Fear of Economic Ramifications Reducing HIV Stigma & Discrimination: A Framework for Program Implementation & Measurement Actionable Drivers & Facilitators Stigma “Marking” Manifestations (Domains) Impacts Outcomes DRIVERS Lack of Awareness Fear of HIV Infection Fear of Social Ramifications Fear of Economic Ramifications Social Judgment Quality of Life HIV Incidence HIV Prevalence Morbidity Mortality Anticipated Stigma Internalized Stigma Experienced Stigma Behaviors Uptake of HIV Services Uptake of Support Other Stigmas Intersecting Stigmas Discrimination This framework depicts the key actionable factors that facilitate and drive HIV stigma, the marking of individuals or groups as socially unacceptable based on behaviors, characteristics and/or HIV status, which manifests for individuals and groups in several ways (domains). These manifestations influence a range of outcomes, including risk behaviors and uptake of HIV prevention, care and treatment services, which ultimately influence individual quality of life, HIV incidence and HIV prevalence. Key drivers of stigma include institutional, cultural and individual and community facilitators, which can either positively or negatively influence stigma. For example, anti-discrimination laws and policies can protect against discrimination, whereas laws that criminalize HIV can propagate stigma. However, drivers highlighted in this framework, including lack of awareness of stigma and its harmful consequences, fear of HIV infection, fear of societal and economic ramifications of illness and death related to HIV, powerlessness and social judgment all negatively influence stigma and discrimination. In an effort to make this a practical, rather than a conceptual framework, only the ‘actionable’ drivers of stigma and discrimination that can be directly addressed through programming and reform are included. These drivers collectively lead to the marking of individuals and groups as socially unacceptable or deviant, based on either behaviors considered to put one at risk for HIV and/or HIV status or association with a person living with HIV. While this framework focuses on HIV stigma, it recognizes the influence of the intersecting stigmas often faced by with people living with or at risk of HIV. Once the stigma has been assigned to individuals or groups, it manifests in 4 key ways: anticipated stigma (the fear of negative social ramifications should one’s HIV status become known, should one associate with a person living with HIV or should one test positive for HIV); internalized stigma (the level of endorsement of negative beliefs and feelings associated with HIV about themselves); experienced stigma (the experience of prejudice and discrimination, based on HIV status or association with a person living with HIV or other stigmatized group, that falls outside the purvey of the law) and discrimination (the experience of prejudice and discrimination that falls inside the purvey of the law). This framework is based on the assumption that all individuals can either anticipate, internalize, experience and/or perpetuate stigma and discrimination, therefore we do not distinguish between specific outcomes on the basis of HIV status. These manifestations of stigma lead to a number of negative outcomes for both infected and uninfected persons that undermine HIV prevention, care and treatment efforts and ultimately influence the course of the HIV epidemic. In addition, the manifestations can also perpetuate the actionable drivers and facilitators of stigma. This framework incorporates 2 key elements that are currently lacking attention in terms of program implementation and measurement globally: institutional facilitators of stigma and intersecting stigmas. The purpose of this framework is to inform the design of interventions to reduce stigma and discrimination, as well as highlight key components that can be measured to monitor and evaluate progress towards reducing stigma and discrimination that will inform programs, policies and funding decisions. HIV Stigma Institutional Cultural FACILITATORS Individual and Community

(outside legal purview) (within legal purview) Actionable Facilitators Reducing HIV Stigma & Discrimination: A Framework for Program Implementation & Measurement Stigma “Marking” Stigma Manifestations (Domains) Stigma Outcomes Impacts Actionable Drivers Lack of Awareness Of stigma Of harmful consequences Fear of HIV Infection Lack of knowledge Irrational fears Fear of Social Ramifications Own family Community Fear of Economic Ramifications Of illness and death Of loss of livelihood Social Judgment Prejudice & stereotypes regarding: HIV status Drug use Sexual behavior Sex work Gender Age Behaviors: Risk Behavior Disclosure Adherence Uptake of HIV Services: Testing Prevention Care Treatment Uptake of Support Psychosocial Legal Economic Stigma assigned for HIV positive status or association with HIV+ person Intersecting Stigmas Stigma assigned for socially discredited behaviors or characteristics Anticipated Stigma Internalized Stigma Experienced Stigma (outside legal purview) Quality of Life HIV Incidence HIV Prevalence Morbidity Mortality Discrimination (within legal purview) Actionable Facilitators Institutional Laws, policies, policy environments Institutions (i.e. healthcare, government, schools, police, religious, media) Individual & Community Power Social support Social assertiveness Resilience Cultural Gender culture Sexual culture Health beliefs Ethics & morality