Background: Health-facility stigma and discrimination (S&D) undermine access to and retention in HIV-services. Health-facility S&D data are essential to tailoring evidence-based S&D-reduction interventions and catalyzing action. In response, the USAID-and-PEPFAR-funded Health Policy Project has partnered with the Ghana AIDS Commission and the Educational Assessment Resource Center, with support from the Global Fund, to measure health-facility HIV-related S&D from the perspective of health facility staff(HFS) and clients. These data have informed the design of a tailored whole-facility HIV-S&D-reduction intervention that engages all levels of staff(medical and non-medical) in improving quality of care while also providing baseline data for an ongoing intervention evaluation.
Methods: Surveys in 20 high HIV caseload facilities in 5 regions with all levels of HFS(1841 female/990 male) and clients living with HIV(192 female/68 male). Key measures included:
1) S&D actionable drivers (fear/attitudes/facility environment) and observed discrimination among HFS;
2) anticipated/experienced S&D, avoidance/delay of health services, and perceptions of health-facility policies among clients.
Results: Fear of status disclosure and lack of confidentiality emerged as a key area to address for S&D-reduction. 36% of clients reported not using their closest HIV facility for HIV care. 74% reported at least one stigma-related reason for not doing so; fear of status disclosure was the most frequently cited(Table 1). 30%(33%female/23%male) of client respondents do not believe their facility keeps HIV records confidential. 7% of clients(female:9%/male:3%) reported that HFS at their regular HIV facility disclosed their HIV status without their consent in the last 6 months. 9% of clients and 27% of HFS reported observing HFS disclosing a client''s HIV status without their consent in the past 6 months. Concern over S&D is relected in HFS'' own hesitancy to seek HIV testing for fear of stigma, as well as their perception of co-workers'' hesitancy to test for HIV, seek treatment if they were living with HIV, and work alongside co-workers living with HIV (Figure 1).
Conclusions: Data from this study were used to tailor whole-facility S&D-reduction interventions. Ensuring confidentiality is an essential part of this approach and critical to reducing anticipated and experienced S&D, and improving service access for and retention of clients living with HIV.



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