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Module 4

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  1. Module 4 Stigma and Discrimination Related to MTCT

  2. Exercise 4.1 Labels Group Game PMTCT Generic Training Package Module 4, Slide 2

  3. Module Objectives • Identify HIV-related stigma and discrimination. • Discuss the impact of stigma and discrimination on people living with HIV (PLHIV). • Discuss strategies to address stigma and discrimination in the delivery of PMTCT services. PMTCT Generic Training Package Module 4, Slide 3

  4. Session 1 • Concepts of Stigma and Discrimination PMTCT Generic Training Package Module 4, Slide 4

  5. Session 1 Objectives • Identify HIV-related stigma and discrimination. • Discuss the impact of stigma and discrimination on people living with HIV (PLHIV). PMTCT Generic Training Package Module 4, Slide 5

  6. Introduction to Stigma and Discrimination • HIV is one of the greatest human rights challenges of our time • Those aware that they are HIV-infected are burdened not only with the disease but also stigma and discrimination. • Stigma and discrimination are major barriers to preventing HIV transmission and providing treatment, care and support PMTCT Generic Training Package Module 4, Slide 6

  7. Introduction to Stigma and Discrimination (Continued) The most effective responses to the HIV epidemic work to prevent stigma and discrimination and protect the human rights of people living with HIV and those at risk PMTCT Generic Training Package Module 4, Slide 7

  8. Stigma: Definition • What is stigma? PMTCT Generic Training Package Module 4, Slide 8

  9. Stigma: Definition • Stigma: unfavourable attitudes and beliefs directed toward someone or something • HIV-related stigma:unfavourable attitudes and beliefs directed toward people living with HIV, their family and friends, social groups, and communities PMTCT Generic Training Package Module 4, Slide 9

  10. HIV-related Stigma • Stigma particularly pronounced when behaviour causing disease is perceived to be under individual’s control, e.g., sex work or injection drug use • Certain groups, e.g., poor people, men who have sex with men, sex workers and injection drug users, often bear heaviest burden of HIV-related stigma. • People who are HIV-infected are often assumed to be members of these groups, whether they are or not PMTCT Generic Training Package Module 4, Slide 10

  11. Examples of Stigma • What are some examples of stigma? PMTCT Generic Training Package Module 4, Slide 11

  12. Examples of Stigma • Believing HIV is divine punishment for moral misconduct • Thinking women are responsible for transmitting HIV and other STIs in our community • A daughter refusing to visit her father once she finds out he has HIV because she felt "dirtied" by contact with him • A woman with HIV refusing to join a support group or tell people outside the family about her HIV because she fears being stigmatized PMTCT Generic Training Package Module 4, Slide 12

  13. Discrimination: Definition • What is discrimination? PMTCT Generic Training Package Module 4, Slide 13

  14. Discrimination: Definition • Discrimination: the treatment of an individual or group with prejudice • Discrimination includes the denial of basic human rights such as health care, employment, legal services and social welfare benefits PMTCT Generic Training Package Module 4, Slide 14

  15. Stigma and Discrimination Linked • Stigmatizing thoughts can lead a person to discriminate against another • Discrimination is a way of expressing stigmatizing thoughts; a distinction made about a person based on stigma that results in unfair or unjust treatment of that person PMTCT Generic Training Package Module 4, Slide 15

  16. Stigma: Other Diseases and HIV Stigma and discrimination also occur with other diseases: TB, syphilis, leprosy HIV-related stigma appears to be more severe than the stigma associated with other infectious diseases

  17. Examples of Discrimination • What are some examples of discrimination? PMTCT Generic Training Package Module 4, Slide 17

  18. Discrimination: Examples HCW denies services to person who is HIV-infected Family or village rejects wife and children of man who died from AIDS Man loses job because people learn he is HIV-infected Community rejects woman who decides not to breastfeed because they assume she is HIV-infected HIV-infected clients receive poor care at a clinic because of HCWs’ fears about caring for people infected with HIV

  19. HIV: 3 Epidemics Epidemic of HIV Epidemic of AIDS Epidemic of stigma, discrimination and denial around HIV and AIDS

  20. Women and HIV Infection • Numbers of infected women worldwide growing more rapidly than men • Women more vulnerable to HIV than men due to: • Poor access to MCH • Poor access to prevention information and methods • Economic, social inequalities (e.g. unable to negotiate safer sex) • Biological factors PMTCT Generic Training Package Module 4, Slide 20

  21. Women and HIV Infection(Continued) • The woman is often the first person in a couple to be tested for HIV • If found to be positive, may be blamed by her partner for introducing HIV into the family • Implicated in mother-to-child transmission • May experience violence, loss of shelter and economic support • May even lose the support of family, community • All of these reasons may compel a woman to keep her HIV status secret PMTCT Generic Training Package Module 4, Slide 21

  22. Women and HIV Infection (Continued) • Women with HIV may be doubly or triply stigmatized: • As women • As a person living with HIV • As a partner of a person who is HIV-infected or the widow of person who died of AIDS PMTCT Generic Training Package Module 4, Slide 22

  23. Women and HIV Infection (Continued) The stigma and discrimination associated with women with HIV can limit access to effective prevention, care, treatment and support services PMTCT Generic Training Package Module 4, Slide 23

  24. International Human Rights and HIV Stigma and Discrimination • According to United Nations Commission on Human Rights, discrimination against people living with HIV or thought to be infected is a clear violation of human rights Freedom from discrimination is a basic human right PMTCT Generic Training Package Module 4, Slide 24

  25. Human Rights in Relationto HIV • All people have a right to make decisions about their sexual and reproductive health • Children have a right to survival, development and health • Women and girls have a right to information about HIV and a way to protect themselves against HIV infection PMTCT Generic Training Package Module 4, Slide 25

  26. Human Rights in Relationto HIV (Continued) • Women have the right to HIV testing and counselling and to know their HIV status • Women have a right to choose not to be tested or to choose not to be told their test result • Women have a right to make decisions about infant feeding, on the basis of full information, and to receive support for the course of action they choose PMTCT Generic Training Package Module 4, Slide 26

  27. Stigma: Actions and Attitudes • A person’s word, action, or belief may be unintentionally stigmatizing toward an individual who is HIV-infected, e.g.: • A person who is against stigmatization may believe people with HIV behave immorally, “deserve what they got,” or are being punished by God • A person who knows HIV cannot be transmitted with casual contact may refuse to buy food from a vendor who is HIV-infected • A person’s behaviours may conflict with their beliefs PMTCT Generic Training Package Module 4, Slide 27

  28. Stigma: Choice of Language • Language is central to stigma • People may not realize they are stigmatizing those with HIV by choosing certain words, for example: • Referring to HIV indirectly: "that disease we learned about" • Calling people with HIV “walking corpses” or “those expected to die” PMTCT Generic Training Package Module 4, Slide 28

  29. Lack of Knowledge → Stigma • Many people lack complete or accurate knowledge about HIV • Many believe an HIV-positive test result = certain death • The fear of death is so powerful that many avoid people suspected to have HIV—even when they know HIV is not transmitted casually Incomplete knowledge and fear act together to allow stigma to grow PMTCT Generic Training Package Module 4, Slide 29

  30. Shame & Blame Associatedwith HIV • Stigmatization often focuses on the sexual transmission of HIV • Many assume that people who are HIV-infected: • Must have been infected through sexual activities that are socially or religiously unacceptable • Are unable to control themselves, and are therefore responsible for their infection PMTCT Generic Training Package Module 4, Slide 30

  31. Stigma in Caring Environments • Loving, supportive caregivers may stigmatize and discriminate against people with HIV (e.g., blaming, scolding, saying “those people”) • May not recognize behaviour as stigmatizing • Stigmatizing happens even among individuals opposed to HIV-related stigma (including HCWs) • People can have correct and incorrect information about HIV PMTCT Generic Training Package Module 4, Slide 31

  32. Exercise 4.2 Examples of Stigma and Discrimination: large group discussion PMTCT Generic Training Package Module 4, Slide 32

  33. Stigma and Discrimination: Examples • What are some examples of stigma and/or discrimination in the media? PMTCT Generic Training Package Module 4, Slide 33

  34. Stigma and Discrimination: Examples • In the media: • Suggesting specific groups of people with HIV are guilty (e.g., commercial sex workers or injection drug users) while others are innocent (for example, infants) • Portraying HIV as a death sentence, leading to: • Fear and anxiety • Believing HIV cannot be managed like other chronic diseases • Referring to HIV as, e.g., the “killer disease” • Showing stereotypical gender roles PMTCT Generic Training Package Module 4, Slide 34

  35. Stigma and Discrimination: Examples (Continued) • What are some examples of stigma and/or discrimination in healthcare settings? PMTCT Generic Training Package Module 4, Slide 35

  36. Stigma and Discrimination: Examples (Continued) • In healthcare settings: • Refusing to provide treatment, care, support to PLHIV • Providing poor quality of carefor PLHIV • Breaking confidentiality • Providing care in specialized settings (e.g., clinics for people with sexually transmitted infections) can further stigmatize, segregate PLHIV PMTCT Generic Training Package Module 4, Slide 36

  37. Stigma and Discrimination: Examples (Continued) • In healthcare settings, cont’d: • Using infection control procedures (e.g., gloves) only with clients thought to be HIV-infected, rather than with all clients • Advising or insisting PLHIV undergo procedures, (e.g., abortion or sterilization) not routinely suggested for women who are not HIV-infected PMTCT Generic Training Package Module 4, Slide 37

  38. Stigma and Discrimination: Examples (Continued) • What are some examples of stigma and/or discrimination in the workplace? PMTCT Generic Training Package Module 4, Slide 38

  39. Stigma and Discrimination: Examples (Continued) • In the workplace: • Requiring testing before hiring • Refusing to hire people who are HIV-infected and HIV-affected • Requiring periodic HIV testing • Firing someone because of HIV status • Breaking confidentiality • Refusing to work with colleagues who are HIV-infected PMTCT Generic Training Package Module 4, Slide 39

  40. Stigma and Discrimination: Examples (Continued) • What are some examples of stigma and/or discrimination in the • context of religion? PMTCT Generic Training Package Module 4, Slide 40

  41. Stigma and Discrimination: Examples (Continued) • In the context of religion: • Not letting PLHIV participate in funerals and other religious traditions and rituals • Refusing to perform marriage ceremonies for PLHIV PMTCT Generic Training Package Module 4, Slide 41

  42. Stigma and Discrimination: Examples (Continued) • What are some examples of stigma and/or discrimination in the • family and local community? PMTCT Generic Training Package Module 4, Slide 42

  43. Stigma and Discrimination: Examples (Continued) • In the family and local community: • Isolating people who are HIV-infected • Restricting participation of PLHIV in local events • Refusing to allow children who are HIV-infected or HIV-affected to go to local schools • Not including partners and children of PLHIV in activities or gatherings PMTCT Generic Training Package Module 4, Slide 43

  44. Stigma and Discrimination: Examples (Continued) • In the family and local community, cont’d: • Using violence against a partner who has tested HIV-positive • Denying support for grieving family members, including orphans PMTCT Generic Training Package Module 4, Slide 44

  45. Effects of Stigma • What are the effects of stigma? PMTCT Generic Training Package Module 4, Slide 45

  46. Effects of Stigma 1. Stigma deters disclosure and limits access to services • Non-disclosure due to fear of response from others  reduced access to support from family, friends, community • Avoidance of health and social services due to fear of unfair treatment/ fear that action would be admission of HIV-status  increased risk of transmission to partners or children  limited choice in health care PMTCT Generic Training Package Module 4, Slide 46

  47. Effects of Stigma (Continued) • May deter people from getting tested • May make people less likely to recognize their risk of infection • May discourage those who are HIV-infected from discussing their HIV status with partners 2. Stigma fuels new HIV infections PMTCT Generic Training Package Module 4, Slide 47

  48. Effects of Stigma (Continued) • Fuels new infections, cont’d • May prevent PLHIV from adopting risk-reduction practices that may label them as HIV-infected (e.g., replacement feeding) • May obstruct prevention, treatment, and care programs PMTCT Generic Training Package Module 4, Slide 48

  49. Effects of Stigma (Continued) • Face rumours and gossip • Be told to leave home • Be rejected by partners and community • Be abused physically and/or verbally 3. Stigma can lead to social isolation PMTCT Generic Training Package Module 4, Slide 49

  50. Effects of Stigma (Continued) • Social isolation, cont’d: • People’s emotional response to HIV may influence them more strongly than their knowledge • Someone may shake hands with several people in room but fail to shake hands with person they think “looks like they have AIDS” • Fear of catching HIV may lead someone to require that person with HIV drinks from glass no one else uses PMTCT Generic Training Package Module 4, Slide 50