"Being seen" at the clinic: Zambian and South African health worker reflections on the relationship between health facility spatial organisation and items and HIV stigma in 21 health facilities, the HPTN 071 (PopART) study.

Virginia Bond,Alice Birch,Helen Ayles,Constance Mubekapi-Musadaidzwa,James Hargreaves,Lario Viljoen,Monde Mwamba,Triantafyllos Pliakas,Sinazo Nomsenge,Nosivuyile Vanqa,Daniel Ziba,Anne Stangl,Janet Seeley,Graeme Hoddinott

doi:10.1016/j.healthplace.2018.11.006

Abstract

Health workers in 21 government health facilities in Zambia and South Africa linked spatial organisation of HIV services and material items signifying HIV-status (for example, coloured client cards) to the risk of People Living with HIV (PLHIV) ‘being seen’ or identified by others. Demarcated HIV services, distinctive client flow and associated-items were considered especially distinguishing. Strategies to circumvent any resulting stigma mostly involved PLHIV avoiding and/or reducing contact with services and health workers reducing visibility of PLHIV through alterations to structures, items and systems. HIV spatial organisation and item adjustments, enacting PLHIV-friendly policies and wider stigma reduction initiatives could combined reduce risks of identification and enhance the privacy of health facility space and diminish stigma.

Highlights

People living with HIV (PLHIV) often report experiencing a fear of “being seen by others” when in health facilities, and this can sometimes adversely affect engagement in care and adherence to anti-retroviral treatment (ART) (Gilbert and Walker, 2009; Horter et al, 2017; Raveis et al, 1998; Wringe et al, 2009)
An example of this is shown in the work of Owolabi et al (2012) in Nigeria who found that PLHIV in Nigeria worried that being seen collecting or carrying anti-retroviral drugs (ARVs) at the health facilities could lead to unwanted disclosure, and PLHIV experienced demarcated HIV services as a form of discrimination
We present Health Workers experiences of how space is navigated by PLHIV and how material items can signify HIV status

Summary

Introduction

People living with HIV (PLHIV) often report experiencing a fear of “being seen by others” when in health facilities, and this can sometimes adversely affect engagement in care and adherence to anti-retroviral treatment (ART) (Gilbert and Walker, 2009; Horter et al, 2017; Raveis et al, 1998; Wringe et al, 2009). The spatial organisation and items associated with HIV services can, by identifying PLHIV to others in health facility settings, enhance the risk of perceived and enacted forms of stigma. An example of this is shown in the work of Owolabi et al (2012) in Nigeria who found that PLHIV in Nigeria worried that being seen collecting or carrying anti-retroviral drugs (ARVs) at the health facilities could lead to unwanted disclosure, and PLHIV experienced demarcated HIV services as a form of discrimination. Despite “being seen” in health facilities persisting in stigma literature (Gagnon, 2015; Li et al, 2007; Wolf et al, 2014), most stigma research in health facility settings has concentrated more on relations within the health facility between providers and clients (Andrewin and Chien, 2008; Famoroti et al, 2013; Li et al, 2007; Opollo and Gray, 2015; Stringer et al, 2016) and broader experiences of PLHIV (Gagnon, 2015; Horter et al, 2017)

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Conclusion