Addressing community-level stigma toward key populations: communication insights from action research in Ghana.

Background: Global HIV response emphasises improving the uptake of HIV testing, providing access to antiretroviral therapy and sustaining viral suppression with a view to curtailing the pandemic by 2030. Stigma and discrimination impede this response by limiting engagement with the HIV continuum among sub-populations such as men who have sex with men (MSM) and female sex workers (FSW). Stigma reduction strategies that explore community-level solutions and barriers to care for these key populations are under-explored. Methods: A formative action research study was conducted in two regions of Ghana to understand community perceptions towards MSM and FSW to identify potential stigma reduction concepts. Multi-day interactive enquiries explored factors underlying stigma including rationale, personal values, perspectives on attitudinal change and related communication. Results: Rationale for stigmatisation of MSM and FSW by participants highlight religious and cultural concerns. Perceived behaviours and practices of MSM and FSW were said to undermine religious, moral and community values. Attitudes of participants towards MSM and FSW became more accepting through critical discussion that revealed contradictions within the stigma construct and discomfort with the effects of stigma. Conclusions: Participants realised that causing hurt or harm to others through stigma was not consistent with their religious and cultural values, nor how they saw themselves as people. There were four entry points that undermined the rationale for stigma: The need to know and understand 'the other', the need to be true to one's moral values, the need for empathy towards others, and recognition of the value of all people within a communal whole. These findings are relevant for engaging communities in stigma-reduction programs and improving health-seeking and adherence to care among key populations in similar African settings.

Planning to improve global health: the next decade of tuberculosis control.

The Global Plan to Stop TB 2006-2015 is a road map for policy-makers and managers of national programmes. It sets out the key actions needed to achieve the targets of the Millennium Development Goals relating to tuberculosis (TB): to halve the prevalence and deaths by 2015 relative to 1990 levels and to save 14 million lives. Developed by a broad coalition of partners, the plan presents a model approach combining interventions that can feasibly be supplied on the ground. The main areas of activity set out in the plan are: scaling up interventions to control tuberculosis; promoting the research and development of improved diagnostics, drugs and vaccines; and engaging in related activities for advocacy, communications and social mobilization. Scenarios for the planning process were developed; these looked at issues both globally and in seven epidemiological regions. The scenarios made ambitious but realistic assumptions about the pace of scale-up and implementation coverage of the activities. A mathematical model was used to estimate the impact of scaling up current interventions based on data from studies of tuberculosis biology and from experience with tuberculosis control in diverse settings. The estimated costs of the activities set out in the Global Plan were based on implementing interventions and researching and developing drugs, diagnostics and vaccines; these costs were US$ 56 billion over 10 years. When translated into cost per disability adjusted life year averted, these costs compare favourably with those of other public health interventions. This approach to planning for global tuberculosis control is a valuable example of developing plans to improve global health that has relevance for other health issues.