ACHIEVING A
STIGMA-FREE
HEALTH FACILITY
AND HIV SERVICES
Resources for
Administrators
This publication was prepared by Dara Carr, Ross Kidd,
Molly Fitzgerald, and Laura Nyblade.
June 2015
HEALTH
POLICY
PROJECT
Suggested citation: Carr, D., R. Kidd, M. Fitzgerald, and L. Nyblade. 2015. Acheiving a Stigma-free Health Facility and HIV Services: Resources
for Administrators. Washington, DC: Futures Group, Health Policy Project.
ISBN: 978-1-59560-095-0
The Health Policy Project is a five-year cooperative agreement funded by the U.S. Agency for International Development under Agreement No.
AID-OAA-A-10-00067, beginning September 30, 2010. The project’s HIV activities are supported by the U.S. President’s Emergency Plan for
AIDS Relief (PEPFAR). HPP is implemented by Futures Group, in collaboration with Plan International USA, Avenir Health (formerly Futures Institute),
Partners in Population and Development, Africa Regional Office (PPD ARO), Population Reference Bureau (PRB), RTI International, and the White
Ribbon Alliance for Safe Motherhood (WRA).
The information provided in this document is not official U.S. Government information and does not necessarily represent the views or positions of
the U.S. Agency for International Development.
Achieving a Stigma-free
Health Facility and HIV
Services
Resources for Administrators
iii
I. Introduction 1
II. Why Intervene? Causes and Consequences of Stigma and Discrimination 2
III. Getting Started 4
IV. Tools 6
Tool 1: Checklist for a Stigma-free Facility Environment and Policies 6
Tool 2: Code of Conduct 10
Tool 3: Action Plan 13
V. For More Information 15
Annex A: Health Worker Questionnaire 16
Annex B: Menu of Training Options 23
CONTENTS
iv
1
I. Introduction
Welcome! is resource guide is designed to help administrators of health facilities promote stigma-free HIV services.
Globally, many people living with or perceived to have HIV experience negative attitudes and harmful actions in health
facilities that undermine their health and ability to lead a productive life. However, administrators and health facility
sta worldwide have taken actions demonstrating that stigma and discrimination can be addressed successfully. Stigma-
reduction eorts in settings as varied as Brazil, China, Ghana, India, Tanzania, and Vietnam have resulted in signicant
changes in health facility sta attitudes and practices, and a better quality of care for people living with HIV (PLHIV) and
other key populations, such as men who have sex with men (MSM), people who use drugs, transgender people, and sex
workers.
A stigma-free health facility is one in which PLHIV and other key populations are treated with respect and compassion,
and provided with high-quality care. In a stigma-free facility, health facility sta members also are able to protect
themselves from HIV transmission in the workplace through the use of Standard Precautions, which the World Health
Organization denes as the basic level of infection control precautions for all patients. Additionally, in a stigma-free
facility, health facility sta feel condent about getting tested for HIV, living with HIV, and continuing to work.
Who is this guide for?
is guide is intended for facility administrators and other personnel who play a role in ensuring that policies, procedures,
and available supplies promote a safe workplace for sta, and the delivery of high-quality services. Others interested in
responding to stigma and discrimination within healthcare settings may also nd the tools in this guide useful.
2
II. Why Intervene?
Causes and Consequences of Stigma and Discrimination
People having an association with HIV oen experience negative attitudes and harmful actions that deter them from
accessing services, disclosing health information to providers, and adhering to treatment. HIV stigma refers to beliefs and
attitudes that deeply discredit a person or group of people because of an association with HIV or AIDS. is can, in turn,
lead to harmful actions or discrimination toward that person or group of people.
Globally, the availability of treatment and care for HIV has transformed the lives of millions of people for the better.
However, groups more vulnerable to HIV infection—sex workers, MSM, transgender people, people who use drugs,
and others—oen do not access lifesaving services because of actual or anticipated HIV stigma and discrimination.
When these groups do access services, they may be mistreated or receive a substandard quality of care. Furthermore, an
association with HIV compounds some people’s existing negative attitudes toward key populations. Additionally, a number
of countries have laws that criminalize key population behavior, which makes it even more dicult for key populations to
access health services and adhere to treatment.
What are the three primary drivers of HIV stigma and discrimination in health facilities?
Limited recognition of stigma and discrimination: Health facility sta may not realize their attitudes, words, and behaviors
are stigmatizing and discriminatory toward PLHIV and other key populations, and have resulting negative consequences.
Fear of acquiring HIV through casual contact: Health facility sta may lack sucient knowledge about HIV transmission,
which can lead to fear of acquiring HIV through everyday interactions with patients. A lack of knowledge, coupled with
the absence of adequate resources and knowledge to implement Standard Precautions, may result in health facility sta
engaging in acts of discrimination.
Moral judgments and values: Health facility sta may hold judgmental attitudes toward PLHIV or key populations. ese
attitudes may aect the services received by clients in unintended and oen unrecognized ways, and act as barriers to
accessing treatment and care.
What forms do HIV stigma and discrimination take in health facilities?
Studies have documented a wide range of discriminatory practices in health facilities toward PLHIV and key populations,
including the following:
Refusing to provide treatment, keeping clients waiting longer, or referring clients unnecessarily to other health facility
sta or facilities
Gossip and verbal abuse, such as scolding and name calling
Dierential treatment, such as requiring clients to take an HIV test before providing care, not providing some forms
of care that are available to others, and conditional treatment (e.g., that depend on contraceptive use)
Marking the les or clothing of patients living with HIV or isolating clients in separate waiting areas or wards when
there is no clinical need to do so
Forcing clients to be tested for HIV or tuberculosis without their consent, without adequate counseling, and without
providing the results of the tests to the client
Disclosing the HIV status of clients to other health sta, family members, or other people without the consent of
clients
Excessive use of barrier precautions, such as using gloves or masks for routine tasks that do not involve the handling
of bodily uids
3
How do HIV stigma and discrimination affect clients?
ose who are stigmatized or fear being stigmatized may behave as follows:
Fear taking an HIV test and delay getting tested until they are desperately ill, well beyond the optimal stage for
antiretroviral (ARV) intervention
Avoid going to health facilities for HIV and other health-related services
Not disclose important information to health facility sta for a proper diagnosis or course of treatment
Travel outside of their communities to access ARVs in secret or hide their use of ARVs and, as a result, take
inconsistent doses of medication
Avoid going to a health facility for delivery or drop out of a prevention of mother-to-child transmission program for
fear of disrespectful care from health facility sta
Avoid disclosing their serostatus to sexual partners or avoid insisting on safer sex
May not access information and services needed to help them prevent getting HIV
How are health facility staff members living with HIV affected?
Health facility sta living with HIV may also face gossip or exclusion by other health facility sta, discrimination at work
if there are no policies in place to protect their rights, and hostility from clients. ey oen hide their HIV status, avoid
discussing their situation with others, and suer in silence. Because of the fear of being stigmatized, or even losing their
job, health facility sta may avoid testing for HIV and access treatment either late or not at all. ey may become seriously
ill or die, causing further strain on an overburdened healthcare system.
4
III. Getting Started
e resources in this guide will assist administrators
in conducting a scan of stigma and discrimination
within the facility, and taking action to promote the
safety of health facility sta and improve the quality
of services for all clients. e guide contains a facility
environment and policy checklist and tools for
developing an eective Code of Conduct and Action
Plan for addressing stigma and discrimination. It also
contains additional tools for measurement and training
in Annexes A and B.
Administrators may use these resources either together as a package or on a stand-alone basis. e best results will likely
be achieved by applying a combination of tools. is guide is part of a suite of tools for addressing HIV stigma and
discrimination within health facilities. Other resources in the collection include the following:
Staff survey. is survey is a brief, standardized questionnaire for measuring the extent and nature of stigma and
discrimination among personnel within a health facility. It may be used to produce baseline information and later
to monitor progress. To develop the questionnaire, an international group of researchers assessed and synthesized
existing measurement tools. e researchers then eld tested the resulting questionnaire in China, Dominica, Egypt,
Kenya, Puerto Rico, and St. Kitts & Nevis. Based on the results, the researchers extracted the most reliable, valid
measures across settings. e questionnaire is accompanied by a user’s manual for implementation.
Training for health facility staff. is resource features participatory training modules, which include exercises to raise
sta awareness about stigma and discrimination in health facilities and help change their attitudes and behaviors
toward PLHIV and key populations. e training modules also cover basic skills on Standard Precautions. e
training modules were selected based on eectiveness in eld application across nine countries. Additionally, training
program menus provide timetables for using core training exercises with dierent types of sta, including managers,
doctors, nurses, support sta, trainers, and others. In delivering the program, each trainer is paired with a person
living with HIV or a member of a key population group.
Combined, these components are designed to be part of a systematic process to transform the attitudes and practices of
facility sta, and the institutions in which they work. e full suite of tools is available on the Health Policy Project (HPP)
website: www.healthpolicyproject.com/index.cfm?id=StigmaPackage.
RESPONDING TO HIV STIGMA AND DISCRIMINATION
IN YOUR HEALTH FACILITY
Checklist for a Stigma-free Facility Environment and
Policies
Code of Conduct
Action Plan
5
Steps for Responding to HIV Stigma and Discrimination
Below are some suggested steps for promoting a stigma-free health facility:
1. Set up or identify a Stigma Action Group. Include senior managers, clinical sta, nonclinical sta, and service users.
e group will be responsible for developing and implementing stigma-related activities in the facility and monitoring
progress.
2. Assess your facility. If possible, assess the levels of stigma and discrimination within your facility. Depending on
your time and resources, you have dierent options for assessment. Implementing the sta questionnaire (Annex A)
will provide you with the most complete information about knowledge, attitudes, and practices in your facility. e
Checklist for a Stigma-free Facility Environment and Policies will provide critical information about the extent to
which the facility supports and delivers stigma-free services. Be sure to share results with sta.
3. Review current policies and practices. In meetings or other regular activities, allocate some time to discuss policies
and practices related to HIV stigma and discrimination. Each department could develop its own ideas on new policies
or guidance to counteract stigma.
4. Get ideas from the community and local organizations, including those that represent key populations with high
burdens of HIV. Encourage these groups to contribute their perspectives on stigma and discrimination, and then meet
with them to discuss the eort to create a stigma-free facility.
5. Develop and launch a Code of Conduct. Organize the development of a written Code of Conduct; then heighten sta,
clients’, and the community’s awareness of it. e Code of Conduct or Practice represents agreed-upon principles
and behaviors in areas such as patient condentiality, patient rights and respect, and quality of care. In facilities, such
Codes of Conduct oen are developed in a participatory manner with health facility sta and may be “peer enforced.”
Plan for a strong launch of the Code by displaying it in service areas and sta rooms, using meetings to let sta
members know what it means for their work, and asking for feedback from clients. Celebrate your aim of creating a
stigma-free facility!
6. Mainstream stigma-free norms and practices. Create an Action Plan to implement the Code of Conduct and any
other activities needed for a stigma-free facility. In developing the Action Plan, note that sustaining change may entail
activities such as training, as well as altering existing procedures, including how you assess sta performance.
7. Monitor progress. Carry out regular assessments of your Code of Conduct, record success stories, and discuss
challenges and progress with sta. Periodically, you might also want to review the Code to see if it needs to be altered
or new points need to be included.
6
IV. Tools
Tool 1: Checklist for a Stigma-free Facility Environment and Policies
is Checklist helps you assess the extent to which your facility supports and delivers stigma-free HIV services. Depending
on time and resources, you may want to assign or create a team to apply the Checklist and report results back to management
and sta. e Checklist touches on several operational and service areas. As such, a working group or task force made up of
dierent types and levels of sta may be best equipped to assess how the facility performs on each of the items.
is tool may be applied to help develop a facility-wide or departmental Code of Conduct. More formal and accurate
assessment information, however, will be obtained by conducting a survey of health facility sta (see Annex A) as well as
applying this Checklist.
STATUS
YES/
ALWAYS
MOSTLY SOMETIMES
NO/
NEVER
DON’T
KNOW
I. EQUAL ACCESS TO QUALITY SERVICES
The facility provides equal access to services
and information regardless of
HIV status
Sexual orientation
Gender identity
Criminalized behaviors (e.g., sex work,
injecting drug use, same-sex sexual relations)
Care for PLHIV—or patients awaiting results
of an HIV test—is provided without delay or
unnecessary referrals for services available
within the facility.
PLHIV are integrated with other patients unless
there is a medical basis for isolation.
All HIV tests are voluntary and accompanied
by informed consent, including for pregnant
women.
II. CONFIDENTIALITY
Information about HIV status is communicated
only to the patient and treating healthcare
workers, and otherwise is kept strictly
confidential. It is not disclosed to a patient’s
family except with the explicit informed consent
of the patient.
7
STATUS
YES/
ALWAYS
MOSTLY SOMETIMES
NO/
NEVER
DON’T
KNOW
Private health matters, such as HIV serostatus,
are discussed with a patient in a way or in an
area where others may not easily overhear the
conversation.
Healthcare records are stored in a secure
location.
Staff such as security guards and porters are not
assigned roles that would make them privy to
confidential patient information.
Beds, wards, staff, and files are not labeled
in ways that would convey HIV status to other
patients or staff.
III. SAFETY
Standard Precautions are practiced in the same
manner with all patients at all times.
Sound waste management is practiced at all
times by all staff.
All staff are informed about and provided with
free hepatitis vaccines and, if required, post-
exposure prophylaxis (PEP).
Essential supplies for Standard Precautions,
infection control, and PEP are available at all
times to all staff for Standard Precautions.
The availability of these essential supplies is
actively communicated to staff.
Educational materials on Standard Precautions
are posted in all wards and staff areas.
IV. TRAINING
All staff are trained in patients’ rights and the
right of PLHIV and other key populations to equal
care.
All treating healthcare workers are trained in the
principles and procedures of voluntary testing
and informed consent.
All healthcare workers are trained in the
principles of confidentiality and patients’ rights
to confidentiality.
8
STATUS
YES/
ALWAYS
MOSTLY SOMETIMES
NO/
NEVER
DON’T
KNOW
All staff are trained on the basis of HIV and
hepatitis transmission and prevention, infection
control (including Standard Precautions), waste
management, and PEP.
Staff members receive ongoing training and
skills development in the areas above.
V. QUALITY ASSURANCE
Staff or a committee are assigned to monitor
adherence to HIV stigma-related policies and
procedures:
Equal care and patient rights
Voluntary testing and informed consent
Confidentiality of the information system and
health records
Patient confidentiality and privacy
The facility takes action to address violations of
policies and procedures.
The facility proactively tries to prevent violations
of policies and procedures.
Supervisors encourage a stigma-free environment
and support staff members in providing
nonstigmatizing services.
An accessible patient grievance redressal
cell, which registers and addresses patient
complaints, is in place and open daily.
The existence of the grievance redressal cell
is posted in each ward and all patient waiting
areas.
The facility provides effective resolution of client
complaints.
An infection control team is in place and meets
regularly (once a month or more) to monitor
infection control practices and supplies.
9
STATUS
YES/
ALWAYS
MOSTLY SOMETIMES
NO/
NEVER
DON’T
KNOW
VI. POLICY
Facility policy specifies respectful and equal
care for all patients, regardless of HIV status,
sexual orientation, gender identity, or other key
population characteristics.
Facility has a policy on voluntary testing and
informed consent.
Facility has a policy on patient privacy and
confidentiality.
Facility has guidelines that define the type of
staff that comprise the treatment team for patients
with HIV, making it clear what types of personnel
have access to information about HIV status.
Facility has clear guidance outlining procedures
and timelines for responding to instances in
which policies and procedures for a stigma-free
facility or services are not followed.
Facility has clear guidance and timelines for
responding to patient complaints related to
stigma and discrimination.
Facility policy guarantees a safe working
environment for all healthcare workers.
Facility policies and procedures that promote a
stigma-free facility are actively communicated to
all staff members and, as appropriate, posted in
all departments and patient waiting areas.
10
Tool 2: Code of Conduct
A Code of Conduct is a set of agreed-upon policies and procedures that guide sta behavior to create a stigma-free facility
and services. e Code of Conduct will be most eective if it is developed collaboratively by health sta and managers.
Drawing upon the contributions of all sta (medical and non-medical) helps ensure it will not be a “top-down” exercise.
Also, by helping to facilitate a sense of ownership by everyone, health facility sta will be more likely to implement the
new practices.
ere are dierent ways to develop a Code of Conduct. One possibility is to hold a broader training on HIV-related stigma
and discrimination that includes a session on developing a Code (see training menu in Annex B). is training helps
ensure that health facility sta members devise a Code that reects a solid understanding of the drivers and manifestations
of stigma in the facility. Other ways of taking this work forward might include assignment to an existing committee or
to a group of department representatives that includes managers and sta. e formulation of the Code may also be
incorporated into existing training activities or sta meetings.
Developing a Code of Conduct
Facilitator’s Note: e Code of Conduct may be developed in two sessions, ideally conducted together.
Objectives: By the end of this exercise, participants will have accomplished the following:
a. Described the challenges of stigma and discrimination within the facility
b. Outlined their vision for a stigma-free facility (Code of Conduct)
Session One: Identifying Our Challenges
Time: 1 hour
Step 1: Begin with a brief presentation of any information gathered on HIV-related stigma and discrimination as part of a
formal or informal assessment process. is presentation could include the ndings from an application of the Checklist
for a Stigma-free Facility Environment and Policies or the health worker survey (Annex A). e presentation serves as a
starting point for group work and discussion (see Step 2).
Step 2: Break the larger group into small groups of about ve and ask them to answer the following guiding questions:
How are PLHIV and other key populations (e.g., Men who have sex with men, sex workers, people who use drugs,
transgender individuals) treated in your facility?
What are our main challenges in providing better quality of care for PLHIV and other key populations?
Let each group know it will be reporting its answers to the whole group.
Step 3: Ask the groups to report back to the whole group. List the responses on a ipchart.
Step 4: Summarize the responses, combining similar answers. Note any responses that came up more than once. Discuss
the full list and agree on any changes.
11
Session Two: Defining our Vision for a Stigma-free Facility
Time: 2 hours
Step 1. Divide into small groups of about ve and ask each group to write a Code of Conduct for a stigma-free facility on
their ipcharts. e following guiding questions can help them design their code:
A stigma-free health facility is one in which...?
If your sister, brother, or child is a person living with HIV or a member of a key population group, how would you like
them to be treated in the health facility?
What behaviors currently occur that need to be changed to create a stigma-free facility?
What behaviors do facility sta need to show to create a stigma-free facility?
Are there any policies, procedures, or practices we need to create, change, or add to address the challenges identied
in the previous session?
Step 2. Each group reports back to the larger group, sharing their ipcharts.
Step 3. Summarize the responses, combining similar answers. Note any responses that have come up more than once.
Facilitate a discussion with the entire group. Are there any changes or additions needed? Are there important similarities
or dierences among the codes created by each group? Is there consensus on items for a single Code of Conduct, including
the language for each point? Bring the group to agreement.
SAMPLE RESPONSES
What challenges regarding HIV stigma and discrimination do PLHIV or key populations face in the facility?
Substandard care: providers take less time with the patient, keep them waiting, treat them last, and refer them to
other providers
Private health records are not kept in a secure way that safeguards confidentiality
Staff avoid contact with the patient and use gloves and masks for routine tasks that don’t involve the handling of
blood and bodily fluids
Staff gossip about the patient and blame them for getting HIV
Staff reveal individuals’ HIV status or other sensitive information to others, including family members, without their
explicit consent
Staff test the patient for HIV without their consent or adequate counseling—and do not always provide the results of
the HIV test
Staff seat the patient in a separate area or on a separate bench, or they are hospitalized in a separate, segregated
room or ward
12
Step 4. Wrap-up on Finalizing and Implementing our Code of
Conduct
In the wrap-up discussion, engage the group in developing a
plan for nalizing and implementing the Code of Conduct. Key
discussion items to consider are as follows:
Who or what entity will nalize the Code?
Who or what entity will organize its rollout to all sta?
How might we disseminate the Code to sta, clients, and other
stakeholders?
How will we monitor adherence to the Code?
What happens when we notice that the Code is not being
followed?
How can we continue to promote adherence to the Code over
time?
When will we review and adjust our Code, if necessary?
Sample Code
At right is a Code of Conduct from St. Kitts & Nevis.
Representatives from facilities throughout the twin-island nation
developed it in 2014 through a participatory process with the
Ministry of Health and National Advisory Council on HIV and
AIDS. It has since been adopted by all government health facilities
in the country. is work was supported through the USAID- and
PEPFAR-funded Health Policy Project.
IDEAS FOR DISSEMINATING THE CODE OF
CONDUCT
Post the Code throughout the facility
Present and discuss the Code during staff meetings
Post the Code on the facility website and announce it
through social media
Share the Code with community groups and
organizations, including those that work with key
populations
Plan an event to launch the code officially and invite staff,
community members, and media to attend
Write a brief article or press release about the Code, send
it to media outlets, and post it on the facility website
We the staff of
pledge to
A
C
o
d
e
o
f
C
o
n
d
u
c
t
9 Offer your understanding and cooperation
9 Respect our staff and other patients
9 Respect the privacy and confidentiality of
other patients
9 Ask questions and be engaged in your care
or treatment
9 Adhere to the rules and policies of this facility
B
We ask you to
9 Provide service that is fair, equitable, and respectful,
regardless of clients’ race, religion, age, education,
economic status, political affiliation, national origin,
gender, health status, or sexual orientation
9 Provide the best possible care we are able
9 Keep all patient information private and confidential
9 Provide appropriate and timely information on
patient care and treatment
9 Communicate effectively and respectfully to provide
the necessary support to you and your persons of
concern
9 Ask for consent before services and treatment
are administered
9 Provide you with the most professional health service
For Compliments & Concerns
Private Medical
Doctors: Chief Medical
Officer
869–467–1270/1173/1172
Hospital
Administration and
Operations: Health
Operations Manager
869–465–2551 Ext 104
Hospital Medical Staff:
Medical Chief of Staff
869–465–2551 Ext 110
Hospital Nursing:
Director of
Institutional Nursing
869–465–2551 Ext 107
Community Nursing:
Director of Community
Nursing, Health
869–467– 1273
Community
Health: Director of
Community-based
Health Services
869–467–1134
Doctors in Hospital:
Medical Chief of Staff
869–469–5473
Private Doctors: Medical
Officer of Health
869–469–7080
Community Health
Nursing: Supervisor
of Community Health
Nursing
869–469–5521 Ext 2051
Community Health
Doctors: Medical
Officer of Health
869–469–7080
Hospital Nurses: Matron
869–469–5473
Hospital Support Staff:
Hospital Administrator
869–469–5473
Public Health Support
Staff: Health Services
Administrator
869–469–5521 Ext 2112
St Kitts Nevis
13
Tool 3: Action Plan
e Code of Conduct should be linked to practical action so that health facility sta put their new skills into practice and
gain support for new norms and attitudes. Ideally, Code items will be integrated into the everyday operations of the facility
and the work of sta. is might mean improving the facility for Standard Precautions, incorporating stigma reduction
into existing training programs, and altering sta supervision and assessment guidance. Action planning is key for
translating your vision for a stigma-free facility into reality.
TANZANIA: STRONGER RESULTS AFTER INCORPORATING STIGMA-REDUCTION TRAINING INTO
EXISTING TRAINING
In Muhimbili Hospital in Tanzania, stigma trainers successfully lobbied to include stigma as an additional component in
a training program for hospital staff on provider-initiated testing and counseling (PITC). More than 650 hospital workers
were trained on stigma reduction through this program. An evaluation of the training found that health workers trained
in both PITC and stigma reduction achieved better patient results than those trained in PITC alone. Those services deliv-
ered by health workers who had received PITC and stigma reduction training showed increased uptake of ARV treatment
among clients and higher disclosure rates.
(International HIV/AIDS Alliance. 2011. Integrating Stigma Reduction into HIV Programming: Lessons from the Africa Regional Stigma
Training Programme, page 28)
Developing an Action Plan
Facilitator’s Note: In a single session, sta can outline an Action Plan for responding to stigma and discrimination. is
is envisioned as a facilitated discussion and working session. e Action Plan summarizes the challenges, desired results,
and recommended actions. It also involves assigning specic sta to lead dierent activities and noting target dates for
completion.
Objective: By the end of this exercise, participants will have created a concrete Action Plan for addressing challenges
related to stigma and discrimination within the facility.
Time: 1.5 hours
Step 1. Summarize with the group the challenges in the facility related to HIV stigma and discrimination.
Possible sources of data or information include the following:
Assessment results from applying the Checklist for a Stigma-free Facility Environment and Policies
Findings from a survey of sta (see Annex A)
Group discussion notes from developing a Code of Conduct (application of Tool 2)
Step 2. Engage the group in a discussion about the relevant Code of Conduct items that address the challenges identied.
Step 3. For each challenge, ask the group to identify root causes. Write down the root causes on a ipchart. Note the
following:
Participants may state a number of possible causes.
Some causes may be behind more than one problem or challenge.
Participants should be encouraged to be open about challenges and willing to bring about change. No one should be
blamed for raising problems or issues.
14
Step 4. Engage the group in identifying priority recommendations for addressing each problem or challenge. To be
addressed eectively, recommendations should be clear, specic, and concrete. Also note what measures facility sta and
management will take to make sure that the proposed recommendations are well implemented or followed.
Step 5. Identify the sta person who will take on the recommended activities and agree on a target date for completion. Be
sure to schedule meetings as needed to track ongoing progress and challenges.
Table 1: Sample Template for Action Planning
WHERE WE ARE
NOW (CHALLENGES)
WHERE WE WANT
TO BE (RELEVANT
CODE OF CONDUCT
ITEM/S)
ROOT CAUSE(S) FOR
CURRENT SITUATION
RECOMMENDED
ACTIONS/QUALITY
ASSURANCE
STAFF LEAD/S
AND TARGET
COMPLETION DATE
Sex workers
are viewed as
troublemakers and are
often made to wait
longer than
other clients
All clients receive the
same high-quality care
without discrimination
Moral judgments and
blame
Belief that other clients
are more important
Train health facility staff on
the needs of sex workers—
and how to provide
appropriate services and
information
Name/Date
Assess training through
pre- and post-surveys of
participants
Name/Date
After training, gather
feedback from clients or
client representatives about
experiences in the facility
Name/Date
People who use drugs
complain they are
not greeted, listened
to, or provided
with information on
available services
Client’s circumstances
or behavior do not act
as a barrier to their
accessing healthcare
and treatment
Health facility staff
speak to clients in
a respectful and
dignified manner
Health facility staff
stigmatize people
who use drugs due to
fears of acquiring HIV
through contact in the
clinic
Staff exhaustion and
burnout are due to
work on HIV issues
Make sure information on
Standard Precautions is
posted
Name/Date
Hold refresher course on
Standard Precautions
Name/Date
Form staff welfare
committee to address
burnout issues
Name/Date
Facility staff avoid
getting tested for
HIV due to lack of
confidentiality
Medical information
of clients is treated
confidentially
Health facility staff
feel confident about
undergoing HIV testing
Lack of secure space
for storing health
records
Unclear guidance to
staff on confidentiality
Lock health records to
ensure security
Name/Date
Develop and disseminate
clear guidance to staff on
confidentiality
Name/Date
Survey staff on
confidentiality to assess
whether conditions have
improved
Name/Date
15
V. For More Information
e resources in this guide are intended to help you foster a stigma-free facility and services. ey are part of a suite of
tools for taking action against HIV stigma and discrimination in health facilities. e full suite includes resources for
assessment, training, and sustaining change (see Table 2). ese resources are available on the HPP website at www.
healthpolicyproject.com/index.cfm?id=StigmaPackage.
Table 2: Suite of Tools for Health Facilities
CHANGE COMPONENT TOOLS AVAILABILITY
ASSESS
Measure and understand HIV stigma
and discrimination in the facility
Checklist for a Stigma-free Facility
Environment and Policies for HIV
stigma and discrimination
Questionnaire for facility staff
Checklist is in this guide
Staff questionnaire is in Annex A
and on the HPP website
User’s guide for implementing the
questionnaire is on the HPP website
TRAIN
Conduct participatory training to raise
awareness and change attitudes and
behaviors
Menu of training programs for
different types of staff
Modules with instructions and
exercises
Menu of training programs is in
Annex B and on the HPP website
Full collection of modules is on the
HPP website
SUSTAIN
Develop and mainstream action items
and policies to sustain a stigma-free
facility and HIV services
Code of Conduct
Action Plan
Code of Conduct tool in this guide
Action Plan tool in this guide
16
Annex A: Health Worker Questionnaire
Section 1: Background Information
First we will ask about your background.
1. How old were you at your last birthday? years
2. What is your sex?
□ Female □ Male
3. What is your current job?
Adjust as appropriate for country context by adding or deleting categories according to sample.
□ Accountant □ Cashier □ Cleaning staff □ Clinical Officer □ Dentist
□ Dental Technician/Hygienist □ Doctor □ Educator □ Laboratory Technician
□ Lay Health Worker/Peer Educator □ Medical Records Personnel □ Medical Technician
□ Nurse □ Pharmacist □ Receptionist □ Security Guard □ Ward Attendant
□ Phlebotomist □ Other
4. How many years have you worked in healthcare? years
5. Have you ever worked in a clinic/hospital/department that specialized in HIV care and treatment?
□ Yes □ No
6. If low prevalence, use question 6a. If high prevalence, use question 6b.
a. In the past 12 months, approximately how many HIV-positive patients did you provide with care or
services?
b. In a typical week, approximately how many HIV-positive patients do you provide with care or services?
7. Do you typically use any of the following measures when providing care or services for a patient living
with HIV?
a. HIV stigma and discrimination □
b. Infection control and universal precautions (including post-exposure prophylaxis) □
c. Patients’ informed consent, privacy, and confidentiality □
d. Key population stigma and discrimination □
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Section 2: Infection Control
Now we will ask you about infection concerns in your health facility.
8. How worried would you be about getting HIV if you did the following?
If any of the following is not one of your job responsibilities, please select “Not applicable.”
a. Touched the clothing of a patient living with HIV
□ Not worried □ A little worried □ Worried □ Very worried □ Not applicable
b. Dressed the wounds of a patient living with HIV
□ Not worried □ A little worried □ Worried □ Very worried □ Not applicable
c. Drew blood from a patient living with HIV
□ Not worried □ A little worried □ Worried □ Very worried □ Not applicable
d. Took the temperature of a patient living with HIV
□ Not worried □ A little worried □ Worried □ Very worried □ Not applicable
9. Do you typically use any of the following measures when providing care or services for a patient living
with HIV?
a. Avoid physical contact
□ Yes □ No □ Not applicable
b. Wear double gloves
□ Yes □ No □ Not applicable
c. Wear gloves during all aspects of the patient’s care
□ Yes □ No □ Not applicable
d. Use any special infection-control measures with patients living with HIV that you do not use with other
patients
□ Yes □ No □ Not applicable
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Section 3: Health Facility Environment
Now we will ask about practices in your health facility and your experiences working in a facility
that provides care to people living with HIV.
10. In the past 12 months have you seen a person living with HIV in your health facility?
□ Yes (Go to question 11)
□ No (Skip to question 12)
□ Don’t know (Skip to question 12)
11. In the past 12 months, how often have you observed the following in your health facility?
a. Healthcare workers unwilling to care for a patient living with or thought to be living with HIV
□ Never □ Once or twice □ Several times □ Most of the time
b. Healthcare workers providing poorer quality of care to a patient living with or thought to be living with
HIV, relative to other patients
□ Never □ Once or twice □ Several times □ Most of the time
c. Healthcare workers talking badly about people living with or thought to be living with HIV
□ Never □ Once or twice □ Several times □ Most of the time
12. If low prevalence, use question 12a. If high prevalence, use question 12b.
a. How worried are you about
i. People talking badly about you because you care for patients living with HIV?
□ Not worried □ A little worried □ Worried □ Very worried □ Not applicable
ii. Friends and family avoiding you because you care for patients living with HIV?
□ Not worried □ A little worried □ Worried □ Very worried □ Not applicable
iii. Colleagues avoiding you because of your work caring for patients living with HIV?
□ Not worried □ A little worried □ Worried □ Very worried □ Not applicable
b. In the past 12 months, how often have you
i. Experienced people talking badly about you because you care for patients living with HIV?
□ Never □ Once or twice □ Several times □ Most of the time
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ii. Been avoided by friends and family because you care for patients living with HIV?
□ Never □ Once or twice □ Several times □ Most of the time
iii. Been avoided by colleagues because of your work caring for patients living with HIV?
□ Never □ Once or twice □ Several times □ Most of the time
13. How hesitant are healthcare workers in this facility to work alongside a coworker living with HIV, regardless
of their duties?
□ Not hesitant □ A little hesitant □ Somewhat hesitant □ Very hesitant
Section 4: Health Facility Policies
Now we are going to ask about the institutional policy and work environment in your facility.
14. In my facility it is not acceptable to test a patient for HIV without their knowledge.
□ Strongly Agree □ Agree □ Disagree □ Strongly Disagree
15. I will get in trouble at work if I discriminate against patients living with HIV.
□ Yes □ No □ Don’t Know
16. Do you strongly agree, agree, disagree, or strongly disagree with the following statements?
a. There are adequate supplies in my health facility that reduce my risk of becoming infected with HIV.
□ Strongly Agree □ Agree □ Disagree □ Strongly Disagree
b. There are standardized procedures/protocols in my health facility that reduce my risk of becoming
infected with HIV.
□ Strongly Agree □ Agree □ Disagree □ Strongly Disagree
17. My health facility has written guidelines to protect patients living with HIV from discrimination.
□ Yes □ No □ Don’t Know
20
Section 5: Opinions About People Living With HIV
Now we are going to ask about opinions related to people living with HIV.
18. Do you strongly agree, agree, disagree, or strongly disagree with the following statements?
a. Most people living with HIV do not care if they infect other people.
□ Strongly Agree □ Agree □ Disagree □ Strongly Disagree
b. People living with HIV should feel ashamed of themselves.
□ Strongly Agree □ Agree □ Disagree □ Strongly Disagree
c. Most people living with HIV have had many sexual partners.
□ Strongly Agree □ Agree □ Disagree □ Strongly Disagree
d. People get infected with HIV because they engage in irresponsible behaviors.
□ Strongly Agree □ Agree □ Disagree □ Strongly Disagree
e. HIV is punishment for bad behavior.
□ Strongly Agree □ Agree □ Disagree □ Strongly Disagree
19. Women living with HIV should be allowed to have babies if they wish.
□ Strongly Agree □ Agree □ Disagree □ Strongly Disagree
20. Please tell us if you strongly agree, agree, disagree, or strongly disagree with the following statement:
a. If I had a choice, I would prefer not to provide services to people who inject illegal drugs.
□ Strongly Agree (Go to question 20b)
□ Agree (Go to question 20b)
□ Disagree (Skip to question 21)
□ Strongly Disagree (Skip to question 21)
b. I prefer not to provide services to people who inject illegal drugs because (check all reasons that apply)
i. They put me at higher risk for disease. □ Agree □ Disagree
ii. This group engages in immoral behavior. □ Agree □ Disagree
iii. I have not received training to work with this group. □ Agree □ Disagree
21
21. Please tell us if you strongly agree, agree, disagree, or strongly disagree with the following statement:
a. If I had a choice, I would prefer not to provide services to men who have sex with men.
□ Strongly Agree (Go to question 21b)
□ Agree (Go to question 21b)
□ Disagree (Skip to question 22)
□ Strongly Disagree (Skip to question 22)
b. I prefer not to provide services to men who have sex with men because (check all reasons that apply)
i. They put me at higher risk for disease. □ Agree □ Disagree
ii. This group engages in immoral behavior. □ Agree □ Disagree
iii. I have not received training to work with this group. □ Agree □ Disagree
22. Please tell us if you strongly agree, agree, disagree, or strongly disagree with the following statement:
a. If I had a choice, I would prefer not to provide services to sex workers (specify: male or female or both,
depending on context).
□ Strongly Agree (Go to question 22b)
□ Agree (Go to question 22b)
□ Disagree (Skip to question 23)
□ Strongly Disagree (Skip to question 23)
b. I prefer not to provide services to sex workers because (check all reasons that apply)
i. They put me at higher risk for disease. □ Agree □ Disagree
ii. This group engages in immoral behavior. □ Agree □ Disagree
iii. I have not received training to work with this group. □ Agree □ Disagree
22
Module 1: Antenatal care, Prevention of Mother-to-child Transmission, and
Labor and Delivery Wards
The following section is to be completed by service providers who work with pregnant women in
antenatal care, prevention of mother-to-child transmission of HIV, and in labor and delivery rooms.
If you do not work in one of these areas, you have completed the questionnaire.
23. How worried are you about assisting in labor and delivery if the woman is living with HIV?
□ Not worried □ A little worried □ Worried □ Very worried □ Not applicable
24. In the past 12 months, how often have you observed other healthcare providers
a. Performing an HIV test on a pregnant woman without her informed consent?
□ Never □ Once or twice □ Several times □ Most of the time
b. Neglecting a woman living with HIV during labor and delivery because of her HIV status?
□ Never □ Once or twice □ Several times □ Most of the time
c. Using additional infection-control procedures (e.g., double gloves) with a pregnant woman living with
HIV during labor and delivery because of her HIV status?
□ Never □ Once or twice □ Several times □ Most of the time
d. Disclosing the status of a pregnant woman living with HIV to others without her consent?
□ Never □ Once or twice □ Several times □ Most of the time
e. Making HIV treatment for a woman living with HIV conditional on her use of family planning methods?
□ Never □ Once or twice □ Several times □ Most of the time
25. Do you strongly agree, agree, disagree, or strongly disagree with the following statements?
a. If a pregnant woman is HIV positive, her family has a right to know.
□ Strongly Agree □ Agree □ Disagree □ Strongly Disagree
b. Pregnant women who refuse HIV testing are irresponsible.
□ Strongly Agree □ Agree □ Disagree □ Strongly Disagree
c. Women living with HIV should not get pregnant if they already have children.
□ Strongly Agree □ Agree □ Disagree □ Strongly Disagree
d. It can be appropriate to sterilize a woman living with HIV, even if this is not her choice.
□ Strongly Agree □ Agree □ Disagree □ Strongly Disagree
23
Annex B: Menu of Training Options
A. Half-day workshop for health facility managers
B. One-day workshop for health facility managers
C. Two-day workshop for medical health workers
D. ree-day workshop for medical health workers
E. Ten-week modular course for medical health workers—two-hour sessions once a week over 10 weeks
F. Four-day workshop for medical sta, including full component of Standard Precautions
G. ree-hour introductory workshop for doctors
H. One-day workshop for doctors
I. ree-hour workshop for doctors on stigma toward key populations
J. One-day workshop for nonmedical health sta
K. Two-day workshop for nonmedical health sta
L. ree-day intensive workshop on stigma toward key populations (also includes basics on S&D)
M. Two-day workshop on stigma toward men who have sex with men (MSM) (also includes basics on S&D)
N. Two-day workshop on stigma toward people who use drugs (also includes basics on S&D)
O. Two-day workshop on stigma toward sex workers (also includes basics on S&D)
P. Four-day training-of-trainers (TOT) workshop for S&D reduction trainers
Q. Half-day reinforcement course—follow-up to all of the courses listed above
R. Pre-service course for health worker trainees—two-hour sessions once a week over 12 weeks
Assumptions
Four sessions in the morning (one hour each) and two sessions in the aernoon (one hour each), producing a total of
roughly six sessions per day and covering roughly six hours. Most sessions can be squeezed into one hour; however, some
sessions may take longer.
Extra Notes
1. e workshops are described as full-day sessions, but you may choose to organize them as half-day sessions.
2. e workshops are described as a block of continuous training over several days—ensuring that the modules are
closely linked and the learning process is sustained. However, it is also possible to organize the training to take
place for two to four hours every week. is depends on the local schedule and the availability of health workers for
training.
The full Facilitator’s Training Guide for a Stigma-free Health Facility is available on the Health Policy Project website
at: http://www.healthpolicyproject.com/index.cfm?id=StigmaPackage.
For more information, contact:
Health Policy Project
Futures Group
1331 Pennsylvania Ave NW, Suite 600
Washington, DC 20004
Tel: (202) 775-9680
Fax: (202) 775-9694
Email: [email protected]
www.healthpolicyproject.com
