A pretest-posttest design to assess the effectiveness of an intervention to reduce HIV-related stigma and discrimination in healthcare settings in Vietnam

Abstract

Introduction: Stigma and discrimination are important barriers to HIV epidemic control. We implemented a multi-pronged facility-level intervention to reduce stigma and discrimination at health facilities across three high-burden provinces. Key components of the intervention included measurement of stigma, data review and use, participatory training of healthcare workers (HCWs), and engagement of people living with HIV and key populations in all stigma reduction activities.

Methods: From July 2018 to July 2019, we assessed HIV-related stigma and discrimination among patients and HCWs at 10 facilities at baseline and 9 months following an intervention. A repeated measures design was used to assess the change in stigma and discrimination among HCWs and a repeated cross-sectional design assessed the change in stigma and discrimination experienced by PLHIV. HCWs at target facilities were invited at random and PLHIV were recruited when presenting for care during the two assessment periods. McNemar's test was used to compare paired proportions among HCWs, and chi-square test was used to compare proportions among PLHIV. Mixed models were used to compare outcomes before and after the intervention.

Results: Semi-structured interviews were conducted with 649 and 652 PLHIV prior to and following the intervention, respectively. At baseline, over the previous 12 months, 21% reported experiencing discrimination, 16% reported self-stigma, 14% reported HIV disclosure without consent and 7% had received discriminatory reproductive health advice. Nine months after the intervention, there was a decrease in reported stigma and discrimination across all domains to 15%, 11%, 7% and 3.5%, respectively (all p-values <0.05). Among HCWs, 672 completed the pre- and post-intervention assessment. At baseline, 81% reported fear of HIV infection, 69% reported using unnecessary precautions when caring for PLHIV, 44% reported having observed other staff discriminate against PLHIV, 54% reported negative attitudes towards PLHIV and 41% felt uncomfortable working with colleagues living with HIV. The proportions decreased after the intervention to 52%, 34%, 32%, 35% and 24%, respectively (all p-values <0.05).

Conclusions: A multi-pronged facility-level intervention was successful at reducing healthcare-associated HIV-related stigma in Vietnam. The findings support the scale-up of this intervention in Vietnam and highlight key components potentially applicable in other settings.

Keywords: HIV/AIDS; Vietnam; community engagement; key populations; people living with HIV; stigma and discrimination.

Figure 1

Four domains related to stigma and discrimination among people living with HIV before (t0) and after the intervention (t1), % (95% confidence interval). Note: Error bars represent 95% confidence intervals; p‐value determined by chi‐squared test; t0 represents the pre‐intervention assessment and t1 represents the post‐intervention assessment. This figure presents the percent of PLHIV participants who reported stigma and discrimination in each of four studied domains (experienced discrimination, internalized stigma, unwanted HIV disclosure and discriminatory reproductive health advice) at baseline and 9 months following the intervention. Abbreviation: PLHIV, people living with HIV.

Figure 2

Five domains related to stigma and discrimination among healthcare workers before (t0) and after the intervention (t1), % (95% confidence interval). Note: Error bars represent 95% confidence intervals; p‐value determined by McNemar's test; t0 represents the pre‐intervention assessment and t1 represents the post‐intervention assessment. This figure presents the percent of healthcare worker participants who reported stigma and discrimination in each of five studied domains (fear of HIV infection, unnecessary precautions, observed enacted stigma, negative attitudes towards people living with HIV and working with colleagues living with HIV) at baseline and 9 months following the intervention. Abbreviation: PLHIV, people living with HIV.

Figure 3

Observed discrimination against key populations among healthcare workers before (t0) and after the intervention (t1), % (95% confidence interval). Note: Error bars represent 95% confidence intervals; p‐value determined by McNemar's test; t0 represents the pre‐intervention assessment and t1 represents the post‐intervention assessment. This figure presents the percent of healthcare worker participants who reported having observed discrimination against key populations at baseline and 9 months following the intervention. Abbreviations: FSW, female sex workers; MSM, men who have sex with men; MSW, male sex workers; PLHIV, people living with HIV; PWID, people who injects drugs; TGW, transgender women.