This 4-page background paper discusses stigma and discrimination as major obstacles to effective HIV and AIDS responses. It preceded a discussion in the Panos London / Healthlink Worldwide Spark series. The paper defines stigma and discrimination and delineates the ways in which they are key barriers to the achievement of universal access to HIV prevention, treatment care, and support by 2010.

The paper focuses on stigma and discrimination as dynamics of groups seeking power through exclusion and chooses three levels for action:

• "working with individuals, households and affected communities to engage and challenge their own stigmatising assumptions, understandings and practices
• non-discriminatory policies and procedures in institutional contexts, such as schools, workplaces and healthcare settings
• legal and national policy frameworks that uphold human rights and do not perpetuate discrimination."

Because, as stated here, underlying norms that tend to perpetuate stigma are enforced at household, community, institutional, and legal and policy levels, mass media can play a role in reshaping attitudes about HIV and AIDS. Media can raise public awareness and challenge the stigma around HIV through high-profile human interest stories featuring prominent individuals who put a human face on the epidemic. However, to surpass the limits of the effects of awareness, interpersonal dialogue is cited as a way to promote reflection and change, which may be key to the effectiveness of a range of different peer-to-peer interventions. "Sustained dialogue within communities can allow community members to work with and challenge their own understandings and assumptions to address stigma, using participatory approaches....Radio Listening Clubs have promoted discussion around stigma in Malawi, and Community Discussion Forums have raised awareness of the situation of older people as carers in Zambia. [A] study of stigma interventions shows that a combination of empowerment of and contact with people living with HIV, and education, have proved effective at promoting change in the attitudes and actions of individuals and communities."


The paper suggests that institutional discrimination in institutions such as workplaces, schools, and health clinics can be tackled through participatory education and dialogue - used successfully with groups such as with teachers in Zambia, healthcare workers in India, Tanzania, and Vietnam, and faith groups in Ethiopia and Rwanda - as a path to action at the level of institutional policy. National governments and business networks are also a focus of development initiatives to reduce stigma.


According to the document, "[a]t the legal and policy level, initiatives have focused on creating an enabling environment for people to claim and exercise their rights." It cites initiatives that include building the capacity of legal services to work on AIDS-related issues by developing community-based legal services and para-legal counselling to improve the access to legal redress for people living with HIV/AIDS (PLWHA).


Civil society, through social movements and alterative cultural and public action, have found routes to generate solidarity, support, and "resistance identities" to challenge PLWHA marginalisation and to redefine their allotted position in society through innovative public responses to discrimination, which, in some places have affected the family and community patterns of support, as well as public acceptance. "The Treatment Action Campaign in South Africa provides a celebrated... example of civil society mobilisation that has also led to legal and policy battles to widen availability and access to HIV treatment."


The document concludes by observing that stigma and discrimination may also be rooted in family economies which are fragile and close to or entrenched in economic poverty; thus, reactions of denial and avoidance may be a coping mechanism for those faced with the prospect of caring for family or friends. "Without improvement in livelihoods and health and social infrastructure, many may continue to face such dreadful choices."