Reducing AIDS-related Stigma and Discrimination in Indian Hospitals

"Problem solving by partnership" was the key communication strategy used to develop tailored interventions to protect the interests and well-being of both patients and staff in the 3 New Delhi hospitals (one private and two government-run) taking part in this research intervention/initiative. The approach was multi-sectoral, and was characterised by participatory research and the involvement of all levels of staff in intervention activities, from ward staff to hospital superintendents. With an eye toward improving the health care environment for PLHA, organisers focused on positioning themselves as partners with the health care staff rather than as critics of them.

Prior to the implementation of the programme, formative research was conducted to understand the causes and manifestations of stigma and discrimination in each particular setting. This involved conducting in-depth interviews with health care workers and HIV-positive patients and focus group discussions with PLHA and NGO service providers. This process informed the development of a self-assessment checklist which identifies institutional strengths and weaknesses of services for PLHA, and of policies and procedures to prevent occupational exposure to HIV by staff. (Click here [PDF] to view the complete checklist.)

Based on the assessment facilitated by this checklist, hospital managers and senior staff developed action plans to address programme and policy gaps. Each action plan varied by hospital, but included:

• Development and dissemination of simply-worded printed hospital policy guidelines for HIV care and management. The guidelines were grouped according to 5 key domains: access to care for PLHA, counselling and testing, confidentiality, infection control, and training and dissemination. Besides the guidelines, this booklet also included references to NACO policy and World Health Organization (WHO) guidelines, as well as a section on operational definitions and explanations of the various policy statements. For ward staff, the guidelines were translated into Hindi and printed as a foldable pamphlet. To disseminate the guidelines, SHARAN contracted the services of SAHARA, an AIDS service NGO. Staff from SAHARA held several question-and-answer sessions in each of the hospitals with the different levels of health care workers; some of these meetings were held impromptu in nursing stations or in the ward staff canteen. In one of the hospitals, the management organised a half-day seminar with a panel of speakers representing NGOs, government agencies, and PLHA groups to debate the key aspects of the guidelines prior to disseminating them to all staff.
• Sensitivity training of health workers about the needs, concerns, and rights of PLHA, which drew on participatory training methods, such as discussions, group exercises, quizzes, games, role plays, and field visits. The strategy here involved developing an interactive training module that built on existing HIV/AIDS knowledge and skills-based training in the hospital, and that was enriched by input from local HIV/AIDS organisations and PLHA. The objectives of the module were: to improve staff members' understanding of HIV/AIDS transmission and procedures for infection control; to introduce concepts of confidentiality, patient/PLHA rights, voluntary counselling and training (VCT), and social care and support; and to clear up misconceptions and fears in order to ensure the provision of humane and equitable care and treatment. As per their expertise, 2 or 3 facilitators were assigned to guide each of the modules; for example, a team comprising a lawyer, a person living with HIV, and a human rights activist led the session on ethical and legal issues.
• Expansion and strengthening of HIV testing and counselling services. The 2 hospitals that had counselling centres expressed the need for a refresher training programme; in response, one of the lead AIDS service NGOs in the city offered a rigourous 1-week training for counsellors. In addition, in the hospital where the counselling centre was managed by a team of NGOs, the study team facilitated discussions between the NGOs and hospital management to streamline the counselling and testing procedures. The third hospital, which did not have a counselling centre, provided one staff member with extensive training on HIV/AIDS counselling techniques and procedures.
• Development (by an information, education, and communications (IEC) consultant) and dissemination of educational material (posters) on infection control procedures and post-exposure prophylaxis (PEP) following "field-testing" with a small group of hospital staff. Then, in each ward, staff were engaged in review and discussion of poster messages. Following the discussions, the team from SAHARA also engaged hospital staff in posting the IEC materials at key vantage points in each of the hospitals for maximum visibility.

HIV/AIDS, Rights.

The initiative was a response to evidence such as that from a study conducted in Bangalore and Mumbai, which found that many health providers denied care to HIV-infected patients, labeled admitted patients as HIV-positive, disclosed their HIV status to family members and others without their permission, and excessively used barrier precautions when working with them (UNAIDS 2001). As reported by PLHA and health care workers, common manifestations of stigma and discrimination in India's hospitals include: unwarranted referrals to other facilities; condescending, judgmental, and moralistic attitudes among staff; segregation and labelling of patients; excessive use of barrier precautions by staff; unconsented HIV testing; inadequate pre- and post-test counselling; withholding of HIV test results from the patient; and unconsented disclosure of test results to family and non-treating staff. Fear of such poor treatment may cause many PLHA to avoid seeking critical health care, organisers argue.