Questions/Answers

Thailand is committed to ending AIDS by 2030. Stigma and discrimination are underlying factors hindering access to HIV-testing services and the late entry of HIV/AIDS treatment, which might obstruct the country to meet the ending goals. The Thailand’s Department of Disease Control in collaboration with the stakeholders including civil society organizations, academia and international agencies has developed and implement the measurement and interventions to address HIV-related stigma and discrimination in healthcare settings. Health facilities are not only the common and critical places that people living with HIV (PLHIV) have to contact for the needed services, but also the places that people see as the role model on practices towards PLHIV. Previously, there was no standardized tool to measure situation nor specific interventions relating to HIV-related stigma. Furthermore, complaints on breach of confidentiality, denial/delayed care to PLHIV and key population are common. The initiative included both the standardized and simplified questionnaire to understand stigma situation and the interventions called the 3x4 package to reduce HIV-related stigma and discrimination in healthcare settings. The package includes three prongs of interventions: 1) individual interventions emphasizing on worry and attitudes of health providers through participatory training; 2) health system interventions aiming to improve policy and health services through quality improvement activities and codes of conduct; and 3) community linkage interventions including listening to client’s voice, and linking with the rights protection mechanism. These interventions aimed to change four-key drivers of stigma namely; negligence, fear of infection, attitudes, and environment within healthcare settings. The initiative was launched in six hospitals of three provinces. The results of evaluation proved that the interventions is effective and well acceptance from both PLHIV and health providers. The initiative has now expanding to over 50 hospitals of 16 Provinces throughout Thailand and also to neighboring countries including Lao, Vietnam, and Cambodia.

HIV/AIDS epidemic remains a significant health and socio-economic problem globally and in Thailand. HIV/AIDS is now effectively treatable with antiretroviral drugs. In Thailand, HIV treatment are freely provided under universal healthcare scheme, there are still many people reluctant to get HIV-tested and receive antiretroviral treatment due to fear of stigma and discrimination from society and in health care. Sigma is considered as a key barrier and a root cause leading to a low HIV testing rate and late entry into HIV/AIDS treatment particularly among key populations; men having sex with men, transgender, people injecting drugs, migrants, sex workers, and people knowing their HIV+status. The overarching goal of the initiative is to ensure universal access to HIV services by eliminating HIV-related stigma and discrimination particularly in healthcare settings. The objectives of the initiative are firstly to measure and understand stigma situation in healthcare providers and PLHIV; secondly to develop pragmatic interventions that be able to reduce stigma and discrimination problems in health facilities; thirdly to improve quality and accessibility of HIV services to all people. The HIV-related stigma-free healthcare will ensure timely and universally access to quality health services that enable Thailand to achieve the ending AIDS goals by 2030.

The Department of Disease Control (DDC), Ministry of Public Health, recognizes the importance of stigma and discrimination reduction contributing to ending AIDS by 2030. The accelerated strategy for reduction of stigma and discrimination was included in the National Strategic Plan for Ending AIDS by 2030. This plan committed to reducing stigma and discrimination by 90% at the end of 2030 through key measures: promoting HIV-related stigma-free healthcare settings; promoting AIDS friendly environment in workplace, education, and communities; supporting and expanding the rights protection mechanisms; empowerment of PLHIV and key populations; and changing HIV-negative image. To achieve the goal, the DDC has prioritized stigma and discrimination reduction in healthcare as the strategic initiative to change situation. All healthcare providers at all levels are expected to be a role model in society by not practicing stigma behavior nor discriminating clients. During 201-2017, the DDC in collaboration with the stakeholders including civil society namely AIDS Access Foundation, Foundation for AIDS Rights, Thailand networks of PLHIV; academic institutions namely Chiangmai University and International Health Policy Program; and international agencies namely Research Triangle Institute (RTI), etc, has developed a measurement and interventions for promoting HIV-related stigma-free healthcare and plans to expand to all hospitals nationwide.

Thailand has offered free antiretroviral treatment for over 10 years under universal healthcare scheme. However, stigma keeps people living with HIV away from life-saving services. They seeked HIV treatment when they are severely ill or in late stage as seen from the percentage of newly HIV diagnosed people having CD4 <200 ml3(late stage of HIV infection) are over 50% with little improvement. 13% of PLHIV report avoidance or delayed seeking healthcare because of fear of stigma and discrimination. This phenomenon leads to high mortality and poor quality of life among PLHIV. It may further drive continuation of new HIV infection due to many PLHIV do not know status and continue the transmission. To eliminate the stigma and discrimination, which is a key obstacle for ending AIDS by 2030, stigma and discrimination reduction in the healthcare setting is prioritized. The initiative was developed and designed to ensure that the service system is without stigma and discrimination. Thus, the initiative is in line with the Goal 3 - Ensure healthy lives and promote well-being for all at all ages--of the 2030 Agenda for Sustainable Development. It ensures timely and universally access to essential health services of all people including vulnerable populations.

The 2009 Thailand PLHIV Stigma Index survey showed that stigma and discrimination were prevalent in many settings. The National Survey on Stigma and Discrimination in healthcare settings in 2014 revealed that 60.9% of healthcare providers feared of HIV infection when contact or provide care, 84.5% had negative attitudes towards PLHIV, and 23.7% reported observing stigma toward PLHIV in healthcare settings. The survey also showed that 12.1% of PLHIV had ever been denied treatment or were assigned to a place last in line, or received less care than other patients. One-fourth (24.5%) had their blood tested before treatment (even though it was not indicated) or had their HIV sero-status disclosed without their consent (e.g., by marking medical documents to indicate HIV+ status). Also, 13.0% had ever avoided or delayed receiving health service due to fear of being scorned. In addition, based on the complaints from PLHIV, some standard practices or regulations create stigma or discrimination towards PLHIV, e.g., last queue, compulsory HIV testing before treatment, changing the treatment plan, etc. These practices are routinely used and, in many cases, become the standard practice of healthcare providers without awareness of stigma and discrimination and its consequences.

A young PLHIV said “Growing up and living with HIV is not difficult. But living with prejudice, misunderstanding, and ignorance of people in the society is the hardest.” Thus, it is not surprising that 56% of PLHIV enroll in ART late; when they are ill severely, and even volunteers living with HIV in hospitals, do not dare to disclosure their HIV+ status because of fear of disdain and discrimination. The initiative focused on elimination of stigma and discrimination in health facilities since they are at front line of close contact and provider of a continuum care and services (e.g. reproductive health services, HIV testing, and ARV treatment) for PLHIV and key populations. Furthermore, health facility is a critical agent of change since it is a role model of society, especially in health matters. Thus, this initiative will help healthcare providers understand and reduce stigma and discrimination both in the healthcare setting and in the community to improve quality of life among PLHIV. With this initiative, at least about 25-30% of 450,000 people who are now living with HIV but not receiving ARV can timely and universally access to quality health services and all PLHIV can lives like other in society.

The initiative was divided into 2 phases including: Phase 1 the development of standardized and simplified measurement: the measurement tool of stigma and discrimination experience by PLHIV and key populations was developed to accelerate Thailand’s evidence-informed response to mitigate the stigma and discrimination in 2013. The pilot study was done in 2 provinces to standardize and simplify the questionnaire. Then in 2015, this initiative was scaled up to be a national surveillance survey system to monitor stigma and discrimination in healthcare settings every 2 years. Phase 2 the development of effective intervention: the intervention began in 2015 with reviewing and developing the participator training on stigma and discrimination reduction, and then piloted in 2 hospitals. Meanwhile, the framework of intervention was designed and called the 3x4 package of intervention. In 2016, there were 6 hospitals of 3 provinces was enrolled voluntarily to test the implementation of the 3x4 package of intervention. At hospital, the participatory training was held for at least 50% of healthcare staff. Also, some healthcare conducted in-depth interviews/focus-group discussions to hear the voices of PLHIV and better understand the PLHIV’s needs and problems. Lastly, the national measurement tool was applied to measure the effectiveness of this intervention.

The initiative both measurement tool and intervention began with adaptation of a global tools to the local context (especial in the context of healthcare setting in Thailand). The tools were piloted to gain knowledge about what needed to be improved, and how to implement it effectively and fit with the Thai context. To promote the HIV-related stigma and discrimination-free healthcare, only training for healthcare provider was not enough to make change. Therefore, the DDC added more interventions, and packaged these as a set, called the 3x4 package of intervention. The package includes three prongs of interventions: 1) individual interventions with emphasis on worry and attitudes of health providers through participatory training; 2) health system interventions which aimed to improve policy and health services through quality improvement activities and codes of conduct; and 3) community linkage interventions, included listening to the voice of clients, and linking with the rights protection mechanism. These interventions aimed to change four-key drivers of stigma namely; negligence, fear of infection, attitudes, and environment within healthcare settings.

The resources for this initiative were supported by various partners, both at the national and local level as follows: Budget: Budget came from two sources: the Thai government, and international agencies of United Nations and US governments through Research Triangle Institute and International Health Policy Program. The budget, USD 69,377, from RTI used for 1) building capacity of the local teams, and 2) supporting the participating healthcare setting and provinces in implementation of the initiative used for meeting and traveling for coaching team Human resources: At the national level, AIDS Access Foundation and the Foundation for AIDS Rights Protection worked with the DDC team in developing the model package and provided technical support for the local team. The personnel responsible for launching this initiative at the operational level were supported by local government organizations; provincial health offices, hospitals, local civil society; NGOs and the PLHIV network, among others. Materials and methods: A tools kit, including two handbooks, activity tools, pictures and video clips, were developed to guide interventions; measurement tools for evaluation were adapted from the National Stigma and Discrimination Survey to measure the effectiveness of the initiative. Technical support: RTI provided an international consultant for this initiative.

Yes

To transfer the knowledge from this initiative widely, the DDC organized a lesson-learned workshop in late 2017. Based on the lessons learned and challenges, the DDC has improved the initiative to be more suitable for the context of healthcare settings, and it plans to scale up to healthcare settings nationwide. In 2018, 50 healthcare settings of 16 provinces are applying for promoting the HIV-related stigma and discrimination-free healthcare. The knowledge gained from this initiative is beneficial for other countries. Thus, the DDC has plans to organize an international training course for other countries in this region to learn and share experience with them. This training is scheduled for April 2-6, 2018, Thailand. The expected participants are representatives from Lao PDR, Myanmar, China, Indonesia, the Philippines, and Malaysia. Also, the knowledge gained in Thailand has been shared with other countries during international meetings and study tours, for example: 1) Southeast Asia Stigma Reduction Collaborative Design Meeting on May 24, 2017, in Bangkok, and 2) The South-to-South Learning and Exchange Experiences Workshop on Thailand Validation of Elimination of Mother-to-Child Transmission (EMTCT) during November 6-10, 2017 in Bangkok and Chiang Rai.

For measurement tool of stigma and discrimination in healthcare, after the tool had been standardized and simplified to fit with the Thai context. Now this tool was used for the national surveillance survey for monitoring the stigma and discrimination situation in healthcare every 2 years. For sustainability of intervention at national level, the DDC cooperates with the health accreditation team to integrate the intervention of stigma and discrimination into existing system of quality service improvement. Now there are 50 hospitals participating in the phase of scaling-up to link quality improvement with stigma and discrimination reduction. At local level, the goal of stigma and discrimination reduction is consistent with the mission of healthcare in providing care with service-mind. The Jana Hospital, in the southern province of Songkhla, one of the participating healthcare settings, had integrated this initiative with the mission of their facility to be an ethical hospital and service-minded environment to humanize healthcare. Presently, stigma and discrimination reduction is part of the hospital’s plan and there is a set of indicators and targets to be achieved in the years ahead. In addition, the DDC recognizes the necessity to build capacity of provincial staff and the healthcare setting team to launch and expand the stigma and discrimination intervention package by themselves, with technical support from the DDC team and partners. The technical support is delivered through workshops and on-site coaching. Currently, six participating healthcare settings are a model for other locations both in and outside the country to learn and share their experiences. Also, the trained trainers in this initiative will serve as trainers in the expansion phase.

Because reducing stigma and discrimination is one of the three “zero” goals of the country to end the AIDS epidemic by 2030, thus the measurement tool still be significant to regularly and continuously monitor the changing and success of the intervention. Whereas, intervention needs to continuously develop and scaling-up until achieving the goal of ending AIDS by 2030. For the six participating healthcare settings, they have continued to improve service delivery to reduce stigma and discrimination. After achieving the target of training at least 50% of total healthcare providers, they now have a plan to train all healthcare providers for continuous quality improvement of the service. Also, some healthcare settings are planning more interventions on self-stigma reduction among PLHIV and key population, as well as encouraging them to speak out on how to improve service delivery. This year, tools for baseline, midterm, and endline data measurement were developed. The tools will help the participating healthcare settings to monitor the situation, fill gaps and identify development opportunities. Reducing stigma and discrimination is a continuous development process. Though this initiative focuses on HIV/AIDS, the experience will be a good example for other diseases. Sustainability is not the end of discrimination related to AIDS – the fight will continue for other stigmatized diseases in society.

Yes

1. Primary data collection to measure: 1) whether the stigma and discrimination reduction package can change four key drivers of stigma and discrimination in healthcare settings, and 2) what and how activities of the package work in order to inform plans for expansion. There were two methods as the following: Quantitative method: A cross-sectional survey was applied to explore the stigma and discrimination situation of each hospital and measure the success of the overall initiative. A baseline and endline survey in participating hospitals was done using the national standard questionnaire. Participating staff of hospitals voluntarily filled out the questionnaire. Qualitative methods: Focus group discussions were conducted to understand and describe why and how the intervention package can change or not change the four key drivers of stigma and discrimination, as well as soften the impact on PLHIV. Also, a lessons learned workshop was convened at the end of initiative. 2. Secondary data was collected to measure the impact of stigma and discrimination in the long-run. The data about number of PLHIV receiving ARV, new cases of HIV, retention in care and other related data during the initiative were collected to assess longer-term outcomes.

The immediate outcome: the initiative has improved four actionable drivers of stigma and discrimination. Comparing baseline and endline, the percentage of providers who feared HIV infection declined from 80.7% to 59.0%, stigmatized attitudes declined from 85.4% to 64.5% and observed stigma towards PLHIV declined from 15.2% to 12.4%. Also, some regulations or practices which stigmatized PLHIV are to be improved. The practice of relegating PLHIV to the end of the patient queue in dental clinics conflicts with national policy. Currently, the Thai Dentists Association, in cooperation with NGOs, the PLHIV network, and the DDC are improving the guidelines and practices so that they are non-discriminatory. There are 2,953 PLHIV who are receiving healthcare services at the participating healthcare outlets. These PLHIV get the benefit from the improved attitudes and practices of healthcare providers. In addition, the ultimate goal, access to HIV services, appears to have increased slightly. For example, the number of PLHIV who know their HIV+status in Songkhla increased from 8,171 in 2015 to 8,903 in 2017, and the number of PLHIV receiving ART increased from 6,258 in 2015 to 7,154 in 2017.

The indicators that were used in the evaluation are at two levels: 1) indicators to measure change in four actionable key drivers that cause stigma and discrimination in healthcare settings over time, and 2) indicators to measure the impact of stigma and discrimination reduction on access to healthcare service leading to ending AIDS, and quality of life among PLHIV. The first indicators focused on primary outcomes: 1) the percentage of providers who fear accidental HIV infection during services to PLHIV; 2) the percentage of providers who reported using unnecessary precautions when providing care for PLHIV; and 3) the percentage of staff observing stigma by other healthcare staff during the previous 12 months. These indicators are measured through a cross-sectional survey administered at baseline and endline points. Secondly, the initiative should improve clinical outcomes which will lead to ending AIDS. The indicators include: 1) the percentage of newly diagnosed PLHIV with CD4<200; 2) the percentage of ART retention at 12 months; and 3) the percentage of undetectable viral load suppression. These indicators are tracked through the existing database system. However, the change based on these indicators needs time to develop.

This initiative has been developed in collaboration of partners at different levels as follows: Nationally, this initiative was initially designed by cooperation between the DDC and civil society, including FAR and ACCESS, under the guidance of RTI, Chiangmai university with partially funding from international agencies of UN and USG. To ensure that the design fits the local context, the initiative involved beneficiaries; comprising health providers from the participating healthcare setting and provincial health offices (PHOs), and most importantly the people living with HIV and key populations (KPs). At the local level, the PHO was assigned to be a coordinator and to establish a provincial team comprising government, NGOs, and PLHIV networks to implement the package of intervention to support the hospital team in collecting and analyzing baseline and endline data, planning and conducting the activities and, especially, facilitating the learning process for healthcare providers and HIV peer groups through participatory training. This training was designed for all health professionals in different sectors, with a target coverage of at least 50%. With HIV peer groups, they identified stigma and discrimination events that occurred in their healthcare setting, and brainstormed solutions to resolve them. Focus group discussions and in-depth interviews gave voice to the PLHIV and KPs themselves, and elicited suggestions for quality improvement. Also, life testimony is one activity of the participatory training that was designed to help healthcare providers to better understand stigma and discrimination through the real stories of clients.

Lesson learned from the past five-year of initiative to eliminate stigma and discrimination in healthcare settings are as the following: 1. Inclusion S&D reduction as a specific goal in the national strategy is essential to mobilizing commitment and action 2. The S&D measurement serves as platform for data collection, analysis and routine monitoring of HIV related S&D 3. The data serves as a catalyst for policy makers, HIV programmers, PLHIV, Key Populations to design and implement evidence based S&D reduction activities and program. 4. the 3x4 package of intervention was proved that it is effective and can reduce HIV-related stigma and discrimination in healthcare setting. 5. The promotion of stigma and discrimination reduction in healthcare settings should be done through linkages to the existing quality improvement of services to be sustained in the long term.To expand the package, the tools and curriculum will need to be simplified. However, the shortened curriculum still has to remain focused on changing the four key drivers. Trainers need to be from inside the healthcare settings; otherwise, the cost and burden of contracting outside trainers might be prohibitive.