This document discusses HIV/AIDS related stigma and discrimination. It begins by defining stigma as unfavorable attitudes directed towards someone, while discrimination refers to treating someone with prejudice. The document then explores several key aspects of stigma: how it works through social hierarchies, how language reinforces it, and its internal and external forms. Specific examples of external stigma include avoidance, rejection and abuse, while internal stigma comprises feelings of shame and fear of disclosure. The document considers approaches to addressing stigma at national, community, healthcare, and individual levels through education, policies, and community involvement. It emphasizes that stigma and discrimination undermine HIV/AIDS programs by discouraging testing, treatment, and prevention efforts. Overcoming stigma requires promoting human rights and a supportive

1. HIV/AIDS
Related Stigma & Discrimination
Dr. M. MUNAWAR KHAN
BCC Coordinator
Enhanced HIV/AIDS Control Program Sindh

2. OBJECTIVES:
• Define and discuss stigma: its background
and social mechanisms
• Address the specific features of HIV that
lead to stigma
• Consider specific factors that should be
addressed in education

3. Lesson Objectives
1. Define and identify HIV/AIDS-related Stigma & Discrimination.
2. Better understand international and national human right issues.
3. Clarify personal values and attitudes with regard to HIV/AIDS
prevention and care.
4. Know how to address stigma and discrimination in the context of
providing HIV services

4. ‘Many people
suffering from AIDS
and not killed by the
disease itself are
killed by the stigma.’
Nelson Mandela, 14th International AIDS Conference, Barcelona July 2002

5. Stigma & Discrimination
• Stigma: (Tohmat) refers to unfavourable attitudes
and beliefs directed toward someone or something
• Discrimination:(imtiazi salook) is the treatment of
an individual or group with partiality or prejudice
• Stigmatization reflects an attitude
• Discrimination is an act or behaviour

6. Components of Stigma
Labeling
Stereotyping
Devaluing
Discriminating
Ignorance
Prejudice/intolerance

7. How stigma and discrimination
“work”?
• Stigma works by producing and reproducing
social structures of power, hierarchy, class and
exclusion by transforming difference into
inequality. The stigma attached to HIV/AIDS is
layered upon pre-existing stigma.
• Stigma is not unique to HIV/AIDS. It has also
been seen associated with TB, syphilis and
leprosy. It is seen in diseases associated with
transgression of social norms.

8. How stigma and discrimination
“work”? cont…..
• Language is crucial to stigma. Powerful
metaphors act to reinforce and legitimize
stigmatization. These include HIV/AIDS as
death, horror, shame, punishment, and
otherness.
• Stigma can be internal or external. Internal
stigma (felt or imagined) is the shame
associated with HIV/AIDS and the fear of being
discriminated against. External stigma refers
to the actual experiences of discrimination.

9. TYPES OF STIGMA
Two main types :
1-External stigma:
[the experience of individual treated differently to
other people]
2-Internal stigma :
[the way a person feels about themselves [e.g.
shame, fear of rejection, discrimination]

10. 1-Examples of EXTERNAL stigma
• Avoidance
• Rejection
• Moral judgment
• Stigma by association
• Discrimination (the ACT associated with stigma)
• Abuse
• Victimization
• Abuse of human rights

11. 2-Examples of INTERNAL stigma
• Self-exclusion from services or opportunities.
• Perceptions of self: low self esteem.
• Social withdrawal.
• Overcompensation.
• Fear of disclosure.

12. WHAT IS SELF ESTEEM?
• Self esteem is the image of one’s own self.
• Person’s view of his worth and value.
• If this image is positive person sees himself
valuable, worth while and comfortable.
• If this image is negative he feels, worthless,
incompetent and unlucky.

14. Factors that can influence self esteem:
1. Previous performance.
2. Event and circumstances of live.
3. Physical appearance.
4. Judgment of significant others.

15. 1-HIGH SELF ESTEEM
A person with high self esteem enjoys:
• Good feelings about him self
• Make others feel good
• Good decision making
• Healthy relationships
• Full utilization of his strengths and potential.

16. 2-LOW SELF ESTEEM
A person with low self esteem suffers
from feeling of worthlessness and
inferiority he
1. Looks at minor failures again and again.
2. Is highly critical to him self.
3. Is self centered.
4. Is shy and insecure.
5. Misinterprets others thoughts and actions
and make himself and others miserable.

17. How to strengthen Self Esteem?
1. Feel good about your self and nurture your
self.
2. Do not run your self down.
3. Bring to light your minor achievements.
4. Recognize the good in others and express
your sincere appreciation.
5. Accept compliment with grace.

18. How to strengthen Self Esteem?
Conti……
• Reject unconditional negative comments.
• Avoid the company of critical people. They make
you feel down.
• Join those group who are supportive and friendly.
• Believe that God created us with all love. We all
have the qualities and positivities.

19. A Dynamic Model of the Four
Manifestations of Stigma
Institutional
Stigma
Public
Stigma
Stigma-by- Self-
Association Stigma

20. Expressions and forms of stigma
• Stigma divide into four loosely defined groups: physical,
social, verbal and institutional.
1-Physical stigma:
– Isolated, shunned, neglected
– Separate living space, eating utensils
– Violence
2-Social stigma:
– Isolated from community
– Voyeurism: any interest may be morbid curiosity or
respect rather than genuine concern
– Loss of social role/identity: social `death`, loss of
standing and respect

21. Forms of stigma (contd.)
3-Verbal stigma:
– Gossip, taunting, Labeling:
– in Africa: "moving skeleton," "walking dead
body," and "keys to the mortuary"
– In Vietnam: "social evils," and "crust of society."
4-Institutionalised stigma:
– Barred from jobs, scholarships, visas
– Denial of health services
– Police harassment (eg of sex workers, HIV-positive
activists in China, outreach workers in India)

22. The impact of stigma
• It creates ‘excluding behaviors'
• It isolates and divides communities
• Causes people to withdraw, putting them
beyond the reach of support services
• It generates a strong ‘us and them’ phenomenon
US THEM

23. ‘HIV-related stigma is
incomparable in:
its scale,
its context/background,
and its causes.’
Mary Robinson, 16th International AIDS Conference, Toronto, 2006

24. HIV stigma and culture…
Stigma is ‘written’ by powerful cultural forces:
and as a social product, exists at the intersection between
power, difference and culture…
Power Stigma Difference
Culture

25. Self Stigma and the person
• Self stigma: “More deadly than the
HIV living within our bodies:
• it infects your mental state resulting in
behaviors beyond your ability to
understand” [Thailand]
Source: ‘Living on the outside’ (HDN, 2005)

26. Self stigma –
derived from enacted (actual) or perceived (anticipated) social
experiences
Related to knowledge of public reactions to stigma reflected
appraisals of others
• Label avoidance
– Avoiding HIV testing
– Avoiding disclosure of HIV status
– Avoiding treatment
– Avoiding safer sex
• Withdrawal from situations where ill treatment might occur
• Internalization of the negative label
– Reduction of self-esteem & self-efficacy
– Hopelessness and depression
– Reduced Immune functioning

27. Stigma & IDU’s
• IDUs: experience additional barriers to care,
and exclusion from ARVs –
• stigma is amplified/increased because of the
double diagnosis
• Disclosure: “Everyone seems to care and is
very sorry about what has happened, but no
one comes within touching distance and no
one is willing to touch or be touched. Your
whole world disintegrates within one day” [Sri
Lanka]

28. HIV stigma & Workplace PLHIV
• PLHIV experience significant stigma in the
workplace, healthcare setting, and in the
religious sector - stigma exists even in
institutions purporting to offer a ‘safe haven’
• “Fear of infection seems to be a powerful
factor in explaining…stigma among health
workers, especially in countries with weak
health care infrastructure” [India]
Source: ‘Living on the outside’ (HDN, 2005)

29. HIV stigma & Media
• “The Media wants to sensationalize/exaggerate
issues…and this becomes even more dangerous
when media personnel are not knowledgeable to
start with” [Ethiopia]
• “The media is a direct reflection of the
development and consciousness/awareness of a
society” [Ethiopia]
Source: ‘Living on the outside’ (HDN, 2005)

30. Stigma & Health service
• Discourages access to ANC services
• Prevents access to counselling , HIV testing and MTCT
services
• Discourages disclosure of HIV test results to partner(s)
• Discourages acceptance of MTCT interventions
• Inhibits use of safer infant-feeding practices
• Confers secondary stigmatisation on the child

31. 1- Root Causes of stigma
The role of knowledge about HIV and AIDS and fear
surrounding it:
Peoples believe that the fear of transmission from casual
transmission, and the various "what if scenarios" are the
result of:
1) The lack of specific, in-depth information about HIV
transmission,
2) Fear-based public messaging, and
3) The evolving nature of knowledge about HIV and AIDS.

32. 2-Root Causes of stigma
2. The role of values, norms, and moral judgment:
 This stigma is exacerbated by the seriousness of the
illness, its mysterious nature, and its association with
behaviors that are either illegal or socially sensitive (e.g.,
sex, prostitution, and drug use).
 Also relevant is the perception that HIV infection is the
product of personal choice:
 That one chooses to engage in "bad" behaviors that put
one at risk and so it is "one's own fault" if HIV infection
ensues."

33. Addressing stigma
• Educate and train healthcare providers in:
• HIV transmission
• Activities to address stigma
• Awareness of language that describes PLWHA
• MTCT-related policies
• Counselling and safer infant feeding practices

34. Addressing stigma
Enlist manager’s help to ensure policies and
procedures are in place and implemented for:
• Non-discrimination policies
• Confidentiality
• Universal precautions
• Post-exposure prophylaxis (PEP)

35. Effects of stigma
• Social isolation
• Limited rights and reduced access to services
• HIV/AIDS related stigma fuels new HIV infections
• Secondary stigma (stigma by association)

36. INTERVENTIONS
Interventions addressing HIV-related
stigma can take place at all levels:
1. National
2. Community and social/cultural
3. MTCT site/facility
4. Individual

37. 1-National Level Interventions to
Address Stigma
Support
• Human rights legislation
• National efforts to scale up ARV treatment
• Funding for PPTCT services, and training
Share
• MTCT success stories

38. 2-Community Level Interventions
In the community, promote
• HIV awareness and knowledge
• MTCT activities as integral to health care and
HIV/AIDS prevention and treatment
• Referrals to and from MTCT services
• Awareness of MTCT interventions

39. Community level interventions
(contd……)
Support
• Partnership with schools, social and community
organizations
• PLWHA ( people living with HIV/AIDS) in
implementing initiatives
• Networking with needed linkages
• Ongoing training

40. 3-Program level interventions
• Integrate MTCT into antenatal services
• Encourage partner involvement
• Enlist partner and family support to
decrease HIV transmission

41. The woman in the picture, Marie, is on her way to the market. Her husband was recently
diagnosed as HIV-positive and has been quite ill. People in the community suspect that he is
HIV-positive. Ask participants:
»»What do you think the community members sitting on the chairs are thinking?

42. Negative attitudes about different groups of people can lead to discrimination. For example,
Anna is in Class 4 and is the best in her class. Her father recently died of AIDS and her mother
and baby brother are HIV-positive.
Ask participants:
»»What is happening in this picture?

43. Who does stigma and discrimination
affect?
Anyone infected, affected, or potentially at risk
for HIV (illustrative list):
Injecting drug users
Commercial sex workers
HIV orphans
Family and friends of HIV+ people of high-risk
groups
Caregivers

44. Stigma and discrimination impacts on
HIV/AIDS programs
• They can make life unbearable for those who live
with the disease.
• Stigma may make people who may have been
exposed unwilling to be tested,
• To change their behavior,
• To reject prevention methods,
• And can perpetuate poor quality of care and
discrimination.
• Example, a woman may be unwilling to bottle feed if
she believes that it will brand her as HIV infected.

45. Illustrative barriers
• PLWA denied basic rights, access to care, treatment
and services.
• IDU’s and sex workers are forced to register their
status and are discriminated against.
• Sex workers face imprisonment due to the
criminalization of their trade.
• Children in institutions cannot access services and are
increasingly vulnerable to trafficking after
‘graduation’

46. How to address stigma and
discrimination
• Care and support also mean emotional and social needs for those
who are affected by HIV. This includes
• visitation programs,
• support groups,
• and methods aimed at overcoming fears of the affected and society.
• IEC can include counseling,
• conflict resolution,
• and educational messages tailored to target audiences (for
example, knowledgeable health care workers).
• Sindh AIDS Control Program
– Giving voice to those affected by HIV/AIDS
– Promoting a supportive environment through communication strategies
– Protecting the rights of those affected by HIV/AIDS

47. Summary
• Stigmatisation reflects an attitude
• Discrimination is an act or behaviour
• Stigma and discrimination are often linked to violations
of human rights
• Human rights declarations affirm all peoples’ rights to be
free from discrimination, including discrimination based
on HIV/AIDS status.
• Stigma discourages:
-Disclosure of HIV status
-Acceptance of safer infant-feeding practices
-Access to education, counselling, and treatment even when
such services are available and affordable

48. Summary contd
 The MTCT programs and staff can help reduce stigma and
discrimination in the healthcare setting, in the community, and at the
national level
 Encourage MTCT staff to serve as role models
 Involve PLWHA
 Promote partner participation and community support
 HIV/AIDS-related stigmatisation and discrimination can discourage
access to key HIV services, including:
 Testing
 MTCT services
 Antenatal care
 ARV prophylaxis

49. Our experience of
stigmatized and stigmatizer
• PART ONE: think about a time in your life when you
felt isolated or rejected for being seen to be different
from others, or when you saw other people treated
this way. What happened? What impact did it have
on you?
• PART TWO: Think about a time in your life when you
isolated or rejected someone else because they were
different. What happened?? How did you feel? What
was your attitude? How did you behave? [individual,
then share: 5 mins]

50. Challenge
HIV-related stigma is increasingly recognized as
the single greatest challenge to slowing the
spread of HIV/AIDS
HIV/AIDS – a threefold epidemic
• HIV
• AIDS
• Stigma, discrimination, and denial

51. Human rights
• Freedom from discrimination is a fundamental
human right
• Discrimination on the basis of HIV/AIDS status,
actual or presumed, is prohibited by existing
human rights standards
• Discrimination against persons living with
HIV/AIDS (PLWHA), or those thought to be
infected, is a clear human rights violation

52. Any questions?