma in low-HIV prevalence settings. A quasi-experimental study design was used to evaluate the effect of anti-HIV stigma intervention in one hospital in Egypt. A control hospital was selected and matched to the intervention hospital by type, size and location. The intervention focused on HIV-related stigma, infection control and medical ethics. Stigma was measured at baseline and at three months post-intervention. A standardized, 10-point scale was developed to measure stigmatizing attitudes and fear-based stigma among participants. Comparisons of overall and job-stratified stigma scores were made across the intervention and control hospitals, before and after the intervention, using two-sample t-test and multivariate regression analysis. Mean stigma scores did not reveal significant differences between the intervention and control hospitals at baseline. After intervention, the overall value-based and fear-based stigma scores were significantly lower in the intervention hospital compared to the control hospital (2.1 and 1.1 compared to 3.8 and 3.2, respectively; p < .001). Context-specific and culturally appropriate HIV stigma-reduction interventions in low-HIV prevalence settings can reduce fear-based and value-based stigma among physicians and nurses.

Implementing a stigma reduction intervention in healthcare settings

Introduction

Globally, HIV-related stigma is prevalent in healthcare settings and is a major barrier to HIV prevention and treatment adherence. Some intervention studies have showed encouraging outcomes, but a gap continues to exist between what is known and what is actually delivered in medical settings to reduce HIV-related stigma.

Methods

This article describes the process of implementing a stigma reduction intervention trial that involved 1760 service providers in 40 hospitals in China. Guided by Diffusion of Innovation theory, the intervention identified and trained about 15–20% providers as popular opinion leaders (POLs) to disseminate stigma reduction messages in each intervention hospital. The intervention also engaged governmental support in the provision of universal precaution supplies to all participating hospitals in the trial. The frequency of message diffusion and reception, perceived improvement in universal precaution practices and reduction in the level of stigma in hospitals were measured at 6- and 12-month follow-up assessments.

Results

Within the intervention hospitals, POL providers reported more frequent discussions with their co-workers regarding universal precaution principles, equal treatment of patients, provider-patient relationships and reducing HIV-related stigma. Service providers in the intervention hospitals reported more desirable intervention outcomes than providers in the control hospitals. Our evaluation revealed that the POL model is compatible with the target population, and that the unique intervention entry point of enhancing universal precaution and occupational safety was the key to improved acceptance by service providers. The involvement of health authorities in supporting occupational safety was an important element for sustainability.

Conclusions

This report focuses on explaining the elements of our intervention rather than its outcomes. Lessons learned from the intervention implementation will enrich the development of future programs that integrate this or other intervention models into routine medical practice, with the aim of reducing HIV-related stigma and improving HIV testing, treatment and care in medical settings.

Methodological considerations in the measurement of institutional and structural forms of HIV discrimination

The systematic measurement of HIV/AIDS-related discrimination is imperative within the current rhetoric that holds discrimination as one of the two 'biggest' barriers to HIV/AIDS pandemic intervention. This paper provides a methodological critique of the UNAIDS (2000b) Protocol for the Identification of Discrimination against People Living with HIV (the Protocol). Specifically, the paper focuses on the Protocol's capacity to accurately identify and measure institutional levels of HIV-related discrimination that allows data that are reliable and comparable across time and contexts. Conceptual issues including the Protocol's objective as an indicator versus a direct measure of discrimination and the role of the Protocol as a tool of research versus a tool of advocacy are explored. Design issues such as the operationalization of discrimination, appropriateness of indicator content, sampling and data collection strategies and issues of scoring are also evaluated. It is hoped that the matters outlined will provide readers with ways of critically reflecting and evaluating the findings of the research papers presented in this Special Issue, as well as pointing to ways of improving research design.

Effectiveness of a knowledge-contact program in improving nursing students' attitudes and emotional competence in serving people living with HIV/AIDS

This study compared the effectiveness of an AIDS knowledge-only program (knowledge) with a combined program of AIDS knowledge and contact with people having HIV/AIDS (PHA) (knowledge-contact) in reducing nursing students' stigma and discrimination towards PHA and in enhancing their emotional competence to serve PHA. Eighty-nine nursing students from two universities in Hong Kong were randomly assigned to either the knowledge or the knowledge-contact condition. All participants completed measures of AIDS knowledge, stigmatizing attitudes, fear of contagion, willingness to treat, positive affect, and negative affect at pre-test, post-test, and six-week follow-up. Findings showed that in both groups, significant improvement in AIDS knowledge, stigmatizing attitudes, fear of contagion, willingness to treat, and negative affect were found at post-test. The effects on AIDS knowledge, fear of contagion, willingness to treat, and negative affect were sustained at follow-up for both groups. Intergroup comparisons at post-test showed that the effectiveness of knowledge-contact program was significantly greater than knowledge program in improving stigmatizing attitudes. No significant difference between the two groups was found at follow-up. Findings showed the short-term effect of contact in improving nursing students' attitudes and emotional competence in serving PHA. Implications for research and training of nursing staff were discussed.

Evaluating re-identification risks with respect to the HIPAA privacy rule

OBJECTIVE

Many healthcare organizations follow data protection policies that specify which patient identifiers must be suppressed to share "de-identified" records. Such policies, however, are often applied without knowledge of the risk of "re-identification". The goals of this work are: (1) to estimate re-identification risk for data sharing policies of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule; and (2) to evaluate the risk of a specific re-identification attack using voter registration lists.

MEASUREMENTS

We define several risk metrics: (1) expected number of re-identifications; (2) estimated proportion of a population in a group of size g or less, and (3) monetary cost per re-identification. For each US state, we estimate the risk posed to hypothetical datasets, protected by the HIPAA Safe Harbor and Limited Dataset policies by an attacker with full knowledge of patient identifiers and with limited knowledge in the form of voter registries.

RESULTS

The percentage of a state's population estimated to be vulnerable to unique re-identification (ie, g=1) when protected via Safe Harbor and Limited Datasets ranges from 0.01% to 0.25% and 10% to 60%, respectively. In the voter attack, this number drops for many states, and for some states is 0%, due to the variable availability of voter registries in the real world. We also find that re-identification cost ranges from $0 to $17,000, further confirming risk variability.

CONCLUSIONS

This work illustrates that blanket protection policies, such as Safe Harbor, leave different organizations vulnerable to re-identification at different rates. It provides justification for locally performed re-identification risk estimates prior to sharing data.

AIDS and the stigma of sexual promiscuity: Thai nurses' risk perceptions of occupational exposure to HIV

This paper examines the culturally shaped meanings of AIDS and perceptions of accidental occupational exposure to HIV among a group of twenty nurses in Bangkok, Thailand. The findings are based on data collected as a part of a larger mixed-methods study that examined how perceptions of risk behaviours (including sexual promiscuity) shape health workers' perceptions of patients living with HIV/AIDS. Nurses' narratives revealed that despite acknowledgement of the low probability of occupational exposure to HIV, the fear of HIV infection remained and was largely driven by the enormity of the anticipated social (rather than the health) consequences of being HIV-positive. The perceived certainty of social ostracism was reinforced by participants' observations of the social rejection experienced by people living with HIV/AIDS both within and outside clinical settings. For female nurses, the dominant social perception that women living with HIV/AIDS were violators of gender norms, and thus 'guilty' victims, was an issue central to their self-identities. Ways of improving care for people living with HIV in the light of the nurses' concerns and future research are discussed.

A global assessment of the role of law in the HIV/AIDS pandemic

This article examines the dynamic role of law as a tool, and potential barrier, to public health interventions designed to ameliorate the negative impacts of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) globally. Law impacts the lives of persons living with (and at risk of) HIV/AIDS in many ways. Laws may: (1) help to ensure that public health authorities are empowered to provide effective prevention and treatment programmes; (2) effectuate the human rights to life, health, work, education and property ownership of persons living with, or at risk of, HIV/AIDS; and (3) protect persons living with HIV/AIDS from social risks, stigma and other harms by respecting privacy and prohibiting unwarranted discrimination. However, laws can also create legal barriers in many countries that impede effective HIV/AIDS interventions by penalizing those with HIV/AIDS through criminal sanctions or other policies. As a result, it is recommended globally that laws should facilitate the prevention and treatment of HIV/AIDS consistent with scientific and public health practices and with a human rights framework. Effective use of existing laws that promote the public's health, and reforms of laws which impede it, contribute to improved individual and communal health outcomes concerning HIV/AIDS.

HIV/AIDS and maternity care in Kenya: how fears of stigma and discrimination affect uptake and provision of labor and delivery services

Although policies and programs exist to promote safe motherhood in sub-Saharan Africa, maternal health has not improved and may be deteriorating in some countries. Part of the explanation may be the adverse effects of HIV/AIDS on maternity care. We conducted a study in Kisumu, Kenya to explore how fears related to HIV/AIDS affect women's uptake and health workers' provision of labor and delivery services. In-depth qualitative interviews with 17 maternity workers, 14 pregnant or postpartum women, four male partners and two traditional birth attendants; as well as structured observations of 22 births; were conducted at four health facilities. Participants reported that fears of HIV testing; fears of involuntary disclosure of HIV status to others, including spouses; and HIV/AIDS stigma are among the reasons that women avoid delivering in health facilities. Maternity workers now have to take into account the HIV status of the women they serve (as well as their own fears of becoming infected and stigmatized) but do not seem to be adequately prepared to handle issues related to consent, confidentiality and disclosure. Importantly, it appeared that women of unknown HIV status during labor and delivery were likely to be targets of stigma and discriminatory practices and that these women were not receiving needed counseling services. The findings suggest that increasing infection control precautions will not be enough to address the challenges faced by maternity care providers in caring for women in high-HIV-prevalence settings. Maternity workers need enhanced culturally sensitive training regarding consent, confidentiality and disclosure. Furthermore, this study points to the necessity of paying more attention to the care of women of unknown HIV-serostatus during labor and delivery. Such interventions may improve the quality of maternity care, increase utilization and contribute to overall improvements in maternal health, while also enhancing prevention of mother-to-child-transmission and HIV care.

HIV/AIDS, reproductive and sexual health, and the law

The law is a frequently overlooked tool for addressing the complex practical and ethical issues that arise from the HIV/AIDS pandemic. The law intersects with reproductive and sexual health issues and HIV/AIDS in many ways. Well-written and rigorously applied laws could benefit persons living with (or at risk of contracting) HIV/AIDS, particularly concerning their reproductive and sexual health. Access to reproductive health services should be a legal right, and discrimination based on HIV status, which undermines access, should be prohibited. Laws against sexual violence and exploitation, which perpetuate the spread of HIV and its negative effects, should be enforced. Finally, a human rights framework should inform the drafting of laws to more effectively protect health.

AIDS denial in Asia: dimensions and roots

AIDS denial has long been viewed as the obstacle to forging effective response in many Asian countries. This article examines the dimensions and roots of this phenomenon. It identifies seven types of views, attitudes, or tendencies that can be described as denial, dissent, disagreements, or doubts. Three major factors underlying the AIDS denial are discussed. These are (1) historical impressions that STDs are Western diseases, (2) desire of some Asian leaders to forge Eastern points of view, and (3) long-held negative image towards the peoples or groups who happened to be at the front-line of the population groups exposed to the epidemic. The third factor is the most important source of denial. AIDS denial is not a new and isolated phenomenon but the one shaped by the global and historical institutions. Asian AIDS denial reflects the authoritarian and moralist grievances arising from the perceived deterioration of traditional moral order.

Understanding and measuring AIDS-related stigma in health care settings: a developing country perspective

AIDS-related stigma and discrimination remain pervasive problems in health care institutions worldwide. This paper reports on stigma-related baseline findings from a study in New Delhi, India to evaluate the impact of a stigma-reduction intervention in three large hospitals. Data were collected via in-depth interviews with hospital staff and HIV-infected patients, surveys with hospital workers (884 doctors, nurses and ward staff) and observations of hospital practices. Interview findings highlighted drivers and manifestations of stigma that are important to address, and that are likely to have wider relevance for other developing country health care settings. These clustered around attitudes towards hospital practices, such as informing family members of a patient's HIV status without his/her consent, burning the linen of HIV-infected patients, charging HIV-infected patients for the cost of infection control supplies, and the use of gloves only with HIV-infected patients. These findings informed the development and evaluation of a culturally appropriate index to measure stigma in this setting. Baseline findings indicate that the stigma index is sufficiently reliable (alpha = 0.74). Higher scores on the stigma index--which focuses on attitudes towards HIV-infected persons--were associated with incorrect knowledge about HIV transmission and discriminatory practices. Stigma scores also varied by type of health care providers--physicians reported the least stigmatising attitudes as compared to nursing and ward staff in the hospitals. The study findings highlight issues particular to the health care sector in limited-resource settings. To be successful, stigma-reduction interventions, and the measures used to assess changes, need to take into account the sociocultural and economic context within which stigma occurs.