Assessing stigma and perceptions of respectful care in Malawi’s index case testing program: Findings from a cluster randomized controlled trial

BACKGROUND: Healthcare worker (HCW) HIV-related stigma can reduce participation in HIV prevention services in Malawi, including HIV index testing. However, evidence on interventions to reduce HCW stigma and improve client experiences of care in index testing settings remains limited. We evaluated HCW stigmatizing attitudes and also assessed anticipated stigma and perceptions of respectful care among both people living with HIV (index clients) and their sexual partners (contact clients) in index testing settings. METHODS: We conducted a cluster randomized controlled trial across 33 clusters providing index case testing in southeastern Malawi. All HCWs received standard, in-person training. Enhanced cluster HCWs additionally received the blended learning training package consisting of tablet-based modules and in-person sessions incorporating stigma-reduction content. HCW stigmatizing attitudes were evaluated one-month (wave 1) and one-year post-training (wave 2). A subset of index and contact clients completed anticipated stigma and respectful care scales at exit interviews. Scales ranged from 0-3 (HCW stigma), 0-1 (anticipated stigma), and 1-5 (respectful care), with higher scores reflecting more stigma or respectful care. Generalized estimating equations with an identity link and gamma distribution estimated adjusted mean differences between arms. RESULTS: We enrolled 305 HCWs, 341 index clients, and 194 contact clients. Overall stigma levels were low and respectful care ratings were high across arms. Mean HCW stigma scores were 0.8 (wave 1) and 0.7 (wave 2); adjusted mean differences between arms were -0.1 (p = 0.3) at wave 1 and 0.0 (p = 1.0) at wave 2. Index and contact client anticipated stigma means were both 0.1; adjusted mean differences between arms were 0.0 (p = 0.9) for index and 0.0 (p = 0.7) for contact clients. Respectful care means were 4.0 for index and 4.2 for contact clients; adjusted mean differences between arms were 0.0 (p = 0.9) for index and -0.1 (p = 0.3) for contact clients. CONCLUSIONS: The enhanced training package did not improve HCW or client stigma-related outcomes. Further research is needed to reduce HCW and client stigma and improve respectful care.