Discrimination in health-care settings is one of the major obstacles to ending the AIDS epidemic as a public health threat by 2030. Evidence shows that discrimination in health-care settings is widespread across the world, seriously reduces the quality of life of people who experience it and impedes the use of health services, thus preventing people exercising their right to health.
In order to accelerate action to end discrimination in health-care settings, the UNAIDS Programme Coordinating Board—during its 41st meeting, which took place in Geneva, Switzerland, from 12 to 14 December—reviewed the available evidence of the effects of discrimination in health-care settings on the efforts to reach the global HIV prevention and treatment targets and identified programmatic actions to end such discrimination.
Often driven by stigma, discrimination in health-care settings may be manifested when an individual or group is denied access to health-care services that are otherwise available to others, or when care, treatment and/or medical procedures are refused or delayed on a discriminatory basis.
Evidence provided during the meeting shows that discrimination in health-care settings excludes or deters people from seeking health services for fear of stigma, judgemental attitudes or lack of confidentiality. It acts as a barrier to reaching the 90–90–90 targets and has negative impacts along the continuum of care, which encompasses HIV prevention, testing, treatment and sustained viral load suppression.
Where people cannot or will not access health services, they are less likely to be tested for HIV at all, let alone in a timely manner to ensure that they benefit from the early initiation of treatment. Similarly, where people living with HIV do initiate treatment, discrimination can lead to them being lost to follow-up and less likely to adhere to treatment.
Furthermore, health workers are also subject to the same drivers of discrimination as others, including negative attitudes towards people living with HIV, key populations and women and girls. Health-care provider surveys in Thailand reveal that attitudes about HIV among health facility staff may prevent them from adequately caring for people living with or affected by HIV. The attitudes include notions that HIV is a punishment for immoral behaviour, that most people living with HIV do not care if they infect other people and that it can be appropriate to sterilize a woman living with HIV, even without her consent. In some cases, health workers explicitly state that they would prefer not to provide services to members of key populations.
Solving these challenges and eliminating discrimination in health-care settings requires the implementation and scale-up of focused, coordinated, time-bound, evidence-informed, multisectoral actions.
The participants at the meeting agreed upon a set of programmatic approaches to reduce discrimination in health care, including the following:
- Programmes and other measures to eliminate discrimination in health-care settings must be based on the evidence. Discrimination must therefore be monitored, measured and tracked. In particular, it is important to gauge both the experiences of service users and the attitudes and practices of service providers, as well as to monitor the existence and implementation of national-, local- and facility-level non-discrimination policies.
- As part of a comprehensive strategy to eliminate discrimination in health-care settings, countries should provide pre-service and in-service education to the health workforce. This allows health workers to develop human rights and gender equality competencies and strengthens the understanding of medical ethics and workers’ rights, roles and responsibilities in relation to discrimination in health-care settings.
- Countries should review and strengthen laws to prohibit discrimination in the provision and distribution of health services and provide access to remedies for individuals whose rights have been violated, as well as penalties for the perpetrators. Eliminating formal discrimination rooted in laws and policies is one part of the solution. However, states must also put in place measures that protect people living with HIV and members of key populations in and beyond health-care settings.
The participants agreed that addressing stigma and discrimination, including in health-care settings, is a fundamental requirement for achieving the Fast-Track Targets set for 2020 and the promise of the 2030 Agenda for Sustainable Development of leaving no one behind.
“Health-care workers need to become human rights defenders. UNAIDS welcomes a global compact for ending stigma and discrimination and calls for the disaggregation of data, interventions in health-care settings, including training, and acting quickly to address all forms of HIV criminalization and other legal and policies barriers to services.”
“Empowering health-care workers and giving them the knowledge and skills from a human rights perspective will help them provide better services.”
“Key populations need to feel safe when they seek health services. In our clinic we bring trust to the communities, providing quality health-care services, a space of confidentiality and a warm welcome.”
“Transgender people have been legally accepted in India since 2003, but the government is taking too much time to enact a bill that addresses the health needs of the community and to provide safe and secure health services for transgender people.”
“Health workers face discrimination as well. They need to be supported not only to fulfil their roles and responsibilities, but also to claim their rights. Health workforces have to be champions of the right to health.”