Measuring Stigma And Discrimination In Health Facilities In Ghana For Intervention Design: The Importance Of Measuring Stigma Towards Both People Living With HIV And Key Populations Presented by: Kyeremeh Atuahene Abstract Team: Kyeremeh Atuahene1, Nii Akwei Addo2, Emma Gyamera2, Christin Stewart3, Suzie Jacinthe4, Emmanuel Essandoh4, Pia Mingkwan3, Andrew Zapfel3, Laura Nyblade3 Affiliations: Ghana AIDS Commission1, Educational Assessment Research Center2, United States Agency for International Development4, Health Policy Plus Project3

Partners on the Study Study team: Supported by: Education Assessment Research Center (EARC) Health Policy Plus Project (HP+) National AIDS Control Programme (NACP) Ghana AIDS Commission (GAC) Supported by: USAID and PEPFAR Global Fund We would like in particular to thank USAID/PEPFAR and the Global Fund—without their support and encouragement, this work would not have been possible.

Stigma and Discrimination in Health Facilities towards people living with HIV and Key Populations are barriers to: HIV prevention HIV testing Linkage to care Retention in care Adherence to treatment, and ultimately Viral load suppression

Key Populations Background Information 2016-2020 National Strategic Plan notes key populations as Men who have sex with men (MSM) Transgender persons People who inject drugs Sex workers and their clients Sero-negative partners in sero-discordant couples The strategy includes the need for specific interventions for key populations including use of drop-in centers, improved data collection on size of populations and geographic locations, mobilization of peer educators, and reduction of stigma and discrimination throughout society.

The Total Facility Approach to S&D reduction: Three Phases Jan 2017 – Jan 2018 Sept 2017 – March 2018 March 2018 – Sept 2018 Assessment (Baseline) Intervention Evaluation (Endline) Quantitative survey of health facility staff (n=2,836) and clients living with HIV (n=250) in 20 facilities in 5 regions (Ashanti, Brong Ahafo, Eastern, Greater Accra, & Western) Based on findings from Phase 1 Designed in partnership with intervention facilities (1 per region) Participatory skills building plus other activities Data collected in 5 intervention and 5 comparison facilities

Health facility staff questionnaire focused on: Focus of the Study Health facility staff questionnaire focused on: Three key actionable S&D drivers: Health facility environment Fear of HIV transmission Attitudes toward people living with HIV and key populations Manifestations of S&D towards people living with HIV and key populations Special Module: pregnant women living with HIV Client questionnaire Stigma within HIV care & general care Satisfaction with care Confidentiality of status Perception of health facility policies Reporting and redress opportunities Key population identity and key population stigma

Key Population Questions in the Health Facility Staff Baseline Survey Negative attitudes towards sex workers and men who have sex with men Observed discrimination towards each of the three key populations in the past 6 months in their facility Health workers unwilling to provide care Health workers providing poorer quality of care Health workers talking badly about Health workers disclosing a person’s HIV or other key population status without the client’s consent in a situation that was not medically warranted Beliefs of getting into administrative trouble for discriminating against men who have sex with men, female sex workers, and people who inject drugs Perceived hesitancy of co-workers to care for key populations Own preference not to provide services to key populations

Key Findings

Mid-Level Medical Staff Perceptions of Health Facility Policies & Their Enforcement with Respect to Key Populations Agreement Senior Medical Staff Mid-Level Medical Staff Admin & Support Staff Not Stated Total N 222 2,088 502 28 2,840 I will get into trouble at work if I discriminate against patients who are men who have sex with men. 59.9% 70.2% 58.9% 57.1% 67.3% I will get into trouble at work if I discriminate against patients who are sex workers 63.1% 73.9% 64.7% 71.3% I will get into trouble at work if I discriminate against patients who inject drugs for non-medical reasons. 61.3% 60.2% 46.4% 68.3%

Observed Discrimination in the Past 6 Months, by Category of Staff (composite of 3 items-yes to at least one)

Perceived Hesitancy of Coworkers to Provide Care for Key Populations Perceived hesitancy of coworkers to provide care to Senior Medical Staff (n=222) Mid-Level Medical Staff (n=2088) Admin & Support Staff (n=502) Total (n=2812) Men who have sex with men or thought to be having sex with men 35.9% 43.5% 47.4% 43.6% Sex workers or people thought to be sex workers 34.4% 42.3% 44.7% 42.1% People who inject drugs for non-medical reasons or thought to be injecting drugs 40.3% 41.9% 40.1%

Conclusions Despite staff reporting that their facilities have policies against discrimination of key population clients, S&D is still observed towards men who have sex with men, sex workers, and clients who inject drugs. Interventions to improve quality of care for clients living with HIV must address stigma reduction towards key populations, in addition to HIV-related S&D.

Study Next Steps Endline data collection in 5 pilot facilities and 5 comparison facilities to evaluate interventions and note change in S&D behavior in facility Findings to be disseminated in June with public report to come out in September 2018