One of the challenges facing communities in accessing health services is stigma.
Kanakulya Godfrey, who works at the AIDS support Organisation (TASO) in Uganda on empowerment programmes for people living with HIV and AIDS, says stigma may have reduced in communities but it is always there and can manifest itself in many forms.
HIV stigma in Ugandan health facilities
With integration of sexual and reproductive health (SRH) and HIV, stigma is an important area to address. There are very serious issues resulting from stigma that affect people living with HIV (PLHIV), commercial sex workers, the youth and men who have sex with men (MSM). The greatest challenge to preventing stigma in health facilities is that it is entrenched in many health workers’ attitudes – yet these are the people who are meant to provide vital services for the groups most at risk to HIV.
Kanakulya said: “Of course we would like to have zero stigma but we see it in care every time PLHIV are confronted with the need to care. Some people still have those misconceptions that PLHIV are the outcasts of society who should not be touched or taken care of.
“As a person who frequents health facilities in urban and rural Uganda, there is no doubt about the existence of stigmatising situations in facilities. I have seen health workers pointing fingers and whisper unfriendly remarks at PLHIV, even in what are considered to be the best HIV facilities, which integrate SRH and HIV services.”
With such observations, can health facilities within Sub Saharan Africa also provide services where all people irrespective of their status are freely attended to without any forms of discrimination? This seems very unlikely in the short term, but there is definitely need for a way forward.
Studies on forms of HIV stigma
Following the release of the People Living with Stigma Index, based on research carried out in Malawi and the United Kingdom, a team of scholars followed up key reflections shared by researchers who were involved in the index survey. Their findings have now been compiled in a book chapter by Stackpool-Moore, et al (2012) An Antidote to Stigma: The People Living with HIV Stigma in Malawi and the United Kindom (UK).
The book notes that: “The process (of participation, of consultation and of understanding documenting human rights realities) can be just as important as the product or outcome.”
Lately, programming for people lving with HIV have relied on models based on the greater involvement of people living with Aids and the meaningful involvement of people living with AIDS, known respectively as the GIPA and MIPA frameworks, where networks of people living with HIV have been at the forefront for prevention and treatment support.
Stackpool-Moore, et al (2012) observe that such principles can be a strong basis for reducing stigma, especially since such a principles enable communities to organise and build themselves for an effective intervention for HIV and related stigma.
But again, with a bigger and more dynamic complex reality, they wonder whether the GIPA and MIPA models are enough to meet the needs of very different lives in diverse social contexts touched by HIV. They identify HIV related stigma that can have an impact at three key levels: the personal, where self-stigma manifests in different ways; services, where stigma creates a barrier to accessing health services such as HIV prevention and treatment; structurally, where stigma reinforces power inequalities and affects the dynamic interplay between individuals and the social structures that influence their lives.
Stackpool-Moore, et al (2012) also argue that “Stigma relating to HIV still remains a significant challenge, because it has an impact on the accessibility and orientation of services (not only health but also legal, care and support services) and the general quality of life.”
But on a positive note, stigma is seen as able to “Trigger positive forces for change and networks of solidarity that rise to challenge the social norms and practices that marginalise, stigmatise and discriminate.”
The authors conclude that, to perform the kind of personal and social change necessary to overcome stigma, our efforts need to engage conscious attitudes as well as those less conscious. To effectively address a complex multilevel concern like HIV-related stigma, a complex multilevel solution is needed. The authors argue we need to: “Look beyond HIV, to engage wider issues of discrimination, marginalisation, racism, homophobia and other social injustices.”
How IPPF addresses HIV stigma for effective programming
One of the authors mentioned in this study is Lucy Stackpool-Moore, an HIV officer with International Planned Parenthood Federation (IPPF), who made further clarifications on their approach to stigma in programming for key populations at higher risk:
“At IPPF, our projects and other initiatives are aimed at all clients whether they are MSM, sex workers, lesbians, young or old, women and men. We also work with our providers so that they can provide services which are stigma free. We work institutionally around having HIV policy to ensure that staff and providers are aware of HIV and that they are respectful of colleagues who may be HIV positive.”
She adds that IPPF want their staff and providers to be able to ask the right questions but in the right way, so they can provide a comprehensive range of services to a diverse range of clients.
She continues: “We are also seeking to provide the best and quality services to people who might be marginalised by the law, like networks of LGBTI and sex workers. We start with what populations need and we look at how best we can provide the services without stigmatising them. We believe that each client has a right to access services irrespective of their differences.”
Stackpool-Moore, L., M.L. Chirwa, S. de Croy, A. Hudson, D. Kamkwamba, R. Kundecha, P. Mahaka, S. Onyango & E. Sinyemu. ‘An antidote to stigma? The People Living with HIV Stigma Index in Malawi and the United Kingdom (UK) (2012). In P. Chittagong (ed), Cross-cultural reflection on stigma. Melbourne: Springer.
- IPPF leader in reduce stigma