1. Laura Nyblade, PhD Nelson Varas-Díaz, PhD MEASURING HIV/AIDS STIGMA AMONG HEALTH PROFESSIONALS

2.  Denial of services: Yes, it happened to me once. I went to a dentist in Canóvanas (town) and after they sat me in the chair and the technician started to ask for my data, she asked me if I had any conditions. I told her that I was HIV positive and she refused to see me. She went and spoke to the dentist and told me ‘we can’t see you’. (Puerto Rico)  Subtle discrimination:...it’s a subtle discrimination, it’s not that they won’t see you, but it’s a way of not being authentic with the patient. I see a lot of that, especially when they (the patients) are ignorant… for example a drug addict, a prostitute, or someone with no education. (Puerto Rico)  Stigma combinations: There were many people living with HIV going to govt. hospitals, but if we, sex workers, went, we were always sent away on some pretext, or we would be made to wait the whole day. By the time our turn came, the OPD will be closed. This discouraged us from going there. (India) STIGMA AND HEALTH PROFESSIONALS (HPS)

3. FORMS-HEALTH PROVIDERS STIGMA INDICATORS WORKING GROUP, TANZANIA Neglect  Had to wait longer  Not having bed pans changed  Receiving less care/attention Denied care  Referral to another provider/facility  Senior provider pushed client to a junior provider  Junior provider pushed client to a senior provider Differential treatment  HIV test required before care was given  HIV test required before scheduling surgery  Using gloves for non- invasive exams  Extra precautions in sterilizing instruments Lack of consent  HIV testing without consent  Disclosing HIV status to family without client’s consent Verbal stigma Gossip about a client’s HIV status Scolding or blaming a client

4.  Avoidance of health related services by PLHIV.  Self-medication by PLHIV.  Problems with communication during routine check- ups (e.g. avoidance of “sensitive” subjects)  Provision of substandard services.  Denial of services by HPs.  Among others… CONSEQUENCES WHEN MANIFESTED BY HPS

5. Understand/Baseline of levels & forms to: Help guide future interventions by providing information on: how to intervene (i.e. which stigma dimensions). and with whom (i.e. nurses, physicians, etc). Monitor HIV stigma levels reported by HPs to: Improve services, encourage and maintain stigma-free facilities. Compare (triangulation) with levels reported by PLHIV. Sometimes one group can perceive stigma differently in the same event. Provides opportunity for intervention. WHY MEASURE STIGMA AMONG HPS?

6.  Uys (2009)  Population: Nurses.  Setting: Various countries in Africa.  Li (2007)  Population: Health professionals.  Setting: China.  Varas-Diaz & Neilands (2009)  Population: Health professionals in training (Physicians, Nurses, Psychologists, Social Workers).  Setting: Puerto Rico. SOME EXAMPLES OF EXISTING MEASURES

7.  Geared towards research ventures therefore:  Often long and therefore not appropriate for routine monitoring/evaluation of programs and national-level reporting.  Tested and validated in only one site or country context.  Often with only one type of health professional, not reflecting varied levels of staff within health system.  Training  Client Interaction WHAT ARE THEIR LIMITATIONS / CHALLENGES

8. IN RESPONSE: DEVELOPING A SHORT AND ACCESSIBLE MEASURE OF HIV- RELATED STIGMA AMONG HPS

9. The Health Policy Project (HPP) with USAID funding is leading a global effort to develop, test, validate and standardize a brief stigma and discrimination measurement tool for health care settings. Process: A “Technical Meeting to Consolidate HIV Stigma and Discrimination Measures for Health Settings”, convened on September 21-23, 2011 in Washington DC. Joint Effort for Field Testing across diverse settings (prevalence, language, health systems) Individual and cross-site analysis Finalization of tool Submission of proposed indicators to the UNAIDS MERG BACKGROUND

10. Puerto Rico China Kenya Egypt St. Kitts and Nevis Dominica Alabama PARTICIPATING SITES

11.  Infection Control  Level of worry of infection when conducting certain activities, e.g. taking blood pressure, giving an injection etc.  Use of ‘protective’ measures when providing care or services to a patient living with HIV  Avoid physical contact  Wear gloves during all aspects of the patient’s care (history-taking, physical examination, etc.)  Health Facility Environment  Observation of stigmatizing or discriminatory care  Healthcare workers unwilling to care for a patient living with HIV  Secondary/Courtesy S&D experienced by HPs  Been avoided by colleagues because of your work caring for patients living with HIV KEY S&D DOMAINS

12.  Health Facility Policies and Work Environment.  Existence & enforcement of policies that protect patients  My health facility has policies to protect patients living with HIV from discrimination.  Supplies, training & policies to support facility staff to provide non-stigmatizing care & protect themselves from infection.  Opinions about People Living with HIV & Key Populations.  Attitudes  Empathy  Willingness to care KEY S&D DOMAINS

13. LET’S REVIEW OUR STIGMA MEASURE AS A POTENTIAL TOOL FOR FUTURE USE IN HEALTH SCENARIOS…

14. QUESTIONS?