Background: Stigma and discrimination(S&D) are barriers to every aspect of the HIV response. Globally, including in Tanzania, youth living with HIV demonstrate lower rates of adherence to ART and higher virologic failure than children or adults. Recognizing that youth account for a disproportionate number of new infections and face S&D when trying to access HIV and sexual and reproductive health services, the USAID-and-PEPFAR-funded Health Policy Plus project included youth (15-24) living with HIV in a study to: 1) determine the prevalence and actionable drivers of HIV-related S&D in the health system from the perspective of health facility staff (HFS) and clients; 2) inform the design of a tailored HIV-stigma reduction intervention 3) support evaluation.
Methods: Survey data was collected from 233 HFS(148female/83male/2not stated), 243 adults living with HIV, (166female/77male) and 88 youth living with HIV (40female/44male) in two district hospitals, Morogoro region, Tanzania (July-September 2017). Key measures included among staff: presence and levels of S&D key drivers (fear/attitudes/health facility environment) and observed discrimination among staff. Among clients: anticipated, observed, and experienced S&D in health services and avoidance/delay of health services among youth clients.
Results: Youth reported routinely receiving supportive care and high satisfaction with HIV services. However, over 50% also reported having experienced discrimination in the past three months, more than all other age groups (Graph 1), with little variation by sex. HFS also reported high observed discrimination toward all categories of youth (Table 1), greatest toward unmarried pregnant youth (41%). Stigmatizing attitudes toward youth were prevalent among staff with over 90% reporting a least one of four stigmatizing attitudes and highest among medical staff (93%). 46% of HFS believed that youth living with HIV should not have sex. More staff reported negative attitudes towards sexually active girls (69%), compared to their male counterparts (46%).
Conclusions: These data are informing design and evaluation of health facility-based stigma-reduction interventions with youth participation at all levels, starting with questionnaire development. Measuring and addressing S&D towards youth within health facilities is critical to improve health systems, ensure equitable access to care, reach and retain youth in HIV services, and strengthen the quality of service delivery for youth.

Figure 1
[Figure 1]

Table 1: Observed discrimination toward youth living with HIV in the health facility during the 3 months before the survey, by job category
Observed at least 1 of 3 acts of discrimination: unwillingness to provide care, provision of poorer quality of care, and talking badly about a youth client, last 3 monthsMedical Staff (n=149)Administration Staff (n=21)Support / Auxiliary Staff (n=38)Total (n=208)
Sexually-active adolescents43.6% (65/149)38.1% (8/21)26.3% (10/38)39.9% (83/208)
Young people living with HIV who did not acquire HIV perinatally42.3% (63/149)38.1% (8/21)21.0% (8/38)38.0% (79/208)
Perinatally infected young people living with HIV40.9% (61/149)38.1% (8/21)23.7% (9/38)37.5% (78/208)
Unmarried pregnant adolescents46.3% (69/149)38.1% (8/21)23.7% (9/38)41.3% (86/208)
[Table 1]

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