Avoidance of health care among key populations because of stigma and discrimination (A–D)

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Avoidance of health care among key populations because of stigma and discrimination
What it measures
This indicator is divided into four subindicators:
 
A. Avoidance of health care by sex workers because of stigma and discrimination.
 
B. Avoidance of health care by men who have sex with men because of stigma and discrimination.
 
C. Avoidance of health care by people who inject drugs because of stigma and discrimination.
 
D. Avoidance of health care by transgender people because of stigma and discrimination.

What it measures

Progress towards reducing discriminatory attitudes and support for discriminatory policies in health-care settings.

 

Rationale
Discrimination is a human rights violation and is prohibited by international human rights law and most national constitutions. In the context of HIV, discrimination refers to unfair or unjust treatment of an individual (either through actions or by failure to act) based on his or her real or perceived HIV status. Discrimination exacerbates risks and deprives people of their rights and entitlements, thus fuelling the HIV epidemic. HIV-related stigma refers to negative beliefs, feelings and attitudes towards people living with HIV, groups associated with people living with HIV (e.g., the families of people living with HIV) and other key populations at higher risk of HIV infection, such as people who inject drugs, sex workers, men who have sex with men
and transgender people.
 
This indicator is important for providing a measure of the proportion of members of key populations who have avoided accessing general health-care services, HIV testing, HIV medical care and HIV treatment due to fear of stigma and discrimination. Related reasons for avoiding such services may include (but are not limited to) the following: a lack (or perceived lack of) confidentiality within health-care settings; negative attitudes and behaviours among health-care providers; and fears of disclosing or hinting at individual behaviours and sexual preference/orientation.
 
Data related to the avoidance of health-care services are important in measuring the proportion of key populations who are not fulfilling their basic health-care needs (such as routine medical check-ups) and thus may be less likely to attend health-care settings for more specialized services and care (such as HIV testing, treatment and medical care).
 
Data related to the avoidance of HIV testing services are important for addressing barriers to health-seeking behaviours, especially when health-care facilities are available and accessible.
 
This indicator is important for understanding and addressing the barriers to achieving the 90–90–90 targets among members of key populations. Data from this indicator directly measure fear of stigma or discrimination. This indicator could provide further understanding and improve interventions in reducing HIV stigma and discrimination by (1) showing change over time in the percentage of people who fear experiencing stigma, (2) enabling comparisons between national, provincial, state and more local administrations, and (3) indicating priority areas for action.
 
This indicator aims to capture avoidance of four characterisations of health-care services:
  1. Avoidance of health-care services in general among all respondents.
  2. Avoidance of HIV testing among all respondents who report not having had an HIV test in the past 12 months.
  3. Avoidance of HIV-specific health -care among respondents who have indicated they are living with HIV and have not received or have stopped receiving HIV care.
  4. Avoidance of HIV treatment among respondents who have indicated they are living with HIV and have never taken or have stopped taking HIV treatment.

 

Numerator
Number of respondents who answer yes to one of the following:
 
Have you ever avoided seeking (i) health-care, / (ii) HIV testing, / (iii) HIV medical care* or (iv) HIV treatment* in the last 12 months due to any of the following:
 
1. Fear of or concern about stigma?
2. Fear or concern someone may learn you [insert behaviour]?
3. Fear of or concern about or experienced violence?
4. Fear of or concern about or experienced police harassment or arrest?
 
Avoidance of services due to fear of stigma and discrimination may be asked in different ways across countries/surveys. Those provided here are examples of how these questions may be worded.
 
* Among respondents who have indicated they are living with HIV, in surveys that ask the HIV status of respondents
Denominator

Number of respondents

Calculation

Numerator/denominator

Method of measurement

Behavioural surveillance or other special surveys

Measurement frequency

Every 2–3 years

Disaggregation
  • A–D: age Age (<25 and 25+ years).
  • A and C: gender Gender (female, male and transgender).
  • A–D: Cities.
Additional information requested
Please provide the questions included in the survey instruments.
 
Please provide city-specific data for this indicator. Space has been created in the data entry sheet to provide information for the capital city as well as one or two other key cities of high epidemiological relevance: for example, those that have the highest HIV burden or have committed to ending AIDS by 2030.
Strengths and weaknesses
As a measure of stigma and discrimination, this indicator focuses on the outcomes of such behaviour. If perceived or experienced stigma and discrimination is sufficiently severe enough to dissuade people from seeking necessary health services, not only can it readily be identified as a problem, but it also affects critical service uptake. Some respondents, however, may experience and perceive important stigmatizing and
discriminatory behaviour in their communities but, because of their own resilience or discrete or specialized services, may still seek out services. The indicator is not going to measure achieving zero discrimination but can inform on whether discrimination is reducing service uptake.
Further information
For further information on stigma and discrimination, and efforts to measure their prevalence, please see: Thematic segment on non-discrimination, 31st meeting of the UNAIDS Programme Coordinating Board. Background note. Geneva UNAIDS; 2012 (http://www.unaids.org/en/media/unaids/contentassets/documents/pcb/2012/2..., accessed 21 November 2017).
 
Stangl A, Brady L, Fritz K. Technical brief: measuring HIV stigma and discrimination. Washington (DC) and London: International Center for Research on Women and London School of Tropical Medicine, STRIVE; 2012 (http://strive.lshtm.ac.uk/system/files/attachments/STRIVE_stigma%20brief...).
 
Stangl A, Lloyd JK, Brady LM, Holland CE, Baral S. A systematic review of interventions to reduce HIV-related stigma and discrimination from 2002 to 2013: how far have we come? J Int AIDS Soc. 2013;16(3 Suppl. 2).www.jiasociety.org/index.php/jias/issue/view/1464
 
Confronting discrimination: Overcoming HIV-related stigma and discrimination in health-care settings and beyond. Geneva: UNAIDS; 2017 (http://www.unaids.org/sites/default/files/media_asset/confronting-discri..., accessed 21 November 2017).