Stigma Reduction is a Smart Investment

Stigma and discrimination hinder HIV prevention and negatively impact all stages of the treatment cascade. Those most affected by stigma are often the most vulnerable to HIV and hardest for prevention and treatment services to reach and retain. The Health Policy Plus (HP+) "total facility" approach to stigma and discrimination reduction in health facilities is evidence-based, adaptable, and scalable. It has proven successful in generalized and concentrated epidemic settings and can be tailored to address stigma toward any population. HP+ tested the approach in Ghana with a focus on key populations (sex workers, people who inject drugs, and men who have sex with men) and in Tanzania with a focus on youth. The HP+ approach consists of three phases: assessment, intervention, and evaluation. Phase 1 involves conducting quantitative baseline surveys of health facility staff and clients living with HIV, followed by participatory dissemination and validation of results with facility staff. This informed intervention design, catalyzed action, and generated strong ownership and buy-in by involving facility management and staff in diagnosing the problem. Phase 2 involves health facility staff attending two days of participatory stigma-reduction workshops facilitated by facility staff and clients living with HIV. Facilitators were trained using guides created based on global tools and survey findings. Training schedules and groups were crafted with facility management to minimize disruption of service delivery and mix staff departments, levels, and cadres to build relationships and spread learning across the facility. Significant reductions in drivers and manifestations of stigma and discrimination among health facility staff were observed, including worry about HIV transmission, stigmatizing avoidance behaviors, stigmatizing attitudes about people living with HIV, and hesitancy to test for HIV. Transformed facility environments and improved quality of care were also reported, including fewer instances of observed discrimination, improved staff behavior, and increased willingness to care for key populations. The HP+ total facility approach is an effective, versatile, and scalable approach that lends itself to sustainable stigma reduction. Keys to success include involving all staff in stigma-reduction efforts, holding sessions at facilities, engaging facility management, using participatory training methods, and building staff capacity and institutionalizing interventions. Some facilities have made stigma reduction part of the onboarding process for new staff, ensuring lasting change.