H EALTH W ORKER P ERCEPTIONS O N T HE I MPACT O F HIV R ELATED S TIGMA A ND D ISCRIMINATION O N H EALTH S ERVICE D ELIVERY I N K ENYA 1

1 Introduction and Back ground 2 Methods 3 Findings 4 Recommendations 2

1. I NTRODUCTION  General HIV context  National HIV prevalence 7.4% (KAIS, 2009)  HIV prevalence is heterogeneous  Stigma and Discrimination context  Public health facilities highest level of discrimination (38.16%) (USAID, 2007)  Other literature suggests that HIV stigma and discrimination among health workers is high 3

S TUDY O BJECTIVES  Assess the expression of stigma and discrimination in health care settings  Identify effects of stigma and discrimination on service delivery  Assess the interventions in place to reduce HIV related stigma and discrimination in health care settings  Make recommendations for policies and strategies to mitigate the impact of stigma and discrimination on health service delivery 4

2. M ETHODS - P ROFILE OF K EY I NFORMANTS  A total of 35 facility level key informants were interviewed in all regions of Kenya  57% of key informant health facility managers, were nurses 5

F OCUS GROUP DISCUSSION PARTICIPANTS  Health workers living with HIV (2)  Health workers with undisclosed HIV status (1)  Community health workers (1)  Community members living with HIV (2) 6

3. F INDINGS : A REAS OF CONCERN BY H EALTH FACILITY MANAGERS  There was evidence of HIV stigma and discrimination among health workers  The lack of health sector interventions such as HIV work place policies for employees to mitigate the impact of HIV 7

E XPRESSION OF HIV S TIGMA AND DISCRIMINATION AT WORKPLACE  Gossip, avoidance and isolation  Self testing by health care workers  Traveling to distant health facilities for ART  Non disclosure of HIV positive status  Sideling from training opportunities 8

H EALTH WORKER PERSPECTIVES ON HIV RELATED DISCRIMINATION “In a department when a patient is positive some procedures are left for you to do because you are positive, just like the patient.”…… “Another subtle form of discrimination is that you find that people are very keen on utensils and cups they (health workers living with HIV) use, they try to either hide their cups or put it in a place where you cannot reach them… others feel they should not share.” FGD with health workers living with HIV –Nyanza (Nurse) 9

T HE TWISTED SPOON 10 “ Marking of cutlery used in common areas was done, to avoid sharing them with health workers known to be living with HIV.” Provincial AIDS Control Unit (ACU) Coordinator

W ORK OVERLOAD “When we came out (with our HIV status) we said don’t want to be treated differently, …..they (other health workers) said that we claimed we can work, so we are overwhelmed with work.” FGD with health workers living with HIV 11

S ERVICE D ELIVERY : P ERSPECTIVES FROM PLHIV IN THE COMMUNITY PLHIV in the community received good support from health workers and did not seem to think stigma was a challenge. “We have support groups which emphasizes health education and it helps. ….. “……. the nurses here at the hospital they are very supportive too. “….In the CCC I have not seen discrimination” PLHIV community FGD Kakamega 12

E FFECTS OF STIGMA ON SERVICE DELIVERY  From the perspective of community health workers, reduction of stigma has translated to improved adherence to treatment.  However, the increased number of clients receiving ART means the workload for facility level health workers has increased. 13

I NTERVENTIONS : H EALTH WORKER HIV P OLICIES  Injection safety and medical waste management  Work place safety  Public sector HIV workplace policy  ILO Code of conduct on HIV in the workplace  Health sector work place policy – developed and disseminated after this study 14

I NTERVENTIONS : TARGETING STIGMA AND DISCRIMINATION  Health workers living with HIV  Nurse driven psycho social support groups in Central, Nairobi, Nyanza and Eastern provinces.  Individual Workplace policies for health facilities reported in four out of 35 facilities – Facility mangers 15

I NTERVENTIONS : TARGETING STIGMA AND DISCRIMINATION  Health workers with undisclosed status “…there are no specific health worker interventions” “ You know the biggest problem that we (health workers) have is that the general public believe the health workers know everything and they are supposed to take care of themselves……nobody intervenes” Respondent FGD Health workers Clinical Officer 16

R ECOMMENDATIONS  The Health sector workplace policy should be widely disseminated and implemented focusing on addressing stigma and discrimination for all cadres  Interventions need to be put in place to address the high workload experienced by health workers living with HIV.  Similar to the community, psycho social support for health workers should be provided e.g. through support groups.  Policies should build on the achievements made in improving health worker attitudes towards PLHIV. 17

A CKNOWLEDGEMENTS Ministry of Medical Services Ministry of Public Health and Sanitation National AIDS Control Council (Kenya) Bon Santé Consulting United Nations Development Programme (UNDP/Kenya) 18 Peter Kinuthia, Regina Ombam Dr. Betty Chirchir, Lydia Mugo, Priscah Matende, Michael Kirui