Addressing HIV-related stigma in health care settings

Five years ago the United Nations (UN) General Assembly held a special session on HIV and AIDS that resulted in the “Declaration of Commitment on HIV/AIDS (2001)”. The Declaration made a specific commitment to reduce the social stigma associated with HIV:

By 2003, [we shall] ensure the development and implementation of multisectoral national
strategies and financing plans for combating HIV/AIDS that address the epidemic in forthright terms; confront stigma, silence and denial; address gender and age-based dimensions of the epidemic; eliminate discrimination … 1

Despite this commitment, health care settings are where many people living with HIV (PLHIV) still experience some of the worst HIV-related stigma. The three driving forces behind this insidious form of stigma are:

Morality: Health care workers often moralise and judge people’s behaviours based on existing prejudice among others in society: religious institutions, the media, and the general public. By legitimising moralistic stances with respect to PLHIV, health care workers often deny people the proper care they need and deserve.

Helplessness: Clinical helplessness colours health care workers’ reactions to PLHIV. This operates on several levels. First, not only are they powerless to cure HIV, health care workers are often unable to alleviate the psychological and physical pain of PLHIV. Second, many are not trained to provide emotional support to PLHIV. Thirdly, health workers in heavily-affected settings have to deal with the impact of HIV in their own communities.

Fear: HIV-related stigma is more pronounced in countries with a weak health infrastructure. In such settings, health care workers must face their daily fear of acquiring HIV because of inadequate access to universal precautions such as gloves, sharps disposal, post-exposure prophylaxis (PEP) and safe blood collection kits. Like others, they may be reluctant to test themselves for HIV. This may consequently be projected onto PLHIV.

Recommendations

National governments, international agencies, health workers, advocacy groups donors, and others should endorse and call for urgent interventions to address the three driving forces behind stigma among health workers, namely:

• Codes of ethics and professional conduct in health care provision must be put in place, with sufficient forms of redress for professional violations
• Practical and attitudinal HIV-related training for all health care providers should be encouraged, especially in light of calls to expand the health care workforce in resource-poor settings.
• Universal precautions should be promoted in order to reduce health care workers’ fear of infection, as well as availability of supplies (gloves, sharps disposal etc). Voluntary counselling and testing, care and support for health care providers need to be promoted.
• Provision of PLHIV-friendly health services, including voluntary counselling and testing, and care and support services must be scaled up. PLHIV must be involved in developing, managing and evaluating such services.
  

1 UNGASS DoC (2001) paragraph 37