Subject - CAN A EMPLOYEE BE TERMINATED BECAUSE HE HAS HIV/AIDS

HI,

INDIAN MARKET IS NO MORE LOCAL ITS GLOCAL NOW,VERY SOON WE CAN SEE LOTS OF EX-PATS COMING TO INDIA,IN SEARCH OF WORK AND/OR PROJECTS. I HAVE SEEN MANY COMPANIES ASKING THEIR HR PROFESSIONALS TO MAKE HIV/AIDS POLICY.BUT HOW MANY OF US KNOW THE PURPOSE OR THE REASON BEHIND THE POLICY,THE LEGAL IMPORTANCE OF THE SAME. I WISH TO SHARE WONDERFUL ARTICLE ON THE DISCRIMINATION OF EMPLOYEES BY THE EMPLOYERS ON THE GROUND OF HIV/AIDS. I HOPE THIS WOULD HELP NOT ONLY US BUT ALSO OTHERS. Despite the passage of a quarter-century since the AIDS/HIV infection was diagnosed, the stigma that surrounds it has not subsided. The number of persons who have become victims of this affliction has swelled to such staggering sums, that its enormous proportions have caused a global effort to be made to combat it. The difficulty States, communities and individuals face in confronting the HIV epidemic lies in the fundamental but difficult issues it raises; issues of sex, sexuality, diversity, 'nonconformist' behavior, inequality of all kinds in all spheres, issues that we as a society have been uncomfortable dealing with and discussing for a long time. This is an epidemic that knows no borders of geography, class, caste, gender and sexuality. The worse kind of discrimination face by Persons Living With HIV/AIDS (PLWHA) has been in the area of employment. Discrimination can be broadly defined as the treatment of one person less favorably than the other in the same or comparable circumstances on the basis of a characteristic that is not immediately relevant to the situation. There is no concrete legal remedy available to PLWHA in case their right to employment is violated in the private sphere. India's socio-economic status, traditional social ills, cultural myths on sex and sexuality and a huge population of marginalised people make it extremely vulnerable to the HIV/AIDS epidemic. In fact, the epidemic has become one of the most serious challenges faced by the country since Independence. Since the first case was reported in 1986 in Chennai, the capital of the South Indian State of Tamil Nadu, HIV has spread rapidly from urban to rural areas and from high-risk groups to the general population. In a country of over one billion people living with HIV/AIDS (NACO, 2004). This is less than one percent of the country's population. Still, India has the second highest number of people living with HIV/AIDS in the world after South Africa. India accounts for almost 10 per cent of the 40 million people living with HIV/AIDS globally and over 60% of the 7.4 million Persons Living With HIV/AIDS (PLWHA) in the Asia and Pacific region. Given the large population base, a rise of just a few percentage points in the HIV prevalence

rates can push up the number of those living with HIV/AIDS to several millions. The second decade of the epidemic is marked by visible heterogeneity. Tracking the epidemic and implementing effective programs is compounded by the fact that there is no one epidemic in India. Rather, there are several localized sub-epidemics reflecting the diversity in socio-cultural patterns and multiple vulnerabilities present in the country. Though the country overall has a low prevalence rate, it has reported concentrated epidemics among vulnerable population such as sex workers. There are already localized epidemics within vulnerable groups in, and the virus has been found to spread among the general population in six states in India. young people in India are among those most vulnerable to HIV. Over 35% of all reported HIV/AIDS cases in India occur among young people in the age group of 15 to 24 years. 1986-1992, Denial of the Threat of HIV: This was a period that saw the beginning of a largely research-based programme. Surveillance activities were launched in 55 cities in three states. The programme activities were left to the states without strong central guidance. 1992-97, Backed by World Bank funding and strong WHO GPA (Global Programme on AIDS) support, this phase saw the creation of the National AIDS Control Organisation (NACO). Achievements included higher levels of awareness creation, establishment of state level structures for programme implementation and improvements in blood safety. The launch of successful individual projects such as the innovative intervention in Sonagachi amongst commercial sex workers and breakthroughs in reaching out to college youth through "University Talks AIDS (UTA)" were amongst its achievements. The scope of these efforts remained however on a limited scale. An emphasis on blood-safety and strengthening of infrastructure yielded some gains, but the approach remained primarily medical with HIV seen largely as a health issue. 1998 onwards, Building on the experience of the first phase, there was a two-fold drive to focus on coverage amongst high risk groups like sex workers, truck drivers and injecting drug users and to make the programme multi-sectoral. It has resulted in a strongly decentralized programme with the responsibility of implementation vested with the states. Flexible State AIDS Societies were formed with stronger mechanisms for state level programme management. An innovative approach for providing technical support to state programmes was launched by establishing a network of 12 Technical Resource Groups (TRGs), each covering different thematic areas of the epidemic. Each of them is mandated to provide technical support to states. International human rights law relating to health and HIV/AIDS includes Article 25(1) of the Universal Declaration of Human Rights (UDHR), the 1966 International Covenant on Economic, Social, and Cultural Rights (ICESCR), and its partner covenant, the International Covenant on Civil and Political Rights (ICCPR).

The International Covenant on Civil and Political Rights, the International Covenant on Economic, Social and Cultural Rights are two covenants that protects a range of economic, social, and cultural rights without discrimination based on creed, political affiliation, gender, or race. Nondiscrimination is a basic tenet of the human rights movement, enshrined in these two covenants, and countless other human rights treaties and declarations. This principle of nondiscrimination has begun to be applied at the national level with regard to individuals infected with HIV. Some nations have adopted legislation aimed at protecting people with HIV/AIDS from discrimination. This action is essential. The stigma associated with HIV/AIDS deprives people of their dignity and communities of productive members. Equally as detrimental, it provides an incentive to avoid testing, especially in circumstances when treatment options are limited or nonexistent. With legal protection, people will feel secure in their rights and dignityand be more willing to seek testing and treatment. Universal Declaration of Human Rights, resolution adopted unanimously in December 1948 by the General Assembly of the United Nations. The objective of the 30-Article declaration is to promote and encourage respect for human rights and fundamental freedoms. The declaration proclaims the personal, civil, political, economic, social, and cultural rights of humans, which are limited only by recognition for the rights and freedoms of others and the requirements of morality, public order, and general welfare. The principle of non-discrimination is fundamental to human rights law and is of particular significance to both displaced people and those living with HIV/AIDS who frequently suffer from high levels of stigma and discrimination. This is reflected in Article 1 of the UDHR, the Preamble to the UN Charter, and Article 2(2) which states that these rights apply without discrimination of any kind as to race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status. Certain provisions relating to right to work of a person suffering from HIV/AIDS as mentioned in UDHR are as follows: i) Right to life, liberty and security of person ii) No person must be subject to forced testing and/or treatment or otherwise cruel or degrading treatment . iii) Everyone, including persons living with a positive 'HIV' diagnosis has the right to work and participate in the cultural life of the community, to enjoy the arts and to share in scientific advancement and its benefits . iv) All, including persons living with a positive 'HIV' diagnosis, are equal before the law and are entitled without any discrimination to equal protection by the law . v) People living with a positive 'HIV' diagnosis have furthermore the rights as outlined in Art. 25(1) UDHR especially the right to adequate standard of living, assistance, medical care and necessary social services, and the right to security in the event of unemployment according to their needs and their treatment choices. The UNAIDS Guidelines, 1996 recognize the existence of vulnerable populations in developing countries and recommend that appropriate safeguards be incorporated in research protocols. The Guidelines further address multi-sectoral responsibilities

and accountability, including improving the roles of the Government and Private sector. In addition they stress the duty of the states to engage in law reform and identify legal obstacles so as to form an effective strategy of HIV/AIDS prevention and care. Regarding anti-discrimination, States should enact or strengthen anti-discrimination and other protective laws that protect people living with HIV/AIDS from discrimination in both the public and private sectors, ensure privacy, confidentiality and ethics in research involving human subjects, emphasis education and conciliation and provide for speedy and effective administrative and civil remedies. The Constitution Of India Article 14 of the Constitution of India guarantees equality to all persons within the territory of India. Equality implies an essential sameness or likeness. On the basis of this sameness, people should possess the same privileges and should enjoy equal rights, along with the accompanying responsibilities. In principle, discrimination is antithetical to equality. The guiding principle of Art 14 is that all persons and things similarly circumstanced shall be treated alike both in privileges conferred and liabilities imposed. Article 16 prohibits discrimination in public employment on grounds of religion, caste, creed, sex, colour etc. One of the main reasons for the establishment of NHRC was because India is a party to the International Covenant on Civil and Political Rights and International Covenant on Economic, Social and Cultural Rights. The human rights embodied in the aforesaid Covenants stand substantially protected by the Constitution. The Commission has taken up a number of individual cases relating to discrimination faced by persons affected or infected by HIV/AIDS with regard to employment, access to medical treatment facilities and education. Further, the Commission has mounted a multi-media campaign to disseminate information on the Human rights and HIV/AIDS to various target groups. The national response to AIDS epidemic was seen in the beginning itself when the first case was reported in India in 1986. The Government constituted a high-power committee in 1986 under the Ministry of Health and Family Welfare. Subsequently, a National AIDS Control Programme was launched in 1987. In India, the National AIDS Control Organisation (NACO) carries out the country's National AIDS Programme, which includes formulation of policy and implementation of prevention and control programmes. Besides NACO, the country also has a National AIDS Control Board, which is chaired by the Union Health Secretary. The Board reviews NACO policies, expedites sanctions, approve procurement and undertake and award contracts to private agencies. The other major functions of the Board are approval of annual operational plan budget, reallocation of funds between programme components, formation of the programme managerial teams and appointment of senior programme staff.

The NAPCP articulates the governments understanding of the HIV/AIDS epidemic. It states that for an effective response, development and human rights need to be addressed through a multi-sectoral collaboration. The NAPCP prioritises human rights protection as an objective and not merely a strategy. Other objectives include reduction of the impact of the epidemic, bringing about a zero transmission rate by 2007, bringing about an enabling socio-economic environment for prevention and control, decentralisation of the programme and working towards a horizontal integration of the HIV/AIDS response with other national programmes relating to health. The implementation of the policy is through the involvement of different departments of the government, decentralisation and collaboration with NGOs especially for the purpose of targeted interventions. For the implementation and management of HIV/AIDS programmes in states, State AIDS Cells were created in 32 States and UTs of the country. However over a period of time, it was realised that due to many cumbersome administrative and financial procedures, there was delay in release of funds sanctioned by the Government of India. This delayed the implementation of programmes at different levels. To remove the bottlenecks at the State level, Ministry of Health and Family Welfare advised the State Governments/Union Territories to constitute a registered society under the chairmanship of the Secretary Health. The society is broad-based with members representing various ministries like Social Welfare, Education, Industry, Transport and Finance and NGOs. On an experimental basis, the Tamil Nadu State AIDS Control Society was created followed by a similar society in Pondicherry. Successful functioning of these societies led to the Government of India advising other states to follow this pattern for implementation of the National AIDS Control Programme. The Lawyers Collective (HIV/AIDS Unit) an NGO in India, with the help of European Commission, has set up this unit to provide legal aid and allied services for people affected by HIV/AIDS and people working in HIV/AIDS. The Lawyers Collective is one of the most prominent Organizations that has been fighting for the rights of PLWHA and has been successful in its legal battles to enforce the same. They have also made valuable contributions in ensuring that people have access to accurate information about HIV to protect themselves. Employment is now emerging as a focal point of debate in the HIV/AIDS context, especially since it has become clear that the large number of persons living with HIV/AIDS in India are those who are employed or of employable age. It, therefore, becomes imperative for employers and companies to evolve policies that address this issue. With Indian economic policy veering toward liberalisation in the last decade, the private sector is rapidly creating the largest employment base. In the context of employment, PLWHAs are often denied jobs at the time of recruitment on account of their HIV status. HIV-positive employees are discriminated against by their co-workers and employers and are frequently terminated from employment altogether. Often, discrimination is subtler and HIVpositive employees are gradually demoted or are kept on the payrolls but asked not

to report to the work place. One study on HIV-related discrimination in India revealed that discrimination by employers largely takes the form of denial of the HIV epidemic altogether. Hence, not only do companies terminate HIV-positive employees as a matter of course, they also regularly deny compassionate employment and other benefits such as provident fund and gratuity to survivors of deceased HIV-positive employees. The legal and ethical issues relevant to the context of the workplace and to these interventions are unclear and untested. But some of the common issues are: Can an employer, for example, legitimately require HIV testing of a prospective or current employee? Does an employer have the right to personal information that the employee may not want to disclose? Does the employee have any legitimate control over the disclosure of medical results? The Constitution of India protects the State employees affected with HIV/AIDS but can such protection be guaranteed in the Private Sector as well? In the private sector there is no legal restriction preventing employers from putting prospective as well as existing employees through HIV/AIDS screening as part of the assessment of fitness to work and to refuse employment if the test is positive. A refusal either to take the test or to allow the results to be given to the employer may result in the applicant/prospective employee not being offered a job and having no form of legal redress. Fitness for the job is a major criterion and as such people living with HIV may find employment difficult to obtain. They also have little protection against dismissal. In general then, those who have developed HIV will be subject to the provisions relating to dismissal on grounds of ill health. Dismissal for reasons of sickness will depend on the circumstances of the case. For example, the length and regularity of absence from work, the need to replace the employee because of the position held within the organisation and the extent to which the employee's absence has a negative impact upon the business of the employer/organisation. Some protection may, however, be sought under Labour Laws relating to dismissal. At the same time, mandatory testing is often justified by the argument that once an employee tests positive, special care and support could be provided for her/him. With respect to testing, it is stated that "HIV screening in the workplace or for purposes of employment should not be undertaken. HIV screening should not be required for employees, candidates for employment or others to enter or reside in another country". With a view to anticipating loss of workers due to HIV/AIDS, many companies would like to know the proportion of the workforce they are likely to lose through AIDS. However, increasingly, employers are beginning to recognize the tremendous negative impact of pre-employment and on the job HIV screening. Testing the existing workforce is not only unethical, but leads to great hostility and is incompatible with effective HIV/AIDS prevention and care programmes at the

workplace. Companies are beginning to find that, by abandoning testing requirements, a conducive climate can be created for workplace prevention programmes. A steadily increasing number of employers in the worst affected countries are reaching the conclusion that prevention is much more cost effective than HIV screening in the long term, and that respect for the rights of workers is a powerful tool in its own right. Testing in the Armed Forces- Although HIV testing as a prerequisite for employment is not permissible in any other sector the policy makes an exception for armed forces, where before employment, HIV screening may be carried out? Voluntarily with pre-test and post-test counseling and the results may be kept confidential. This policy of permitting mandatory but informed testing is a contradiction in terms. A person who after pre-test counseling decides not to take the test may be eliminated as a candidate for employment. Issue of Confidentiality: Duty to maintain confidentiality has its origin in the Hippocratic Oath, which is an ethical code. The Hippocratic oath says, Whatever, in connection with my professional practice, or not in connection with it, I see or hear, in the life of men, which ought not to be spoken of about, I will not divulge, as reckoning this all such should be kept secret. Every person has the right to privacy, which is the right to determine for themselves when, how and to what extent information about them is communicated to others. This issue of confidentiality at the workplace was dealt in the case of MX v. ZY which will be discussed in detail ahead. Discrimination in the Private Sector Articles 14 and 16 of the Constitution of India guarantee the right to equality and provide against discrimination in employment respectively. However, these rights are available against the state and not against private employers. As such, little can be done within the present legal regime to prevent discrimination in the private sector. An anti - discrimination legislation is required to prevent such discrimination which does not exist in India till date. There is no specific employment law that provides protection from discrimination to people living with HIV/AIDS. Owing to a progressive judicial pronouncement by the High Court of Bombay MX v ZY employees of the public sector cannot be denied recruitment merely because of their HIV positive status if they are otherwise qualified and do not pose a substantial risk to others. Moreover they cannot be discriminated on account of their HIV positive status. People Living With HIV/AIDS, their friends and relatives, their communities, national and international policy- and decision makers, health professionals, and the public at large all, to varying degrees, understand the fundamental linkages between HIV/AIDS and human rights. The importance of bringing HIV/AIDS policies and programs in line with international human rights law is generally acknowledged but, unfortunately, rarely carried out in reality. Policymakers, program managers,

and service providers must become more comfortable using human rights norms and standards to guide and limit the actions taken by or on behalf of governments in all matters affecting the response to HIV/AIDS. To control the HIV/AIDS pandemic and mitigate its impact, require legal action not only within a country's own borders but also in line with international human rights obligations through its engagement in international assistance and cooperation. Sustained commitment is critical to the future of the HIV/AIDS epidemics around the world. However, no policy or laws can alone combat HIV/AIDS related discrimination. The fear and prejudice that lies at the core of the HIV/AIDS discrimination needs to be tackled at the community and national levels. A more enabling environment needs to be created to increase the visibility of people with HIV/AIDS as a 'normal' part of any society. In the future, the task is to confront the fear based messages and biased social attitudes, in order to reduce the discrimination and stigma of people who are living with HIV or AIDS. THANK YOU OCTAVIOUS

Contents

Why is there stigma related to HIV and AIDS? Different contexts of HIV-related stigma The effects of stigma Types of HIV/AIDS-related stigma and discrimination The way forward

AIDS-related stigma and discrimination refers to prejudice, negative attitudes, abuse and maltreatment directed at people living with HIV and AIDS. They can result in being shunned by family, peers and the wider community; poor treatment in healthcare and education settings; an erosion of rights; psychological damage; and can negatively affect the success of HIV testing and treatment. AIDS stigma and discrimination exist worldwide, although they manifest themselves differently across countries, communities, religious groups and individuals. They occur alongside other forms of stigma and discrimination, such as racism, homophobia or misogyny and can be directed towards those involved in what are considered socially unacceptable activities such as prostitution or drug use. Stigma not only makes it more difficult for people trying to come to terms with HIV and manage their illness on a personal level, but it also interferes with attempts to fight the AIDS epidemic as a whole. On a national level, the stigma associated with HIV can deter governments from taking fast, effective action against the epidemic, whilst on a personal level it can make individuals reluctant to access HIV testing, treatment and care. UN Secretary-General Ban Ki Moon says: "Stigma remains the single most important barrier to public action. It is a main reason why too many people are afraid to see a doctor to determine whether they have the disease, or to seek treatment if so. It helps make AIDS the silent killer, because people fear the social disgrace of speaking about it, or taking easily available precautions. Stigma is a chief reason why the AIDS epidemic continues to devastate societies around the world."1

back to top Why is there stigma related to HIV and AIDS?

Fear of contagion coupled with negative, value-based assumptions about people who are infected leads to high levels of stigma surrounding HIV and AIDS.2 Factors that contribute to HIV/AIDS-related stigma include:

HIV/AIDS is a life-threatening disease, and therefore people react to it in strong ways. HIV infection is associated with behaviours (such as homosexuality, drug addiction, prostitution or promiscuity) that are already stigmatised in many societies.

Most people become infected with HIV through sex which often carries moral baggage. There is a lot of inaccurate information about how HIV is transmitted, creating irrational behaviour and misperceptions of personal risk. HIV infection is often thought to be the result of personal irresponsibility. Religious or moral beliefs lead some people to believe that being infected with HIV is the result of moral fault (such as promiscuity or 'deviant sex') that deserves to be punished.

The fact that HIV/AIDS is a relatively new disease also contributes to the stigma attached to it. The fear surrounding the emerging epidemic in the 1980s is still fresh in many peoples minds. At that time very little was known about the risk of HIV transmission, which made people scared of those infected due to fear of contagion. From early in the AIDS epidemic a series of powerful images were used that reinforced and legitimised stigmatisation.

HIV/AIDS as punishment (e.g. for immoral behaviour) HIV/AIDS as a crime (e.g. in relation to innocent and guilty victims) HIV/AIDS as war (e.g. in relation to a virus which must be fought) HIV/AIDS as horror (e.g. in which infected people are demonised and feared) HIV/AIDS as otherness (in which the disease is an affliction of those set apart)

View examples of alarming 1980s public health advertisements from the UK and Australia associating AIDS with death.

back to top Different contexts of HIV-related stigma

Konnie Huq: "If I had HIV, would you kiss me?" HIV/AIDS-related stigma is not a straightforward phenomenon as attitudes towards the epidemic and those affected vary massively. Even within one country reactions to HIV/AIDS will vary between individuals and groups of people. Religion, gender, sexuality, age and levels of AIDS education can all affect how somebody feels about HIV and AIDS. AIDS-related stigma is not static. It changes over time as infection levels, knowledge of the disease and treatment availability vary.

In 2003, when launching a major campaign to scale-up treatment in the developing world the World Health Organization (WHO) claimed that: As HIV/AIDS becomes a disease that can be both prevented and treated, attitudes will change, and denial, stigma and discrimination will rapidly be reduced.3 It is difficult to assess the accuracy of this statement as levels of stigma are hard to measure and a number of small-scale studies have shown that the relationship between increased access to HIV treatment and a reduction in stigma is not always clear.4 5 A study of 1,268 adults in Botswana found that stigmatising attitudes had lessened three years after the national programme providing universal access to treatment was introduced. However, the study concluded that although improving access to antiretroviral treatment may be a factor in reducing stigma, it does not eliminate stigma altogether and does not lessen the fear of stigma amongst HIV positive people.6 Moreover, as there are many types of stigma it is possible that the availability of treatment may reduce some types of stigma and not others. For example, a study in Tanzania found that, on the one hand, stigma caused by the perception of people living with HIV as weak and therefore a 'burden' on the community had decreased with the uptake of treatment.7 The tendency of people living with HIV to 'self stigmatise' had also decreased, as contact with not only health professionals but also with other people living with HIV helped them see that they were not alone. On the other hand, 'fear based stigma' was found to have increased. Those studied were concerned that because it was now difficult to differentiate between people infected with HIV, and those who are not, HIV transmission would increase as they would no longer know to "avoid those who 'look ill'".8 The fact that stigma remains in developed countries such as America, where treatment has been widely available for over a decade, also indicates that the relationship between HIV treatment and stigma is not straightforward. An estimated 27 percent of Americans would prefer not to work closely with a woman living with HIV9 . Moreover, preliminary results from the People Living with HIV Stigma Index found that 17 percent of respondents living with HIV in the UK had been denied health care and that verbal harassment or assault had been experienced by 21 percent of respondents.10 11 Stigma may also vary depending on the dominant transmission routes in the country or region. In sub-Saharan Africa, for example, heterosexual sex is the main route of infection, which means that AIDS-related stigma in this region is mainly focused on promiscuity and sex work. "Because it is about sex, in my country they then automatically think you got it because you have been looseyou are not anything better than a prostitute they dont believe you didnt get it any other way.African woman in the UK12 This womans experience reveals the multi-layered nature of stigma. Within her quote she reveals being stigmatised but perhaps unknowingly accepting of the stigma against infected sex workers.

In Western countries where injecting drug use and sex between men have been the most common sources of infection, it is these behaviours that are highly stigmatised. Women with HIV or AIDS may be treated very differently from men in some societies where they are economically, culturally and socially disadvantaged. They are sometimes mistakenly perceived to be the main transmitters of sexually transmitted diseases (STDs). Men are more likely than women to be 'excused' for the behaviour that resulted in their infection. "Even a married woman who has been infected by her husband will be accused by her in-laws In such a male-dominated society no-one ever accepts that the man is actually the one who did something wrong It is even harder on women since it is seen as a fair result of their sexual misbehaviour."HIV-positive woman, Lebanon13

back to top The effects of stigma

"The epidemic of fear, stigmatization and discrimination has undermined the ability of individuals, families and societies to protect themselves and provide support and reassurance to those affected. This hinders, in no small way, efforts at stemming the epidemic. It complicates decisions about testing, disclosure of status, and ability to negotiate prevention behaviours, including use of family planning services."14 AIDS-related stigma has had a profound effect on the epidemics course. The WHO cites fear of stigma and discrimination as the main reason why people are reluctant to be tested, to disclose their HIV status or to take antiretroviral drugs.15 One study found that participants who reported high levels of stigma were more than four times more likely to report poor access to care.16 These factors all contribute to the expansion of the epidemic (as a reluctance to determine HIV status or to discuss or practice safe sex means that people are more likely to infect others) and a higher number of AIDS-related deaths. An unwillingness to take an HIV test means that more people are diagnosed late, when the virus has already progressed to AIDS, making treatment less effective and causing early death.

Activists protest against HIV-related discrimination, India

Research by the International Centre for Research on Women (ICRW)17 found the possible consequences of HIV-related stigma to be:

Loss of income/livelihood Loss of marriage & childbearing options Poor care within the health sector Withdrawal of caregiving in the home Loss of hope & feelings of worthlessness Loss of reputation

Some of these consequences refer to internal stigma or self-stigma. Internal stigma refers to how people living with HIV regard themselves, as well as how they see public perception of people living with HIV. Stigmatising beliefs and actions may be imposed by people living with HIV themselves: "I am afraid of giving my disease to my family membersespecially my youngest brother who is so small. It would be so pitiful if he got the disease. I am aware that I have the disease so I do not touch himI talk with him only. I dont hold him in my arms now." Woman in Vietnam18 Self-stigma and fear of a negative community reaction can hinder efforts to address the AIDS epidemic by perpetuating the wall of silence and shame surrounding the epidemic. Stigma also worsens problems faced by children orphaned by AIDS. AIDS orphans may encounter hostility from their extended families and community, and may be rejected, denied access to schooling and health care, and left to fend for themselves.

back to top Types of HIV/AIDS-related stigma and discrimination

AIDS-related stigma can lead to discrimination such as negative treatment and denied opportunities on the basis of their HIV status. This discrimination can affect all aspects of a person's daily life, for example, when they wish to travel, use healthcare facilities or seek employment.

Government
A countrys laws, rules and policies regarding HIV can have a significant effect on the lives of people living with the virus. Discriminatory practices can alienate and exclude people living with HIV, reinforcing the stigma surrounding HIV and AIDS. In 2010, UNAIDS reported that 71 percent of countries now have some form of legislation in place to protect people living with HIV from discrimination19 . However, Ban Ki-moon, Secretary-General of the United Nations, believes that "almost all permit at least some form of discrimination".20

There are many ways that governments can actively discriminate against people or communities with (or suspected of having) HIV/AIDS. Many of these laws have been justified on the grounds that HIV/AIDS poses a public health risk. Below are some examples of government level stigma and discrimination against people living with HIV/AIDS:

President Museveni of Uganda supports the national policy of dismissing or not promoting members of the armed forces who test HIV positive.21 The Chinese government advocates compulsory HIV testing for any Chinese citizen who has been living outside of the country for more than a year.22 The UK legal system can prosecute individuals who pass the virus to somebody else, even if they did so without intent.

Healthcare
In healthcare settings people with HIV can experience stigma and discrimination such as being refused medicines or access to facilities, receiving HIV testing without consent, and a lack of confidentiality. Such responses are often fuelled by ignorance of HIV transmission routes amongst doctors, midwives, nurses and hospital staff.23 ...they covered the chair, the light, the doctors were wearing three pairs of gloves... Lack of confidentiality has been repeatedly mentioned as a particular problem in health care settings. Many people living with HIV/AIDS do not get to choose how, when and to whom to disclose their HIV status. Studies by the WHO in India, Indonesia, the Philippines and Thailand found that 34 percent of respondents reported breaches of confidentiality by health workers.24 Doctors in healthcare setting in resource-poor areas with limited or no drugs have reported a frustration with the lack of options for treating people with HIV/AIDS, who were seen as 'doomed' to die.25 This frustration may mean that AIDS patients are not prioritised or are actively discriminated against. Fear of exposure to HIV as a result of lack of protective equipment is another factor fuelling discrimination among doctors and nurses in under-resourced clinics and hospitals. Stigma and discrimination in healthcare settings are not confined to developing countries. Below an HIV positive woman in London, UK tells of her experience with an NHS dentist: I have a dental problem and I go to this clinic, and I go there, two maybe three times. So eventually I told them about my condition. They explained that I would have to be the last appointment of the day. I have been to that room, and sat on that chair, and the same doctor examined me as before, but after I told them I was HIV positive. So I went for the last appointment of the day last week, they covered the chair, the light, the doctors were wearing three pairs of gloves26 A review of research into tackling stigma in health care settings advocated a multi-pronged approach, requiring action on the individual, environmental and policy levels. For example, health care workers need to be made aware of the negative effect that stigma can have on the

quality of care patients receive, they should have accurate information about the risk of HIV infection (the misperception of which can lead to stigmatising actions), and they should also be encouraged to not associate HIV with immoral behaviour. Facilities should have sufficient equipment and information so health workers can carry out universal precautions and prevent exposure to HIV.27 Policies within health care settings can also be effective in reducing stigma. Such programmes would involve participatory methods like role play and group discussion, as well as training on stigma and universal precautions. The involvement of people living with HIV could lead to a greater understanding of patients needs and the negative effect of stigma.28

Employment
In the workplace, people living with HIV may suffer stigma from their co-workers and employers, such as social isolation and ridicule, or experience discriminatory practices, such as termination or refusal of employment. Fear of an employers reaction can cause a person living with HIV anxiety: "It is always in the back of your mind, if I get a job, should I tell my employer about my HIV status? There is a fear of how they will react to it. It may cost you your job, it may make you so uncomfortable it changes relationships. Yet you would want to be able to explain about why you are absent, and going to the doctors.HIV positive woman UK29 Though we do not have a policy so far, I can say that if at the time of recruitment there is a person with HIV, I will not take him. I'll certainly not buy a problem for the company. I see recruitment as a buying-selling relationship. If I don't find the product attractive, I'll not buy it.A Head of Human Resource Development, India30 In December 2010, the International Labour Organisation (ILO) and Chinas Centre for Disease Control and Prevention (CDC) issued a joint report entitled HIV and AIDS Related Employment Discrimination in China. It noted that the national policy for recruiting civil servants species that: those who suffer gonorrhoea, syphilis, chanchroid, venereal lympho-granuloma, HPV, genital herpes or HIV will be disqualied.31 Rulian Wu from the ILO commentated: If the government discriminates against people with HIV, then other sectors will follow, for example, if you apply to be a teacher in the local area.32 Whilst Chinese teachers are not civil servants, recruitment policies are usually based upon those of the Chinese civil service. In addition, the report notes that national sanitation guidelines prevent people living with HIV and AIDS from working in 'public places' and documents instances of mandatory HIV testing. All of these activities are in breach of the ILO Code of Practice on HIV/AIDS, to which China is a signatory.33

Restrictions on travel and stay

Many countries have laws that restrict the entry, stay and residence of people living with HIV.

As of December 2010, people living with HIV were subject to restrictions during long-term stays (more than 90 days) in sixty-five countries and of these, 18 also applied restrictions during shortterm stays.34 Restrictions for short-term stays include the need to disclose HIV status or to be subject to a mandatory HIV test. It is reported that around thirty countries including Egypt, Russia, and Singapore deported foreigners based on their positive status alone.35 Some countries have policies that could violate confidentiality of status if, for example, a stamp is required on a waiver or passport in order to gain entry or stay. Students living with HIV are barred from applying to study in certain countries including Malaysia and Syria. Until the 4th of January 2010 the United States restricted all HIV positive people from entering the country, whether they were on holiday or visiting on a longer-term basis.36 A database maintained by the German AIDS Federation, the European AIDS Treatment Group and the International AIDS Society, presents updated information on such travel restrictions (if there are any) in 196 countries: www.hivtravel.org. Deportation of people living with HIV has potentially life threatening consequences if they have been taking HIV treatment. If they are deported to a country that has limited treatment provision, this could lead to drug resistance and death. Alternatively, people living with HIV may face deportation to a country where they would be subject to even further discrimination - a practice which could contravene international law.37

Community

A mural in Ghana challenging HIV-related stigma Community level stigma and discrimination towards people living with HIV is found all over the world. A communitys reaction to somebody living with HIV can have a huge effect on that persons life. If the reaction is hostile a person may be discriminated against and may be forced to leave their home, or change their daily activities such as shopping, socialising or schooling.

"At first relations with the local school were wonderful and Michael thrived there. Only the head teacher and Michael's personal class assistant knew of his illness Then someone broke the confidentiality and told a parent that Michael had AIDS. That parent, of course, told all the others. This caused such panic and hostility that we were forced to move out of the area. Michael was no longer welcome at the school. Other children were not allowed to play with him - instead they jeered and taunted him cruelly. One day a local mother started screaming at us to keep him away from her children and shouting that he should have been put down at birth. Ignorance about HIV means that people are frightened. And frightened people do not behave rationally. We could well be driven out of our home yet again.British woman describing the experience of her foster son in a British school38 Community-level stigma and discrimination can manifest as ostracism, rejection and verbal and physical abuse. It has even extended to murder. AIDS related murders have been reported in countries as diverse as Brazil, Colombia, Ethiopia, India, South Africa and Thailand. In December 1998, Gugu Dhlamini was stoned and beaten to death by neighbours in her township near Durban, South Africa, after speaking openly on World AIDS Day about her HIV status.39 It is therefore not surprising that 79 percent of people living with HIV who participated in a global study, feared social discrimination following their status disclosure.40

Family
In the majority of developing countries families are the primary caregivers when somebody falls ill. There is clear evidence that families play an important role in providing support and care for people living with HIV and AIDS. However, not all family responses are supportive. HIV positive members of the family can find themselves stigmatised and discriminated against within the home. There is concern that women and non-heterosexual family members are more likely than children and men to be mistreated. When I was in hospital, my father came once. Then he shouted that I had AIDS. Everyone could hear. He said: this is AIDS, shes a victim. With my brother and his wife I wasnt allowed to eat from the same plates, I got a plastic cup and plates and I had to sleep in the kitchen. I was not even allowed to play with the kids.HIV-positive woman, Zimbabwe41 A Dutch survey of people living with HIV found that stigma in family settings - in particular avoidance, exaggerated kindness and being told to conceal one's status - was a significant predictor of psychological distress. This was believed to be due to the absence of unconditional love and support, which families are expected to provide.42 Furthermore, people living with HIV are often worried about losing family and friends if they disclose their status. As a global study illustrated, 35 percent of those interviewed cited this as a concern surrounding disclosure.43

back to top The way forward

A video about people living with HIV/AIDS in Egypt. HIV-related stigma and discrimination severely hamper efforts to effectively fight the HIV and AIDS epidemic. Fear of discrimination often prevents people from seeking treatment for AIDS or from admitting their HIV status publicly. People with (or suspected of having) HIV may be turned away from healthcare services and employment, or refused entry to a foreign country. In some cases, they may be forced from home by their families and rejected by their friends and colleagues. The stigma attached to HIV/AIDS can extend to the next generation, placing an emotional burden on those left behind. Denial goes hand in hand with discrimination, with many people continuing to deny that HIV exists in their communities. Today, HIV/AIDS threatens the welfare and wellbeing of people throughout the world. At the end of the 2009, 33.3 million people were living with HIV with 1.8 million died from an AIDS-related illness that year.44 Combating stigma and discrimination against people who are affected by HIV/AIDS is vital to preventing and controlling the global epidemic. So how can progress be made in overcoming this stigma and discrimination? How can we change people's attitudes to AIDS? A certain amount can be achieved through the legal process. In some countries people living with HIV lack knowledge of their rights in society. In this case, education is needed so they are able to challenge the discrimination, stigma and denial that they encounter. Institutional and other monitoring mechanisms can enforce the rights of people with HIV and provide powerful means of mitigating the worst effects of discrimination and stigma. "We can fight stigma. Enlightened laws and policies are key. But it begins with openness, the courage to speak out. Schools should teach respect and understanding. Religious leaders should preach tolerance. The media should condemn prejudice and use its influence to advance social change, from securing legal protections to ensuring access to health care."Ban Ki-moon, Secretary-General of the United Nations45 However, no policy or law can alone combat HIV/AIDS related discrimination. Stigma and discrimination will continue to exist so long as societies as a whole have a poor understanding of HIV and AIDS and the pain and suffering caused by negative attitudes and discriminatory practices. The fear and prejudice that lie at the core of the HIV/AIDS-related discrimination need to be tackled at the community and national levels, with AIDS education playing a crucial role. A more enabling environment needs to be created to increase the visibility of people with

HIV/AIDS as a 'normal' part of any society. The presence of treatment can make this task easier; where there is the opportunity to live a fulfilling and long life with HIV, people are less afraid of AIDS; they are more willing to be tested for HIV, to disclose their status, and to seek care if necessary. The task is to confront the fear-based messages and biased social attitudes, in order to reduce the discrimination and stigma of people living with HIV and AIDS.