be strengthened considerably. Referring to health-related stigma in developing countries in general, the Fogarty International Center of the National Institutes of Health (NIH) has written: “Little is known about the pervasiveness of stigma in the developing world and how healthcare systems can tackle its negative consequences. Effective action has been slow in coming, in part because of the continuing gaps in knowledge” (NIH, 2003). In recognition of this lack of knowledge, in 2002 NIH launched a Stigma and Global Health Research Program. The first 19 awards under the program were announced in October 2003; expected 5-year funding for the program is approximately $16.5 million (NIH, 2003). The NIH grant recipients will establish a global network of researchers to “develop the field of stigma and global health research by testing hypotheses and generating data on the etiology of stigma and effective interventions for its negative effects on health” (NIH, 2003). The network will help identify best practices, opportunities, and obstacles in research on stigma related to global health. Through the studies conducted by this network and others, culture-specific interventions to reduce stigma, perhaps tailored to different demographic groups, should be tried and evaluated.

In June 2001, the United Nations General Assembly Special Session on HIV/AIDS issued a Declaration on Commitment on HIV/AIDS. This declaration included a provision for UN Member States to “develop strategies to combat stigma and social exclusion connected with the epidemic” and “enact, strengthen or enforce, as appropriate, legislation, regulations and other measures to eliminate all forms of discrimination against . . . people living with HIV/AIDS…” (UNAIDS, 2003a). According to a UNAIDS report in 2003, almost half of all African countries had adopted no legislation to prevent discrimination against people living with HIV/AIDS (UNAIDS, 2003b).

Recommendation 4-1. Governmental and community leaders at all levels of civic life should spearhead an effort to create a culture of openness and support in order to eliminate stigma and ensure the successful continuance of antiretroviral treatment and HIV prevention programs.

IDENTIFYING POINTS OF ENTRY

Identifying persons in immediate need of treatment provides one challenge for the efficient and effective scale-up of ART. As noted earlier, there are multiple possible points of entry for treatment programs, each of which may target different sectors of the population and initially identify infected persons at different stages of the disease.

Early detection and counseling to prevent subsequent transmission, with regular follow-up, are desirable even though patients initially entering



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