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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Table 1: Percent of respondents not using nearest health facility for HIV services and reasons for not using closest facility, by sex
 Female (n=192)Male (n=68)Total (n=260)
Do not use the nearest facility with HIV services for HIV care34.9% (67/192)38.2% (26/68)35.8% (93/260)
Reasons for not using the closest facility: (n=93)
1. Fear of HIV status disclosure70.2% (47/67)50.0% (13/26)64.5% (60/93)
2. Fear of discrimination or poor treatment47.8% (32/67)30.8% (8/26)43.0% (40/93)
3. Had a previous negative experience at this healthcare16.4% (11/67)7.7% (2/26)14.0% (13/93)
4. Fear will be denied services7.5% (5/67)11.5% (3/26)8.6% (8/93)
Composite indicator (at least one of the four stigma-related scenarios, items #1-4)76.1% (51/67)69.2% (18/26)74.2% (69/93)
5. Logistical concerns28.4% (19/67)30.8% (8/26)29.0% (27/93)
[Table 1]

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