2. Measuring Stigma And Discrimination In Health Facilities In Ghana For Intervention Design: The Importance Of Measuring Stigma Towards Both People Living With HIV And Key Populations
Presented by: Kyeremeh Atuahene
Abstract Team: Kyeremeh Atuahene1, Nii Akwei Addo2, Emma Gyamera2, Christin Stewart3, Suzie Jacinthe4, Emmanuel Essandoh4, Pia Mingkwan3, Andrew Zapfel3, Laura Nyblade3
Affiliations: Ghana AIDS Commission1, Educational Assessment Research Center2, United States Agency for International Development4, Health Policy Plus Project3

3. Partners on the Study Study team: Supported by:
Education Assessment Research Center (EARC)
Health Policy Plus Project (HP+)
National AIDS Control Programme (NACP)
Ghana AIDS Commission (GAC)
Supported by:
USAID and PEPFAR
Global Fund
We would like in particular to thank USAID/PEPFAR and the Global Fund—without their support and encouragement, this work would not have been possible.

4. Stigma and Discrimination in Health Facilities towards people living with HIV and Key Populations are barriers to:
HIV prevention
HIV testing
Linkage to care
Retention in care
Adherence to treatment, and ultimately
Viral load suppression

5. Key Populations Background Information
National Strategic Plan notes key populations as
Men who have sex with men (MSM)
Transgender persons
People who inject drugs
Sex workers and their clients
Sero-negative partners in sero-discordant couples
The strategy includes the need for specific interventions for key populations including use of drop-in centers, improved data collection on size of populations and geographic locations, mobilization of peer educators, and reduction of stigma and discrimination throughout society.

6. The Total Facility Approach to S&D reduction: Three Phases
Jan 2017 – Jan 2018
Sept 2017 – March 2018
March 2018 – Sept 2018
Assessment (Baseline)
Intervention
Evaluation (Endline)
Quantitative survey of health facility staff (n=2,836) and clients living with HIV (n=250) in 20 facilities in 5 regions (Ashanti, Brong Ahafo, Eastern, Greater Accra, & Western)
Based on findings from Phase 1
Designed in partnership with intervention facilities (1 per region)
Participatory skills building plus other activities
Data collected in 5 intervention and 5 comparison facilities

7. Health facility staff questionnaire focused on:
Focus of the Study
Health facility staff questionnaire focused on:
Three key actionable S&D drivers:
Health facility environment
Fear of HIV transmission
Attitudes toward people living with HIV and key populations
Manifestations of S&D towards people living with HIV and key populations
Special Module: pregnant women living with HIV
Client questionnaire
Stigma within HIV care & general care
Satisfaction with care
Confidentiality of status
Perception of health facility policies
Reporting and redress opportunities
Key population identity and key population stigma

8. Key Population Questions in the Health Facility Staff Baseline Survey
Negative attitudes towards sex workers and men who have sex with men
Observed discrimination towards each of the three key populations in the past 6 months in their facility
Health workers unwilling to provide care
Health workers providing poorer quality of care
Health workers talking badly about
Health workers disclosing a person’s HIV or other key population status without the client’s consent in a situation that was not medically warranted
Beliefs of getting into administrative trouble for discriminating against men who have sex with men, female sex workers, and people who inject drugs
Perceived hesitancy of co-workers to care for key populations
Own preference not to provide services to key populations

9. Key Findings

10. Mid-Level Medical Staff
Perceptions of Health Facility Policies & Their Enforcement with Respect to Key Populations
Agreement
Senior Medical Staff
Mid-Level Medical Staff
Admin & Support Staff
Not Stated
Total N
222
2,088
502 28
2,840
I will get into trouble at work if I discriminate against patients who are men who have sex with men.
59.9%
70.2%
58.9%
57.1%
67.3%
I will get into trouble at work if I discriminate against patients who are sex workers
63.1%
73.9%
64.7%
71.3%
I will get into trouble at work if I discriminate against patients who inject drugs for non-medical reasons.
61.3%
60.2%
46.4%
68.3%

11. Observed Discrimination in the Past 6 Months, by Category of Staff (composite of 3 items-yes to at least one)

12. Perceived Hesitancy of Coworkers to Provide Care for Key Populations
Perceived hesitancy of coworkers to provide care to
Senior Medical Staff
(n=222)
Mid-Level Medical Staff
(n=2088)
Admin & Support Staff
(n=502)
Total
(n=2812)
Men who have sex with men or thought to be having sex with men
35.9%
43.5%
47.4%
43.6%
Sex workers or people thought to be sex workers
34.4%
42.3%
44.7%
42.1%
People who inject drugs for non-medical reasons or thought to be injecting drugs
40.3%
41.9%
40.1%

13. Conclusions
Despite staff reporting that their facilities have policies against discrimination of key population clients, S&D is still observed towards men who have sex with men, sex workers, and clients who inject drugs.
Interventions to improve quality of care for clients living with HIV must address stigma reduction towards key populations, in addition to HIV-related S&D.

14. Study Next Steps
Endline data collection in 5 pilot facilities and 5 comparison facilities to evaluate interventions and note change in S&D behavior in facility
Findings to be disseminated in June with public report to come out in September 2018