There are several existing international guidelines relevant to this issue, although most existing guidelines do not explicitly address discrimination against health workers with HIV or TB. Some relevant WHO and ILO documents cited in Section 2.2.2.
A review of the history of policy development in this area was provided by Wheeler (2009), noting that this topic is not well addressed in the literature. Other than information found in questionnaires of knowledge, attitudes and practices in general few studies explicitly addressed the issue from the perspective of protecting the job security and prospects of HIV-infected health workers. As was described by Wheeler, the dominant concern documented in the literature is discriminating behaviour by health workers towards HIV positive patients, and the extent to which a duty-to-care can be imposed on health professionals.
The Medical Expertise Retention Programme (MERP) of the American Association of Physicians for Human Rights released a survey of HIV-positive and "high risk" untested healthcare workers. Almost two hundred (196) physicians, nurses and dentists responded to the MERP survey, two thirds of whom had tested positive for HIV. The results indicated that a full 73% of those health workers who are living with HIV were afraid of losing their jobs; 67% have avoided seeking treatment or submitting HIV- related insurance claims; and 50% believed that most of their patients would change doctors if they were told that their current provider had HIV.
Numerous studies have examined the knowledge, attitudes, and practices of health workers in relation to HIV, and TB. Some of these will be discussed with respect to other statements to which they are also relevant. The study conducted by Taegtmeyer and colleagues (2008) for example, noted that the underreporting of occupational blood and body fluid exposure is attributed in many settings to concern about stigma. Similarly, Dahab et al. (2008) found that cost was not a barrier to ARV treatment in their study, as treatment was free. However, they did note that long waiting times for clinic services were reported as an important barrier to a patient's ability to return to the clinic for service and to pick up medication, and concern was raised as to whether this might be especially stigmatizing in this working population as spending additional time in the clinic may require additional time off work.
A study by Mahendra et al. (2006) evaluated the impact of a stigma-reduction intervention in three large hospitals in New Delhi, India. These findings informed the development and evaluation of a culturally appropriate index to measure stigma in this setting. The study findings highlight issues particular to the health care sector in limited-resource settings. Although the intervention only assessed stigma by health workers towards patients and not stigmatization of health workers themselves, the authors did conclude that to be successful, stigma-reduction interventions, and the measures used to assess changes, need to take into account the socio-cultural and economic context within which stigma occurs.
Connelly and Rosen (2006) conducted a telephone interview and structured questionnaires with 52 private sector companies, comprising over 6,000 employees from small and medium enterprises in Africa. Respondents cited stigma as a constraint in introducing programmes. Of the 15 companies that had considered implementing services but had not done so, seven cited employees' fear of stigma as the reason. Among the companies that were offering services, the main limitation in implementation reported by managers was not cost but the stigma associated with HIV among workers. Stigma may also be dampening demand for claims for benefits already offered to employees. Managers reported that many employees leave the workplace without claiming benefits; in the surveyed companies, very few employees had claimed disability benefits in the previous two years.
Public Services International has several resources available to the public online regarding HIV, stigma and the workplace. The new Public Sector Unions Fighting against AIDS (PSUFASA) website, part of the PSI/UNISON project to address HIV and AIDS in the workplace, provides useful information, tools and links to assist unions in their response to HIV and AIDS and is an opportunity for sharing good practices, experiences and lessons learned. The need for better promotion and dissemination of policies, codes of practice and training materials in this area is discussed later.
Corbett's five-country study found that 70% of health workers feared promotion and training opportunities would be curtailed as a result of testing positive for HIV. The study also noted that there was weak knowledge of anti-discrimination policies. Similarly, the 17-country national surveys found that while strong worded policies against stigma and discrimination exist in most countries, no strategy/action plans/guidelines were in place. The surveys also found that no operational practices/code of practice against stigma and discrimination were reported. The surveys concluded that policy on stigma and discrimination must be seen to be addressed in workplaces, and that a code of practice or other means must be available at facility level with implementation monitored.
Few studies exist that describe or evaluate the adoption of interventions aimed at stigma reduction among healthcare workers, and indeed the Systematic Review conducted to assess evidence related to interventions in this regard found that no high quality intervention studies have been published. There are however, several studies that examine the knowledge, attitudes, and practices of healthcare workers related to HIV, TB and stigma and documented discrimination and stigma as a major problem.
Nyblade and colleagues (2009) recently published a review to ascertain what works in combating stigma specifically in healthcare settings. They found that, although stigma is a pervasive and daunting problem in the health care setting, much can be done to address its causes and consequences. They state that interventions must focus on the individual, environmental and policy levels (Nyblade et al. 2009). At the individual level, the authors insist efforts must focus on addressing health workers' fears and misconceptions about HIV transmission. They found that fear of acquiring HIV through everyday contact leads people to take unnecessary, often stigmatising actions. Thus programmes need to provide health workers with complete information about how HIV is and is not transmitted and how practicing universal precautions can allay their fears. In addition, health workers must be able to understand the occupational risk of HIV infection relative to other infectious diseases that are more highly transmissible and commonly found in heath care settings. At the environmental level, Nyblade and colleagues focus on the necessity of programmes to ensure that health workers have the information, supplies and equipment necessary to practice universal precautions and prevent occupational transmission. At the policy level, Nyblade et al. found that the lack of specific policies or clear guidance related to the care of patients with HIV reinforces discriminatory behaviour among health workers. They state that health facilities need to enact policies that protect the safety and health of patients, as well as health workers, to prevent discrimination against people living with HIV. Such policies are most successful when developed in a participatory manner, clearly communicated to staff, and routinely monitored after implementation Stigma reduction in health facilities, as argued by Nyblade et al., has important implications for improving patient-provider interactions and quality of care.
Thus there is strong evidence that fear of discrimination and stigma is widespread; that healthcare workers are worried about losing their jobs or opportunities for promotion if they disclose their HIV status; that they refrain from reporting occupational blood and body fluid exposures due to fear of discrimination and stigma; and that lengthy time off work to obtain treatment adds to this problem. There is strong evidence from studies conducted within the last year alone that this problem continues to be quite prevalent. While strong worded policies against stigma and discrimination exist in most countries, strategies/action plans/guidelines to supplement these policies were not in place. No operational practices/code of practice against stigma and discrimination were reported in the national surveys, and Corbett's 5-Country Study revealed that while policies preventing discrimination exist to some extent, health workers are often unaware of these policies. There is very limited evidence as to what stigma reduction strategies are most effective. Intervention studies in the healthcare workplace aimed at stigma reduction would be useful.
The GG concluded that:
- Policies must be in place at the national level to prevent stigma and discrimination.
- Existing ILO/WHO guidelines already call for "the implementation of workplace policies which expressly prohibit discrimination in employment". However, they do not elaborate the discriminatory actions from which HIV positive health workers should be protected, and therefore this should be explicitly addressed.
- There should be no difference between the treatment of a health worker with HIV and a health worker with any other chronic condition.
- HIV status should not to be a factor in selection for employment, which implies that there should be no pre-employment testing. Indeed, current knowledge and existing guidelines, as well as accepted occupational health practice, indicates that no pre-employment health screening is justified for any condition.
- Refusal to register/license a practitioner, or suspension of registration or licence to practice, on grounds of HIV infection is unacceptable.
- No student should be refused admission, or be dismissed from training, on grounds of HIV infection.
- Education and legislation must be synergized to promote social inclusion and measures should promote positive reinforcement rather than just focusing on discrimination/stigma reduction.
- Employer-initiated task reassignment is only justified (a) in the interests of the HIV infected health worker---to which s/he voluntarily consents, or (b) in those rare circumstances, as verified by the relevant professional body, where there is a scientifically established elevated risk of transmission from an HIV positive health worker to patients or colleagues.
- Contract agreements should include clauses to assist in addressing discrimination cases, such that trade unions and professional organizations are held accountable for enforcement.
- An ombudsman should be appointed at the facility or district level to whom aggrieved health workers could appeal to initiate remedial action.
- There must be enforcement of such programmes in the workplace involving trade unions and professional associations in enforcement of the legal provisions.
- The stigma index should be used for monitoring.
- Best practices from other stigmatized medical conditions (i.e. mental health) should be considered and applied.
- HIV and TB stigma reduction programmes must empower infected health workers.
- "Positive Champions" should be identified and provided with leadership roles. Visible positive health workers have the potential to reduce stigma among other health workers, resulting in not only a more supportive work environment but also improved patient care.