Reducing AIDS-related Stigma and Discrimination in Indian Hospitals
http://www.popcouncil.org/pdfs/horizons/inplhafriendly.pdf

Conclusion and Recommendations

The formative research findings clearly indicated the need to address
stigma and discrimination in the hospital setting and corroborated
many of the findings of earlier research in India in this context
(UNAIDS 2001). This study found that although HCWs generally denied
that their hospital refused admission and/or treatment to patients
because of their known or suspected HIV status, caregivers and
patients reported that the access to and quality of in-patient care
in New Delhi hospitals depended on a patient's HIV status.
Experiences with and fears about such treatment was enough to deter
some patients from seeking care, and cause other patients to conceal
their HIV-status from HCWs, if possible. Common manifestations of
differential treatment of PLHA in the participating hospitals
included delay in treatment, unwarranted referrals to other
facilities, segregation, labeling, excessive use of barrier
precautions, breaches of confidentiality, unconsented HIV-testing,
inadequate pre-and post-test counseling, and withholding HIV test
results from patients. The study also found that many health care
workers lacked adequate knowledge and training in the basics of HIV
transmission, infection control, and clinical management of HIV/AIDS.
Also, a lack of hospital policies protecting PLHA and ensuring staff
safety contributed to differential treatment.

These findings highlight that stigma and discrimination in health
settings is fueled by both individual and institutional factors.
Therefore, reducing AIDS-related stigma and discrimination in
clinical settings requires addressing not just the attitudes and
practices of health care workers but also their needs for
information, training, and supplies. The study also showed that all
cadres of health care workers, including doctors, nurses, and ward
staff, carry out discriminatory practices. It was interesting to note
that even though ward staff are not engaged in providing clinical
care to patients, they still had the most discriminatory attitudes
toward PLHA. Because of the important role they play in providing
support services in the hospital, it was critical for the
intervention to target ward staff. This supports the intervention's
basic premise of involving all levels of health care workers, from
ward staff to hospital superintendents, in improving the hospital
environment rather than simply trying to effect change from the top
down by only working with management. The participatory methods used
by the project team proved to be crucial in mobilizing hospital
managers to take action to reduce stigma and discrimination. Facility-
specific survey data, the checklist, and other tools sparked action
among managers to make the hospitals more "PLHA-friendly" and
facilitated ownership of the process. The hospital managers were
engaged in designing and implementing the multilevel intervention
that included training, materials development, and policy reform.
Although the study design does not allow the researchers to
definitively prove the efficacy of the approach, pre- and post-survey
data show significant improvements in health care workers' reported
knowledge, attitudes, and practices related to the care and
management of PLHA. Interviews with hospital managers corroborated
many of the changes detected by the quantitative data. But, despite
these positive findings, there is room for fine-tuning of the
intervention. The study demonstrated that some attitudes and
practices may be more difficult to change than others and may require
more focused activities. For example, support for mandatory testing
for invasive procedures was about the same after the intervention.
This lack of change in HCWs' attitudes toward testing may be due to
their heightened risk perception of contracting HIV from their
patients. To allay these fears, hospitals may need to place a greater
focus on improving HCWs' access to appropriate infection control
methods and the use of universal precautions. Also, the meaning,
norms, and values placed upon seemingly universal principles like
patient confidentiality may in fact differ in different settings. For
example, in this setting, while there was improved respect for
patient privacy in general, many HCWs continued to feel that they
were entitled to know the HIV status of their patients and continued
to share such information with one another.

Therefore, more work is needed to translate changes in attitudes and
beliefs to changes in practice. Even in large public hospitals
confronting a wide range of institutional challenges, it is possible
to create positive change. This study demonstrates that government,
private/non-profit, and research groups each have a role to play in
reducing stigma and discrimination in the health sector. However, a
respectful and open attitude on the part of each sector is required
for such a partnership to succeed. For example, when the intervention
began, hospital managers feared that data about stigma and
discrimination would be used for lawsuits and negative publicity, and
AIDS NGOs tended to blame health care workers for stigmatizing or
discriminatory practices. In response, the study team reassured the
hospitals that the data would be confidential and not be reported by
hospital, and sensitized AIDS NGO staff about the concerns and
difficulties of health care workers who practice in overburdened,
resource-constrained settings.

In sum, the following recommendations emerged from the study:

In order to reduce stigma and discrimination, it is important to
assess and improve HIV/AIDS-related knowledge and attitudes of all
HCWs. Misinformation and judgmental attitudes among all cadres of
HCWs can foster stigma, fear, and differential treatment of PLHA.
This study showed that even the most senior HCWs do not have complete
understanding of HIV transmission and prevention. Therefore, it is
important for programs to target all levels of HCWs with initial and
ongoing refresher training. Such training should go beyond providing
information to include sensitizing staff to the needs, concerns, and
rights of PLHA.Efforts to increase knowledge and improve attitudes
must be accompanied by policies, information, and supplies that
create a safe working environment for HCWs.

This and other studies (Nyblade et al. 2003) have shown that health
care workers perceive themselves to be at high risk of infection
because of their exposure to the virus during service delivery. Thus,
training alone may not have the desired impact on health care
workers' attitudes and practices if they do not perceive environment
within which they work to be safe to implement their newly acquired
knowledge and skills. Thus it is essential to assess and acknowledge
health care workers' fears and risk and then develop and implement
workplace policies that ensure staff safety and respect for health
care workers rights. These policies need to ensure the availability
of essential supplies (e.g., gloves, post-exposure prophylaxis) for
maintaining optimum infection control practices by health care
workers at all times to not only protect themselves but also to
protect their patients from exposure to infection.

A multi-sectoral, participatory approach to reducing stigma and
discrimination is promising.The improvements in reported HCW
attitudes and practices and in hospital policies support an approach
characterized by participatory problem identification and problem
solving, and the involvement of all levels of staff in intervention
activities, from ward staff to hospital superintendents. Groups and
organizations wishing to work in health care settings should consider
positioning themselves as true partners rather than as critics or
watchdogs/whistle blowers if their goal is to improve the health care
environment for PLHA.Further research is needed to determine whether
the improvements observed reflect actual reductions in stigma and
discrimination as perceived by PLHA.

Conducting this research in Indian hospitals that now are seeing
greater numbers of PLHA or in regions with a higher HIV prevalence
would enable researchers to gain valuable feedback from HIV-positive
patients. Also, any further research should examine the role of
increased availability of antiretroviral on stigma and discrimination
in health care settings.