Comprehensive Package for Reducing Stigma and Discrimination in Health Facilities

In health facilities, people with HIV may experience negative attitudes and harmful actions that deter them from accessing services, disclosing information to providers, and adhering to treatment. The United States Agency for International Development (USAID)- and President's Emergency Plan For AIDS Relief (PEPFAR)-funded Health Policy Project (HPP) led a global effort to compile and refine a coordinated package of participatory, evidence-informed, "best practice" stigma reduction tools for health facilities. The resulting intervention package, which based on experiences in nine countries in Africa, the Caribbean, and South and South-East Asia, aims to support a stigma-free facility - one in which people living with HIV and other key populations are treated with respect and compassion, and provided high-quality care.

The total facility approach for reducing stigma and discrimination (S&D) in health facilities covers all staff - from support staff through to clinicians. The tools in this package may be used or adapted to counter S&D based on HIV status, gender identity, sexual orientation, and behaviours such as sex work or injecting drug use. It has been adapted for use in multiple countries in the Caribbean and is the basis for Thailand's national roll-out of an HIV S&D reduction programme.

The package brings together three key intervention elements: assessment (assess), participatory training (train), and a focus on facility policies and environment (sustain). Specifically, the resources include:

• Measuring HIV Stigma and Discrimination among Health Facility Staff: Standardized Brief Questionnaire - User Guide - One of the first steps in developing interventions to reduce S&D is to understand (assess) the views and behaviours of health facility staff toward PLHIV. The purpose of this manual is to offer guidance in administering a standardised HIV-related S&D questionnaire in healthcare settings. It may be used to produce baseline information and later to monitor progress. The manual provides: a short history of the development of this questionnaire; the rationale for measuring S&D in health facilities; a description of the questionnaire sections; practical steps and guidance for questionnaire implementation, including procedures to help ensure ethical data collection and the anonymity of respondents; and counsel on analysis.
• Facilitator's Training Guide for a Stigma-Free Health Facility: Training Menus, Facilitation Tips, and Participatory Training Module - This resource provides detailed, step-by-step instructions on how to plan and facilitate S&D-reduction (training) sessions. It features participatory training modules, which include exercises to raise staff awareness about S&D in health facilities and help change their attitudes and behaviours toward people living with HIV (PLHIV) and key populations. The training modules also cover basic skills on standard precautions. In addition, training programme menus provide timetables for using core training exercises with different types of staff. In delivering the programme, each trainer is paired with a person living with HIV or a member of a key population group. The exercises use a participatory approach - one based on discussion, small group activities, case studies, and other participatory methods (e.g., role-playing, cardstorming) aimed at making the learning lively and fun. The aim is to get participants actively involved in thinking about the issues affecting PLHIV and key populations, rather than passively listening to a lecture. Participants learn through sharing ideas, discussing and analysing issues, relating new concepts to their own experience, trying to find solutions to problems, and planning what they can do to challenge S&D.
• Achieving a Stigma-Free Health Facility and HIV Services: Resources for Administrators - This kit includes tools and resources for ensuring that the facility environment and policies help support and sustain stigma-free HIV services. Facility managers develop policies and procedures, and ensure that appropriate supplies are available to support staff in providing stigma-free services. Administrators also play a key role in helping institutionalise new behaviours and attitudes. These activities may include strengthening referral services to non-governmental organisations (NGOs) and social or gender-based violence services. Specifically, the resources in this guide are designed to assist administrators in conducting a scan of S&D within the facility, and taking action to promote the safety of health facility staff and improve the quality of services for all clients. The guide contains a facility environment and policy checklist and tools for developing an effective code of conduct and action plan for addressing S&D. It also contains additional tools for measurement and training in Annexes A and B.