MEASURING AND RESPONDING TO HEALTH FACILITY STAFF ATTITUDES TOWARD PEOPLE LIVING WITH HIV AND THE REPRODUCTIVE RIGHTS OF WOMEN LIVING WITH HIV Presented by: Kyeremeh Atuahene Abstract Team: Kyeremeh Atuahene1, Nii Akwei Addo2, Emma Gyamera2, Christin Stewart3, Suzie Jacinthe4, Emmanuel Essandoh4, Pia Mingkwan3, 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.

Why and Where We Measure and Address S&D in Health Facilities Adapted from: Nyblade, L. and RTI International. 2016. HIV Stigma Measurement: A Rapid Scan of Two Decades of Work. Presentation at White House Meeting on Stigma, Washington, D.C. HIV Treatment Cascade Reference Literature Testing: (Musheke et al., 2013); 2. Linkage to & Retained in care: (Govindasamy et al., 2012, Alvarez-Uria et al., 2013); Adherence: (Katz et al., 2013)

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

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

(agreement unless otherwise specified) Mid-Level Medical Staff Negative Attitudes Towards People Living with HIV Among All HFS, by Job Category Attitudes (agreement unless otherwise specified) Senior Medical Staff Mid-Level Medical Staff Admin & Support Staff Total Most PLHIV do not care if they infect other people 222 2,088 502 2,840 49.1% 72.4% 69.9% 70.0% PLHIV should feel ashamed of themselves 11.7% 13.8% 26.1% 15.8% Most people living with HIV have had many sexual partners 25.3% 26.4% 43.2% 29.4% People get infected with HIV because they engage in irresponsible behavior 27.0% 29.7% 40.6% 31.4% HIV is punishment for bad behavior 4.9% 7.7% 18.7% 9.4% Women living with HIV should be allowed to have babies if they wish (disagree equals the stigmatizing response) 11.3% 13.4% 27.5% I would be ashamed if I had HIV 37.8% 39.1% 46.8% 40.4% I would be ashamed if someone in my family had HIV 23.4% 22.8% 35.3% 25.1% A woman living with HIV should be provided treatment only if she is using family planning 10.8% 15.2% 23.7% 16.4% Composite indicator (stigmatizing response to at least one of the above attitudes) 96.4% 98.6% 98.4% Stigmatizing attitudes towards people living with HIV emerged as a key area to address. Over 98% of HFS reported holding at least one of nine negative attitudes toward people living with HIV. Women living with HIV are subjected to additional stigmatizing attitudes. Among all HFS, 17% thought that a woman living with HIV should be provided treatment only if she is using family planning and 16% thought women living with HIV should not be allowed to have babies. 28 health facility staff did not respond to this series of questions.

Composite indicator (at least one of the above three items) Negative Attitudes Towards Pregnant Women Living with HIV Among HFS Working in Departments that Care for Pregnant Women, by Job Category Attitudes (agreement) Senior Medical Staff (n=79) Mid-Level Medical Staff (n=880) Admin & Support Staff (n=77) Total (n=1036) Pregnant women who refuse HIV testing are irresponsible. 61.5% 51.7% 66.2% 53.5% Women living with HIV should not get pregnant if they already have children. 23.1% 37.8% 46.8% 37.4% It can be appropriate to sterilize a woman living with HIV, even if this is not her choice 6.4% 22.7% 45.5% 23.2% Composite indicator (at least one of the above three items) 62.8% 69.3% 90.9% 70.5% Among a subset of HFS working in departments that care for pregnant women (ANC, labor/delivery, post-partum care), almost a quarter of respondents agreed that it can be appropriate to sterilize a woman living with HIV, even if it is not her choice (Table 2).

Study Steps Since Baseline (ongoing) Participatory development and testing of a total-facility approach to stigma- reduction in: 5 district-level health facilities, 1 in each of the 5 regions Capacity building for S&D-reduction facility-based trainers (health workers and clients) Two-day participatory training of all levels of health facility staff Facility-developed and implemented stigma-reduction activities, e.g. Posters reflecting positive client interaction and negative client interaction Development of codes of conduct with posters placed in visible areas Incorporation of S&D-reduction in weekly departmental staff meetings Activities specifically addressing attitudes: Participatory training exercises Panel discussion with people living with HIV and key populations Exercises that challenge attitudes about sex, people living with HIV, key populations, and youth Awareness and empathy building Other activities S&D-reduction posters Inclusion of S&D-reduction into weekly departmental meetings

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