Tackling HIV-Related Stigma and Discrimination in South Asia

This report examines an effort on the part of the World Bank's South Asia Region to address the fact that HIV prevalence in India and South Asia is growing among sex workers, injecting drug users, and other marginalised groups - largely because of a widespread failure to prevent stigma and discrimination toward them. The World Bank's 2008 South Asia Region Development Marketplace (SARDM), "Tackling HIV and AIDS Stigma and Discrimination", involved: disbursing relatively small grant amounts; funding organisations led by and for marginalised groups; and supporting implementers in programme design, monitoring, and evaluation. This report describes findings from the 26 SARDM implementers in designing and implementing interventions to address HIV stigma and discrimination.

The research team's approach to this evaluation, conducted in December 2009, involved both in-depth assessment, including case studies conducted by the International Center for Research on Women (ICRW) on 6 projects in Afghanistan, Bangladesh, India, Nepal, Pakistan, and Sri Lanka, and a broad look across the spectrum of implementer experience to distil lessons.

Part I of this report describes key findings and lessons learned that emerged across the 26 implementers. Researchers found that the most promising projects used various approaches to raise awareness about stigma and discrimination, such as correcting misinformation about HIV and marginalised populations, empowering marginalised groups, and addressing harmful norms and behaviours.

• In terms of broad lessons and principles, the experiences of all SARDM implementers suggest the following communication-related learnings:
  1. The most promising work used multiple strategies and stakeholders to address stigma. Even where projects initially appeared to be single-focus interventions (for example, theatre), successful implementation required a range of other activities, such as training, engagement with policy makers, and media relations.
  2. Involving marginalised communities is essential for strengthening capacity, ensuring appropriate messaging, and maximising results. Strategies that foster some interaction between marginalised communities and the public - either directly or through the mass media - can be powerful in inspiring change. Products such as films or plays that are developed by, or strongly reflect the input of, marginalised communities are likely to be more compelling and more rapidly disseminated.
• Several examples of specific actions undertaken by the 26 SARDM implementers are provided in Chapter 3 of the report, with qualitative evidence of impact provided. Communication-related lessons associated with specific programmatic approaches taken by implementers include:
  1. Encourage positive behaviour change by establishing direct connections and engaging in partnerships with groups such as police, health care professionals, and religious leaders who had in the past been blamed or condemned due to their stigmatising and abusive attitudes/actions. Involve local political leaders in modelling non-stigmatising behaviours, and link up with national government authorities to build interest in learning from stigma-fighting innovations, to spark support for replication and scale-up, and to advocate for making stigma reduction a national priority.
  2. To effectively involve marginalised populations in stigma reduction efforts, a number of projects incorporated approaches to address the effects of self-stigma, which is the internalisation of society's negative attitudes. Evidence gathered from community-led interventions also highlights the critical role that supportive networks play in helping strengthen capacity of marginalised communities to reduce stigma and discrimination. Many projects worked closely with local networks of people living with HIV or other groups experiencing stigma to ensure that programme strategies and messages were appropriate for addressing the needs and concerns of the intended population.
  3. By building skills and capacity and providing employment opportunities, several SARDM projects helped combat the perception that vulnerable populations cannot contribute to their families and society. A panchayat leader who saw a play about men who have sex with (MSM) explained: "The play showed that [MSM]...have very special talents and that they can live with a profession and that they don't have to just live by alms. They can be self-sufficient, if they can live with self-esteem and contribute to society. I think that men who have sex with men should be treated equally and they should be given more skills and trade so they can live independently and live with self-esteem."
  4. Theatre, music, dance, and other cultural art forms proved to be an effective way to bring messages about HIV prevention, care, and treatment and the stigma and discrimination faced by vulnerable populations to the general community. These cultural approaches - particularly those rooted in life experience - can foster empathy in audiences, which is key in reducing stigmatising attitudes and behaviours. They can also appeal to positive values to inspire behaviour change and broach taboo subjects.
  5. Traditional media, such as radio, television, and the press, can be powerful tools in efforts to reduce stigma. Mass media can raise the profile of an issue through broad reach and active word of mouth. People living with HIV can inspire journalists to eliminate stigmatising language and stories. Also, participating in media initiatives can be empowering for marginalised populations. However, anyone who participates in awareness-raising activities with journalists needs to understand the possible ramifications of sharing his or her story publicly. Partnering with media-savvy groups can optimise results of media efforts. Training for civil society organisations on media relations is often essential. Several of the SARDM implementers developed their own media - such as documentaries - to promote awareness about stigma and discrimination, share stories of experiences of stigma faced by people living with HIV, and address the specific challenges that marginalised groups faced.

Based on these findings, Chapter 5 offers recommendations for action. For example, it is suggested that the cultural and media efforts of SARDM implementers be leveraged so that other groups can use them to further spread stigma and discrimination reduction messages in different regions or populations in a given country. In addition, to promote greater use of these products as learning tools, viewer or listener guides could help increase understanding and discussion among audiences. These guides could be disseminated through networks and community organisations interested in hosting viewings or listening sessions.

Part II of the report contains case studies for 6 of the implementers, offering a more in-depth look at the lessons and challenges of intervening against stigma and discrimination.

Part III provides summaries of all 26 projects.