We propose a four-year intervention trial that will address both individual and structural components to reduce HIV-related stigma among service providers in China. As the demand for HIV treatment and care increases rapidly, service providers in China are at a critical point with growing responsibilities to deliver adequate services and care for patients living with HIV (PLH). However, HIV-related stigma in health care setting has a tremendous impact on PLH's health outcomes, health seeking behavior, and treatment adherence. This proposed study builds on a three-year pilot study conducted from 2003 to 2006 with 1,344 among service providers in China. We have identified the need to address HIV-related stigma by building a social norm of acceptance while addressing the environmental barriers - access to universal precaution. China CDC has committed to providing universal precaution supplies to all participating hospitals for this study, including those in the standard care condition. Incorporating all core elements of the Popular Opinion Leader (POL) model, the proposed intervention will have four training sessions and bi-monthly reunion sessions. We plan to train 600 POL providers in 20 intervention hospitals. The intervention trial will proceed in two phases. In Phase 1, we will test and finalize the intervention activities, assessment measures and implementation procedures with small samples of service providers and patients from two county hospitals. We will also recruit and train staff and establish quality assurance procedures as well as data encryption and data transfer processes. In Phase 2, we will conduct a randomized controlled trial to evaluate the impact of the intervention in 40 hospitals in Yunnan and Fujian, China, with 1,760 service providers at baseline, 6 and 12-month follow-ups. We will also assess impact of the intervention on patients with three waves of cross-sectional patient surveys (n=1,000/wave). The provider outcomes are providers'attitude and behavior changes. The patient outcomes are patients'perceived stigma, medical service utilization, and satisfaction and treatment adherence. We will collect data through various approaches including self-report, behavioral observation, and using standardized patients (trained staff used to evaluate provider's performance). The number of annual reported HIV infections in China has increased steadily. The China Ministry of Health estimated the total number of PLH at 650,000 by the end of 2005. With one-fifth of the world's population, the potential devastation of a rapidly growing HIV pandemic in China is staggering, and effective measures to prevent and control the spread of HIV/AIDS in China are urgently needed. HIV-related stigma in medical settings discourages PLH from seeking care if they previously experienced unwelcoming treatment or their confidentiality was not protected. As a result, fear of discrimination has created a reluctance to deal with HIV-related matters, which threatens public health and has direct negative consequences on quality of life for PLH. The proposed study will be the first randomized controlled intervention trial that specifically targets stigma and access to universal precautions in medical settings, and is implemented at multiple sites (two provinces) in China.
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