Attending a session with a title slide "No getting to zero without scale-up of stigma reduction" on the first day of AIDS 2012 gave the [him] moderator a chance to think about what works in stigma reduction. Most stigma reduction interventions are not evaluated for effectiveness. Wouldn't acting to decrease discrimination and clearly measuring it be better?

The following is a comment that was addressed to the author of the email posting on the HealthGAP list further below.

And watch for more on stigma and discrimination on [him] in the next while ...

[him] moderator

++++++++++++++++++

Ron MacInnis has written: "Numerous examples of successful, small-scale stigma-reduction programs exist." He provides no examples from Africa. The two Asian references that are provided show that there are almost no stigma reduction programmes that have been shown effective in reducing stigma. They may be small scale but they can hardly be called successful.

[i] Stangl A, Carr D, Brady L, Eckhaus T, Claeson M, Nyblade L. Tackling HIV-Related Stigma and Discrimination in South Asia. Washington, DC: World Bank; 2010.

This paper looks at massive investment in a wide range of community based interventions but stigma and discrimination were hardly ever measured. "Specific indicators to assess changes in stigma and discrimination over time were recommended at a regional monitoring and evaluation workshop that most implementers attended. However, few implementers could conduct quantitative surveys to gather this type of information because of both organizational capacity and budgetary constraints." So no impact evaluation was performed.

[ii] Nyblade L, Hong KT, Anh NV, Ogden J, Jain A, Stangl A, et al. Communities Confront HIV Stigma in Viet Nam: Participatory Interventions Reduce HIV-Related Stigma in Two Provinces. Washington, DC; Hanoi, Vietnam: International Center for Research on Women (ICRW); Institute for Social Development Studies (ISDS); 2008.

This paper examines the effect of an intervention to reduce stigma among community members. "Exposure to intervention activities reduced value-driven stigma in both communities. Although statistically significant, the changes observed were small in magnitude and the overall level of value-driven stigma remained high." Discrimination was not measured.

Is this the best we can do?

Anonymous

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On 7/19/2012 11:43 AM, Ron MacInnis wrote:
> No “getting to zero” on HIV or AIDS without scaling up investments to end Stigma and Discrimination
>
> Posted by Ron MacInnis
> Deputy Director for HIV, Health Policy Project
>
> As HIV treatment access has expanded across the globe, public health policy experts are well aware the challenge HIV stigma poses to its uptake. In 2001, as the World Health Organization (WHO) launched its “Treating 3 Million by 2005” report it wrote, “as HIV/AIDS becomes a disease that can be both prevented and treated, attitudes will change, and denial, stigma and discrimination will rapidly be reduced.”
>
> More than a decade after that assertion, it is difficult to assess the accuracy of that WHO statement. Levels of stigma are rarely measured with accuracy, and a number of small-scale studies have shown that the relationship between increased access to HIV treatment and a reduction in stigma is not always clear. A study of 1,268 adults in Botswana in 2008 found that stigmatizing attitudes had lessened three years after the national program providing universal access to treatment was introduced. However, the study concluded that although improving access to antiretroviral treatment may be a factor in reducing stigma, it does not eliminate stigma altogether and does not lessen the fear of stigma amongst HIV-positive people.
>
> The fact that stigma remains in developed countries such as the United States, where treatment has been widely available for over a decade, also indicates that the relationship between HIV treatment and stigma is not straightforward. As recently as 2009, an estimated 27 percent of Americans would prefer not to work closely with a woman living with HIV. Moreover, preliminary results from the People Living with HIV Stigma Index in 2010, found that 17 percent of respondents living with HIV in the UK had been denied health care and that verbal harassment or assault had been experienced by 21 percent of respondents.
> As HIV treatment access has expanded across the globe over the past decade, public health policy experts have begun to examine how HIV programs can better address stigma within the health sector. Numerous examples of successful, small-scale stigma-reduction programs exist[i]-[ii]. Scaling up these efforts to the national level will require routine monitoring of the prevalence of drivers and manifestations of HIV-related stigma and discrimination. With the increasing push for evidence-based decisionmaking in national AIDS programs[iii], national programs must be able to quantitatively evaluate the impact of stigma reduction programs in order to ensure that these programs are included in national AIDS plans.
>
> HIV-related stigma and discrimination in healthcare settings is most often documented as refusing to admit patients because of their sexuality or drug use, delaying or withholding treatment, breaching confidentiality of patients, and making inappropriate comments. As a result, individuals—especially among key populations at higher risk of HIV infection such as sex workers, men who have sex with men, or drug users—are discouraged from accessing health services, adopting preventive health behaviors, and adhering to treatment.
>
> Despite worldwide recognition of the need to address these barriers, there is a gap between action and the resources required to reduce stigma and discrimination, as well as a lack of a global, standardized set of indicators to measure stigma in health facilities. A better understanding of how to measure stigma and its impact on other HIV programs will help policymakers realize the importance of investing in stigma reduction programs and policies.
>
> The newly released report from the Global Commission on HIV and the Law, after a year-long global review and consultation concludes that “laws based on evidence and human rights strengthen the global AIDS response - these laws exist and must be brought to scale urgently.”
> In many developing countries, these problems are exacerbated by broader structural factors like a weak judicial system, the corruption and lack of accountability of law enforcement, and stigma and intolerance among the general population. Use of cruel, inhuman, and degrading treatment has also been extensively documented both as punishment for drug use and treatment for addiction.  It takes considerable expertise, strong leadership, and evidence-based advocacy to get laws and policies, changed, amended and aligned to support public health.
>
> Reaching the global goals set by UNAIDS, the Global Fund, and PEPFAR to mitigate and end AIDS necessitates reaching larger numbers of people living with HIV, as well as those persons most vulnerable to HIV. To do this, countries need to scale up stigma reduction, and to monitor the effectiveness of stigma-reduction efforts, particularly in healthcare settings, and invest in the enormous work needed across law, policy, governance, human rights and advocacy.
>
> The more people living with HIV and key populations are stigmatized – either by cultural mores, poor health care quality, or state laws and policies that criminalize personal sexual behavior -  the less willing individuals are to approach their own risk for HIV. As a result, almost 60 percent of people living with HIV around the world are unaware of their HIV-positive status, and many who do know they are HIV-positive are ashamed to disclose their status[iv].
>
> Ron MacInnis
> Deputy Director for HIV
> Health Policy Project
> Futures Group
> One Thomas Circle NW, Suite 200
> Washington, DC 20005
> www.healthpolicyproject.com
>
>
> [i] Stangl A, Carr D, Brady L, Eckhaus T, Claeson M, Nyblade L. Tackling HIV-Related Stigma and Discrimination in South Asia. Washington, DC: World Bank; 2010.
> [ii] Nyblade L, Hong KT, Anh NV, Ogden J, Jain A, Stangl A, et al. Communities Confront HIV Stigma in Viet Nam: Participatory Interventions Reduce HIV-Related Stigma in Two Provinces. Washington, DC; Hanoi, Vietnam: International Center for Research on Women (ICRW); Institute for Social Development Studies (ISDS); 2008.
> [iii] Schwartländer, B., J. Stover, T. Hallett, R. Atun, C. Avila, E. Gouws, et al. Towards an improved investment approach for an effective response to HIV/AIDS. Lancet. 2011 Jun 11; 377(9782):2031-41
> [iv] UNAIDS World AIDS Day Report 2011 Geneva, Switzerland. 2011.
>
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