Ellen Weiss

COMBATING HIV STIGMA IN HEALTH CARE SETTINGS: WHAT WORKS?

The purpose of this review paper is to provide information and guidance to those in the health care setting about why it is important to combat HIV-related stigma and how to successfully address its causes and consequences within health facilities. Research shows that stigma and discrimination in the health care setting and elsewhere contributes to keeping people, including health workers, from accessing HIV prevention, care and treatment services and adopting key preventive behaviours.Studies from different parts of the world reveal that there are three main immediately actionable causes of HIV-related stigma in health facilities: lack of awareness among health workers of what stigma looks like and why it is damaging; fear of casual contact stemming from incomplete knowledge about HIV transmission; and the association of HIV with improper or immoral behaviour.To combat stigma in health facilities, interventions must focus on the individual, environmental and policy levels. The paper argues that reducing stigma by working at all three levels is feasible and will likely result in long-lasting benefits for both health workers and HIV-positive patients. The existence of tested stigma-reduction tools and approaches has moved the field forward. What is needed now is the political will and resources to support and scale up stigma-reduction activities throughout health care settings globally.

Women's lives and sex: Implications for AIDS prevention

Preliminary findings from the Women and AIDS program, a research grants program of the International Center for Research on Women in Washington, D.C. that supports 17 studies in developing countries worldwide, provide a glimpse into the complex interaction between womens social and economic status and risk of HIV infection. In many settings, the cultural norms that demand sexual fidelity and docile and acquiescent sexual behavior among women permit — and sometimes even encourage —early sexual experimentation, multiple partnerships, and aggressive and dominating sexual behavior among men. Drawing upon the findings from the program, the paper analyzes how such cultural norms, together with womens social and economic dependency, can limit a womans ability to negotiate safer sex with her partner; restrict her access to information and knowledge about her body; force her to sometimes barter sex for survival; increase her vulnerability to physical violence in sexual interaction; and compromise her self-esteem. The findings highlight the limitations of the current HIV/AIDS prevention strategy for reducing womens risk of HIV, and underline the urgency for an approach to prevention that is grounded in the realities of womens lives and sexual experiences — an approach that recognizes the relationship between the dynamics of gender relations, sexual behavior, and HIV risk.

High Rates and Positive Outcomes of HIV-Serostatus Disclosure to Sexual Partners: Reasons for Cautious Optimism from a Voluntary Counseling and Testing Clinic in Dar es Salaam, Tanzania

The rates, barriers, and outcomes of HIV serostatus disclosure to sexual partners are described for 245 female voluntary counseling and testing (VCT) clients in Dar es Salaam, Tanzania. VCT clients were surveyed 3 months after HIV testing to describe their HIV-serostatus disclosure experiences. Sixty-four percent of HIV-positive women and 79.5% of HIV-negative women (p = 0.028) reported that they had shared HIV test results with their partners. Among women who did not disclose, 52% reported the reason as fear of their partners reaction. Both 81.9% of HIV-negative women and 48.9% of HIV-positive women reported that their partner reacted supportively to disclosure (p < 0.001). Less than 5% of women reported any negative reactions following disclosure. VCT should continue to be widely promoted. However, intervention approaches such as development of screening tools and new counseling approaches are important to ensure the safety of women who want to safely disclose HIV serostatus to their sexual partners.

Addressing gender dynamics and engaging men in HIV programs: lessons learned from Horizons research.

In the field of human immunodeficiency virus (HIV) prevention, there has been increasing interest in the role that gender plays in HIV and violence risk, and in successfully engaging men in the response. This article highlights findings from more than 10 studies in Asia, Africa, and Latin America—conducted from 1997 through 2007 as part of the Horizons program—that have contributed to understanding the relationship between gender and mens behaviors, developing useful measurement tools for gender norms, and designing and evaluating the impact of gender-focused program strategies. Studies showed significant associations between support for inequitable norms and risk, such as more partner violence and less condom use. Programmatic lessons learned ranged from insights into appropriate media messages, to strategies to engage men in critically reflecting upon gender inequality, to the qualities of successful program facilitators. The portfolio of work reveals the potential and importance of directly addressing gender dynamics in HIV- and violence-prevention programs for both men and women.

Reducing HIV-Related Stigma: Lessons Learned from Horizons Research and Programs

Since the early years of the human immunodeficiency virus (HIV) epidemic, stigma has been understood to be a major barrier to successful HIV prevention, care, and treatment. This article highlights findings from more than 10 studies in Asia, Africa, and Latin America—conducted from 1997 through 2007 as part of the Horizons program—that have contributed to clarifying the relationship between stigma and HIV, determining how best to measure stigma among varied populations, and designing and evaluating the impact of stigma reduction-focused program strategies. Studies showed significant associations between HIV-related stigma and less use of voluntary counseling and testing, less willingness to disclose test results, and incorrect knowledge about transmission. Programmatic lessons learned included how to assist institutions with recognizing stigma, the importance of confronting both fears of contagion and negative social judgments, and how best to engage people living with HIV in programs. The portfolio of work reveals the potential and importance of directly addressing stigma reduction in HIV programs.

Gender, sexuality and HIV: making a difference in the lives of young women in developing countries

Most new HIV infections are occurring in young people, with young women hit particularly hard in parts of the developing world. This paper explores the impact of gender and sexual norms on young womens sexual experiences, expectations and vulnerability to HIV/AIDS. It argues that the power imbalance characteristic of sexual relations among men and women has many of its roots in adolescence. The data that support these findings were collected from studies conducted in Africa, Latin America, and Asia and the Pacific as part of the Women and AIDS Research Programme of the International Center for Research on Women. The paper concludes with recommendations for educators, therapists, and counsellors who work with young people and their families.

Promoting Dual Protection in Family Planning Clinics In Ibadan, Nigeria

Integration of efforts to prevent HIV and sexually transmitted infections (STIs) and of condom promotion into family planning (FP) services is urgently needed because of the escalating HIV epidemic in sub-Saharan Africa. Counseling on dual protection--concurrent protection from unintended pregnancy and HIV and other STIs--and provision of the female condom were introduced in six FP clinics in Ibadan Nigeria. Structured observations of interactions between clients and service providers clinic service statistics provider interviews and other qualitative and quantitative methods were used to assess FP providers promotion of dual protection. Following intensive training providers delivered dual-protection counseling to a majority of clients and demonstrated the female condom to 80% of the new clients observed. Discussion of the sexual behavior of clients and their partners of the relative ability of various contraceptives to protect against HIV infection and of how to negotiate condom use increased significantly as did STI assessment. Providers internalization of the importance of HIV/AIDS prevention was crucial to promoting and sustaining the dual-protection initiative. Condom purchases increased from a baseline of 2% of all FP visits in 1999 to 9% in January-June 2001. This increase came mainly from acceptance of the female condom used either alone or in conjunction with another contraceptive. Integrating dual-protection counseling and female condom provision into FP services appears feasible as is service providers acceptance of dual-protection objectives. While providers and clients are key to transforming FP to dual-protection services the attitudes and behaviors of clients male partners must be considered in gauging the success of the dual-protection intervention. (authors)

Cost-Effectiveness of Environmental–Structural Communication Interventions for HIV Prevention in the Female Sex Industry in the Dominican Republic

Behavior change communication often focuses on individual-level variables such as knowledge, perceived risk, self-efficacy, and behavior. A growing body of evidence suggests, however, that structural interventions to change the policy environment and environmental interventions designed to modify the physical and social environment further bolster impact. Little is known about the cost-effectiveness of such comprehensive intervention programs. In this study we use standard cost analysis methods to examine the incremental cost-effectiveness of two such interventions conducted in the Dominican Republic in sex establishments. In Santo Domingo the intervention was environmental; in Puerto Plata it was both environmental and structural (levying financial sanctions on sex establishment owners who failed to follow the intervention). The interventions in both sites included elements found in more conventional behavior change communication (BCC) programs (e.g., community mobilization, peer education, educational materials, promotional stickers). One key aim was to examine whether the addition of policy regulation was cost-effective. Data for the analysis were gleaned from structured behavioral questionnaires administered to female sex workers and their male regular paying partners in 41 sex establishments conducted pre- and postintervention (1 year follow-up); data from HIV sentinel surveillance, STI screening results conducted for the intervention; and detailed cost data we collected. We estimated the number of HIV infections averted from each of the two intervention models and converted these estimates to the number of disability life years saved as compared with no intervention. One-way, two-way, three-way, and multivariate sensitivity analysis were conducted on model parameters. We examine a discount rate of 0%, 3% (base case), and 6% for future costs and benefits. The intervention conducted in Santo Domingo (community mobilization, promotional media, and interpersonal communication) was estimated to avert 64 HIV infections per 10,000 clients reached, and resulted in a cost per disability-adjusted life year (DALY) saved of

Improving the lives of vulnerable children: implications of horizons research among orphans and other children affected by AIDS.

1,186. In Puerto Plata a policy/regulatory intervention was added, which resulted in 162 HIV infections averted per 10,000 clients reached, and yielded a cost per DALY saved of

From Beneficiaries to Change Agents: The Rise of Women's Leadership in International Development

457. Cost-effectiveness estimates were most correlated to the discount rate used and base rates of sexually transmitted infection (which affects the HIV transmission rate). Both intervention models resulted in cost-effective outcomes; however, the intervention that included policy regulation resulted in a substantially more cost-effective outcome.