Laura Nyblade, PhD. HP+/RTI International Reducing Health Worker Stigma and Discrimination Is Critical to Reaching 90-90-90 Targets and Is Possible: Evaluation Results of a Whole-Facility Approach in Ghana Laura Nyblade, PhD. HP+/RTI International

Acknowledgements Coauthors: Supported by: Nii Akwei Addo, Educational Assessment Resource Center Kyeremeh Atuahene, Ghana AIDS Commission Emma Gyamera, Educational Assessment Resource Center Christin Stewart, RTI International Suzie Jacinthe, U.S. Agency for International Development Emmanuel Esandoh, U.S. Agency for International Development Nabil Alsoufi, U.S. Agency for International Development Richard Vormawor, Educational Assessment Resource Center John Kraemer, Georgetown University Supported by: USAID and PEPFAR Global Fund

The Total Health Facility Approach to S&D Reduction: Three Phases Jan 2017 – Aug 2018 Sept 2017 – March 2018 March 2018 – Sept 2018 Assessment (Baseline) Intervention Evaluation (Endline) Quantitative surveys: Health facility staff of all levels Clients living with HIV 20 facilities in 5 regions: Ashanti, Brong Ahafo, Eastern, Greater Accra, & Western Based on findings from Phase 1 Designed in partnership with intervention facilities (5 total, 1 per region) Participatory skills building plus other activities Quantitative surveys: Health facility staff Clients living with HIV 10 facilities in five regions 5 intervention and 5 comparison facilities Dissemination at facilities

Evaluation Methods Ten district-level health facilities in five highest HIV prevalence regions; five intervention, five comparison Baseline (N=1,149) Endline (N=1,149) Pre-Post intervention comparison through baseline- endline surveys with health facility staff of all levels (clinical and non-clinical) Estimated before-after trends and difference-in- differences Ashanti, Brong Ahafo, Eastern, Greater Accra, & Western

Summary and example of Results

Summary of Results Statistically significant before-after improvements in most outcome domains in the intervention facilities Significant difference-in-differences reductions between intervention and comparison facilities Intervention facility staff report significantly greater improved behavior of staff towards clients relative to comparison sites, compared to previous year Staff: intervention facilities were 21.5% (p=0.019) more likely to report that behavior toward patients was much better at follow-up than staff at the comparison facilities Clients from intervention facilities were 28% more likely to report that behavior toward patients was much better at follow-up than staff at the comparison facilities

Fear of Transmission and Stigmatizing Avoidance Behaviors Pre-Post change in intervention facilities: Worry about HIV transmission declined by 26.9% (p=0.000), Stigmatizing avoidance behaviors declined by 23.7%; (p=0.000) Difference-in-differences: Greater decline in intervention over comparison facilities: Unnecessary fear: 23.9% (p<0.001) Stigmatizing avoidance behaviors: 15.7% (p=0.011) “I am free! As a model of hope (PLHIV attached to facilities) I was called to come to the ward to care for  (wash, change the patient bed, clothes etc) in-patients with HIV who didn’t have family around. They would call me at all hours of night or day to come and take care of “your people”. Now, the staff take care of the patients themselves. I am now free!! Mr. Theophilus Agbogyalo – Model of Hope, Agomanya Hospital

Understanding and interactions with key populations improved Preference not to treat men who have sex with men Pre-Post change in intervention facility: 15% decline (P=0.000) Difference-in-differences: 14.2% (p=0.001) greater reduction in intervention over comparison facilities “Since the training we have seen an increase in MSM living with HIV coming for services. We think this is mostly due to the change in our staff and how they interact with key populations. We also see MSM coming freely for their medicines during regular facility hours. Before they preferred coming after hours, to avoid being seen by staff.” Mr. Kofi Atakorah-Yeboah Jnr, Champion Team Member, Bekwai Hospital

Key Elements of the Total Health Facility Approach Utilizes data to catalyze action, tailor approach & evaluate progress Strengthens capacity for facility-owned and driven stigma-reduction for a sustainable response Early and continued engagement of facility management Trainers: both facility staff and clients Champion teams that design and implement activities Uses participatory approaches to learning and behavior change Creates new opportunities for contact outside the provider-client relationship Recognizes that all staff at a facility have a role to play to reduce stigma

Action to reduce facility stigma is possible! Global measurement and intervention tools are easily adaptable across diverse contexts