A recent study of HIV-related stigma and discrimination in health-service delivery in three Mexican states revealed three main types of stigma: pre-existing stigma; HIV-related stigma; and enacted stigma (the borderline between stigma and discrimination). The study was part of an overall multi-faceted HIV-related stigma-reduction project called Mo Kexteya, by the POLICY Project Mexico (The Futures Group) with support from MACRO Measure Evaluation.

Enacted stigma – the actual experience of stigma and discrimination – was illustrated in three priority areas: 1) identification of infected persons; 2) isolation from others; and 3) imposing restrictions.

Restrictive opinions and discrimination

Although 87% said that testing should be voluntary, many thought testing should be compulsory for particular populations: 86% thought sex workers should be tested; 66% for men who have sex with men; and 55% for all foreigners. Although 90% said that information about HIV status should not be made public, almost 40% said that employers had the right to know the HIV status of their employees. It was noted that different hospitals had procedures to visually mark HIV-positive patients through signs, such as coloured coding in wristbands.

Many health professionals thought that it was best to isolate HIV patients. Seventy-four percent said that isolation was to protect the patient from infections from other patients; 46% to protect other patients from them; and almost 30% to protect medical staff. Although 75% agreed that universal precautions were sufficient for PLWHA, almost 50% said that they would use additional precautions if they suspected or knew someone to be HIV-positive. Fifteen percent of those surveyed said that they could visually identify a person with HIV.

Almost one-fifth of respondents thought that a PLWHA should be prohibited from using public services such as swimming pools or washrooms. Thirty-six percent said HIV-positive surgeons should not be allowed to perform surgery. Sixty percent said HIV-positive women should be prohibited from having babies. Almost 25% would not buy food from someone with HIV; and 43% would not consult a dentist with HIV.

Overall, the levels of stigma and discrimination related to HIV in health professionals in the three states surveyed were alarming. Because the information was relatively consistent among the three states, it is reasonable to think similar outcomes would be found in other states.

Addressing AIDS-related stigma and discrimination

Critical issues in addressing stigma and discrimination lie in the areas of policy and legal reform, leadership, programme action, and partnerships.

Policy and legal reform – Reforms are difficult, as Mexico has four primary health schemes – for formal-sector (registered) employees; for public-sector employees; private health services; and for unemployed or those working in the informal sector. A study in the same overall project showed that existing laws on equality and anti-discrimination were adequate, but that the problem lied with their enforcement.

An important issue is the need for clear policies that are effectively communicated to health professionals. This should include a confirmation of codes of conduct and strengthening universal precautions (UPs) in treating PLWHA; and clear articulation and communication of policy issues regarding compulsory testing, testing without informed consent, and confidentiality.

Furthermore, simple, effective means of registering and following up complaints need to be instituted, as existing systems to file complaints are often complicated, time-consuming and ineffective. Sanctions for persons who do not comply with policies should be implemented. Finally, PLWHA should have a place in policy dialogue, programme planning and implementation.

Leadership – Mexico's Ministry of Health at the highest levels has been stressing the need to confront HIV-related stigma in health and other state services. This requires training and sensitisation programmes for counsellors, social workers and psychologists, focusing on issues such as improper (often illegal) HIV testing and interactions around testing. In addition, appropriate services for affected populations (men who have sex with men, sex workers, injecting drug users, poor women or street children) should be developed.

Training and education for health professionals should also address the distinction between HIV and AIDS; HIV-transmission facts and UPs; and updates on treatment protocols for HIV/AIDS and opportunistic infections. Other important themes include stigma and discrimination in health services, sexuality, drug use, stress and nutrition. A recent evaluation of a 4-week HIV training course for health professionals clearly showed that HIV-related stigma can be reduced significantly by increasing knowledge and changing attitudes among health professionals.

Programme action – A priority area for programme action is addressing prevention issues with PLWHAs, or "positive prevention". Programmes in health-care settings should also help to foster the development and use of PLWHA self-support groups, and establish effective referral services for other health or community services for PLWHAs.

Partnerships – Critical partnerships are needed with health-professional unions and civil society in areas such as counselling, legal support and income generation. The survey showed that families and friendship networks are the most important source of support to PLWHA.

Although stigma is deeply rooted in social and cultural mores a concerted and collaborative effort can mitigate its impact and improve future health-service delivery. Some of the building stones of such an approach have been described in this article.

This article was written by the authors on behalf of the research group on HIV-related stigma and discrimination in health-service delivery in Mexico.