**U.S. Agency for International Development**

**Highlights from the XIV International AIDS Conference**

**July 31, 2002**

## "Stigma"

***Buck Buckingham of USAID*** began by noting the challenges that
stigma and discrimination pose to HIV/AIDS interventions. Program
planners must consider and plan to counter the effects of stigma and
discrimination; otherwise, their interventions will fail. The importance
of stigma and discrimination is now recognized. At Barcelona, USAID's
session on stigma and discrimination was its best-attended session, and
UNAIDS has made reducing stigma and discrimination the theme of the 2002
and 2003 World AIDS Days. Stigma, discrimination, and their effects are
pervasive. For example, stigma keeps many women away from
mother-to-child transmission prevention programs, while those who go may
be discriminated against for doing so. Greater program involvement of
people living with HIV/AIDS (PLWHA) is essential in fighting stigma and
discrimination, but some PLWHA were kept away from the Barcelona
conference by discriminatory restrictions on travel.

***Program Approaches. Kevin Osborne of the POLICY Project*** began by
affirming the importance and centrality of stigma and discrimination
issues in HIV/AIDS prevention and care and by acknowledging the
challenge of not letting stigma and discrimination become a rhetorical
"crosscutting" issue like gender. It is essential to find indicators to
measure stigma and discrimination and establish baseline data.
Indicators can be specific to certain settings such as workplaces, or
they can be more generalized in society. They can be formalized in laws,
regulations, and policies, or they can surface in the media.
Internalized stigma, which can prevent PLWHA from utilizing services,
must also be addressed. The POLICY Project is conducting studies in
Mexico, where HIV/AIDS is concentrated in certain high-risk groups, and
South Africa, where the epidemic is generalized, to compare approaches
to confronting stigma and discrimination.

Important statements were made at Barcelona to the effect that until
social disgrace, stigma, and discrimination are addressed, "all our
efforts will be meaningless." The involvement of PLWHA in activities for
reducing stigma and discrimination is essential. Their involvement
empowers them to confront stigma and discrimination, develop strategies
to reduce them, and strengthen the ability of PLWHA networks to advocate
for human rights protections. These efforts require strong personal and
public leadership. Community- and faith-based organizations are also
important contributors in the fight against stigma and discrimination.
Faith-based organizations in particular have the ability to influence
the attitudes and behaviors of their memberships. USAID and the POLICY
Project are providing technical and financial assistance to faith and
community groups that are seeking to increase advocacy and reduce stigma
and discrimination.

Knowledge and training alone are not enough to address HIV/AIDS-related
stigma and discrimination. Individuals and communities need to talk
openly and frankly about these issues and convert their communication
into action. Again, indicators are necessary so that their actions can
be properly directed. Even as successful anti-stigma,
anti-discrimination actions are implemented, they will not completely
solve these problems, and it is safe to predict that stigma and
discrimination will remain key features of the XV International AIDS
Conference in Bangkok in 2004.

# Overview from Barcelona. Julie Pulerwitz of Horizons described stigma and discrimination interventions in India and South Africa that were the subject of presentations at Barcelona. In India, the baseline survey of a pilot intervention to make hospitals "PLWHA-friendly" found various manifestations of stigma and discrimination, including early hospital discharge, ward segregation, isolation, lack of confidentiality (with patients' HIV status shared with all hospital health care workers and other patients, and with patient beds, files, and wards marked or labeled), and selective application of "universal" precautions. The knowledge of hospital workers about the basics of HIV/AIDS was high, but many myths and fears about transmission persist. There were also judgmental attitudes about PLWHA as "bad people" who "deserve" their fate. Interventions to sensitize health care workers on HIV/AIDS issues and help the hospitals become more PLWHA-friendly included interactive worker training; strengthened counseling; information and education about infection control and post-exposure prophylaxis; institutional self-assessment checklists; and institutional policy guidelines on HIV/AIDS care and management. The interactive training has resulted in knowledge and attitude changes among health care workers, and the overall participatory approach of the intervention's design and implementation has generated good support from public hospital managers and staff. The results of the intervention and its impact on reducing stigma and discrimination in medical care settings will be available early next year.

Interventions in South Africa have addressed HIV/AIDS stigma and
discrimination in the workplace and community and also looked at
gender-related aspects of stigma and discrimination. They have found
that workplace HIV/AIDS policies can make workers feel secure they will
not be discriminated against by being fired, but many workers still fear
stigmatization in terms of isolation or ridicule. They have also
demonstrated that workplace interventions can have an effect beyond the
workplace and translate into reduced stigma in the community.
Gender-based surveys have found that men are more likely than women to
hold discriminatory or stigmatizing attitudes and that men fear
discrimination and stigma less than women. Women who have HIV/AIDS are
perceived to be subjected to more stigma and discrimination in the
community than men who have HIV/AIDS. Workplace programs need to be
directed at both male workers and their sexual partners and take these
gender-based attitude differences into account.

Other studies reported at Barcelona have identified the importance of
sustaining PLWHA support groups. This is facilitated through common
objectives and expectations, defined roles and responsibilities, and the
development of coping mechanisms to help group members face illness,
death, bereavement, or grief. Other important issues related to stigma
and discrimination included the sensitivity of confidentiality and
public disclosure questions; the obstacle that perceived stigma poses to
access to services; the role of voluntary counseling and testing; and
the attitudes and approaches of church- and faith-based groups to issues
involving sexuality and morality.

***Questions and answers*** addressed such issues as moving away from
coping to empowerment; psychosocial needs of health care providers and
the "secondary" stigma to which they may be subjected; the need for
public discussion of stigma and discrimination; and anti-stigma,
anti-discrimination efforts as a struggle about justice.