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November 23, 2011
By David J. Olson

In a major speech at the National Institutes of Health on Nov. 8, 2011, Secretary of State Hillary Clinton asserted that in order to create “an AIDS-free generation,” America would have to step up use of “combination prevention,” with three elements that have been proven most effective — prevention of mother-to-child transmission, voluntary medical male circumcision, and treatment of people living with HIV. 

These interventions need to be delivered in a mutually reinforcing package through programs formulated to respond to local realities, usually in health facilities by trained health professionals. People at risk for HIV will not benefit from these life-saving prevention services if they are denied access to them, are afraid to seek them, or experience stigma or discrimination when trying to access them.

“They [the three interventions] depend on institutional and social changes like ending stigma; reducing discrimination against women and girls; stopping gender-based violence and exploitation, which continue to put women and girls at higher risk of HIV infection; and repealing laws that make people criminals simply because of their sexual orientation,” said Secretary Clinton.

At the 2011 Caribbean HIV Conference in The Bahamas, Nov. 18–21, Dr. Farley Cleghorn, senior vice president of Futures Group, posed the question: “Can we end HIV and AIDS in the Caribbean without addressing stigma and discrimination?” in a plenary presentation at the closing ceremony. His answer was a resounding “no.”

Dr. Cleghorn, a gay man from Trinidad and Tobago whose work in HIV began when he initiated an HIV service 25 years ago in Port of Spain, spoke to Caribbean communities, health officials, and workers attending the conference, highlighting that “HIV program success or failure depends on attitudes, skills, and experience of staff.” He said that while the whole of society is important to the HIV response in the region, the health care setting, in particular, should be an “oasis from stigma and discrimination,” and outlined how health care providers can model desired behavior (e.g., awareness of types of stigma and resulting prejudice, preserving confidentiality and avoiding gossip, reinforcing appropriate behaviors with colleagues, and speaking up when witnessing discrimination).

Unfortunately, stigma and discrimination are still realities that manifest themselves in a variety of ways, such as refusing to admit patients, delaying or withholding treatment or other forms of care, not attending to patients in beds, testing without consent, breaching confidentiality, and making inappropriate comments. Internalized self-stigma is a barrier to the individual and vulnerable groups embracing and adopting appropriate health preservation behaviors and services.

One type of stigma is bad enough. But “layered stigma”— in which one stigma (such as stigma because of HIV infection) is “layered” on pre-existing stigma such as gender, poverty, and sexuality or sexual orientation—is even worse. Layered stigma promotes concentrated HIV epidemics, Dr. Cleghorn said, resulting in HIV prevalence among men who have sex with men ranging from 6.7% in Suriname to 20% in Trinidad and Tobago and among female sex workers ranging from 4.8% in the Dominican Republic to 24% in Suriname (UNAIDS, Keeping Score III, 2011). These high prevalence rates are maintained by continuing high HIV incidence rates driven by poor program penetration to stigmatized groups.

Dr. Cleghorn presented a snapshot of the HIV-related legal environment in the Caribbean (UNAIDS, Keeping Score III, 2011):

• 56% of countries report no legal protection against HIV-related discrimination.
• 75% of countries report laws and regulations that present obstacles to HIV services for vulnerable population groups.
• 69% of countries criminalize same-sex activities among consenting adults.
• 81% of countries criminalize some aspects of sex work.

Stigma and discrimination are major barriers to reaching prevention, care, and treatment targets, which is why UNAIDS has made zero discrimination one of the pillars of its strategy:

“The future of the HIV epidemic will depend on how well the Caribbean will address identified challenges. Leadership is needed to remove punitive laws that diminish stigma and discrimination. Laws that perpetuate stigma and discrimination and limit access to health care and fuel the spread of HIV are not in the national interest” (UNAIDS).

Greater political and policy commitment are needed to make health-related services “stigma free.”

A continuing barrier is that there are no globally agreed measures or indicators to measure how and under what conditions stigma affects health outcomes. Measuring and implementing stigma reduction programs and protocols in health care settings is one of the major areas of focus of the Health Policy Project. Putting a value on how much stigma and resulting discrimination discounts the overall HIV investment in the regions will help policymakers prioritize such interventions.

Dr. Cleghorn presented a variety of ways that different organizations can take action and “be the change we want to see.” For ministries of health, he suggests providing incentives for stigma-free health facilities, monitoring uptake of services, urging “do no harm” anti-stigma and discrimination approaches in certifying health professionals, and investing in training that is integrated into services.

What would stigma-free health services look like? They would ensure, Dr. Cleghorn said, that all personnel (“from the receptionist to the guard to the surgeon”) are trained, guidance exists for stigma- and discrimination-free services, client satisfaction is monitored, and key populations are included among staff and in evaluating services.

View Dr. Cleghorn's plenary presentation (PDF, 1MB).

The Health Policy Project produced this video on stigma, aimed primarily at health care professionals, for viewing at the Caribbean HIV Conference.

In addition to the closing plenary session that Dr. Cleghorn addressed, the Health Policy Project co-sponsored three other conference sessions: “Stigma, Evidence, and Health Systems Strengthening in the Caribbean;” “Measuring Stigma and Discrimination in Health Care Settings;” and a booth on “Responding to Stigma and Discrimination in the Caribbean.”

See more information about these sessions on the Health Policy Project website.

David J. Olson is a blogger and global development consultant with +20 years experience on five continents, and covers global development, related policy and communications and non-profit use of social media.