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QAP Studies Stigma in HIV/AIDS Healthcare Services in Rwanda
by Cynthia F. Young

Dr. Rachel Jean-Baptiste, PhD, MPH, Quality Advisor for QAP, recently completed the first phase of research on HIV/AIDS stigma within the healthcare sector in Rwanda. The study evaluated HIV/AIDS knowledge, attitudes, and practices of health providers in Prevention of Mother to Child Transmission (PMTCT) services. Focus groups were completed with providers from PMTCT programs in six health centers and hospitals and with women from six associations of people living with HIV/AIDS that surround provider sites.

HIV/AIDS stigma has been identified as one of the greatest challenges to efforts designed to mitigate the impact of the HIV/AIDS epidemic, and the healthcare sector its single biggest perpetrator. Numerous reports of denial of treatment, degradation of patients with HIV, as well as breaches of confidentiality speak to this fact in many countries in Africa and in Asia. Additionally, studies have reported negative beliefs, attitudes, and practices of healthcare providers (core concepts of "provider-stigma") towards persons living with HIV/AIDS.

In Rwanda, where approximately 11 percent of the population are HIV positive (HIV+), and thousands of children are born to HIV+ mothers every year, serious efforts have been made to provide care and support to individuals and families with HIV. However, no studies to date have been done to evaluate the role of stigma in ensuring efficacy of programs. Like many other countries that are faced with a high burden of disease due to HIV/AIDS, stigma in the healthcare sector may be affecting the type of care being provided, as well as an individual's decision to seek health services in a timely manner in Rwanda. Most unfortunate is that stigma due to HIV/AIDS could be having a negative impact on HIV/AIDS programs with clear, evidence-based guidelines and proven cost-effectiveness, such as programs for the prevention of mother to child transmission (PMTCT) of HIV/AIDS. Thus the aims of this assessment were to evaluate dominant attitudes, beliefs, and practices by healthcare providers that might prevent pregnant women from participating in PMTCT programs.

Preliminary results from the providers' focus groups reveal that while providers have accurate knowledge of PMTCT and are able to describe the PMTCT process, they still avoid certain procedures for HIV+ women. Further, providers admit to selective use of precautions (gloves, gowns, boots only for women known or suspected to be HIV+) and to testing patients for HIV at times without their consent.

Such behaviors by providers were found to be linked mostly to fear of becoming infected in the workplace. This fear that is not totally unfounded since providers are exposed daily to HIV+ patients, sharps, lack of protective material and knowledge about the use of proper precautions. In addition, only one of the sites included in this phase of the study had access to post-exposure prophylaxis. Attitudes and beliefs of healthcare providers toward pregnant women with HIV included a negative opinion of HIV+ women who choose to have children, a sense that such women are "trying their luck to have an HIV negative (HIV-) baby" and that nevirapine encourages such women to become pregnant. It was also noted that most healthcare providers say they treat HIV women like other patients, and that the problem of stigma is more of a community issue.

However, focus group discussions with HIV+ women who have gone through PMTCT reveal poor pre-test and post-test counseling, violations of confidentiality, and disrespect and passive rejection when presenting to health centers in labor. Discussions further reveal that disrespectful experiences at a healthcare facility during labor and delivery is one of the barriers to delivering at such facilities, particularly for HIV+ women.

Key recommendations of the study included making providers aware of these stigmatizing behaviors and their consequences, reinforcing universal precautions, and ensuring provision of sufficient protective equipment. The research team also recommends ensuring post-exposure prophylaxis at all PMTCT sites, diminishing maternity costs and reinforcing training in HIV/AIDS disease management, providing HIV counseling, and implementing infection control and prevention measures.

The research team included QAP, the Rwanda Ministry of Health/DSS, Prime II, TRAC (Treatment Research AIDS Center), CNLS (National Commission for HIV/AIDS Control), and the CDC (Centers for Disease Control-Rwanda).

For more information on QAP's HIV/AIDS stigma research contact rjeanbaptiste@urc-chs.com.

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The Quality Assurance Project (QAP) is funded by the U.S. Agency for International Development
(USAID) under Contract Number GPH-C-00-02-00004-00.