In mid-January, in a sparsely populated corner of northern Ghana, I met a 13-year-old girl named Hannah. I asked her about her responsibilities at home and her studies and how she imagined her future. Her response was quick. She said she would like to become a nurse. When I asked why, her answer was as prompt. She explained that a few months previously she had been sick and taken to a health clinic. The nurses there, she said, did not have a good attitude towards patients. She wanted to change that. There are many reasons why the patient care Hannah experienced might have been less than optimal. While Ghana has invested significantly in increasing the number of nurses and midwives and exceeds the WHO’s recommended nurse to population ratio, many challenges to ensuring quality care remain, including the training and mentoring of newly trained nurses [1]. Another challenge is stigma and discrimination. Stigma and discrimination may be due to multiple factors, but centres on the identification of an “other” and their devaluation. Stigma may be based on expectations of roles in society (e.g. racism), cultural norms (e.g. homophobia) and/or fears of contagion (avoidance of infectious diseases). In the case of HIV, stigma and discrimination may have multifactorial causes and expressions. Stigma and discrimination have been much discussed in the HIV response, as well in public health interventions seeking to expand access to sexual and reproductive health and mental health services. Nonetheless, they remain a persistent obstacle to achieving the goal of universal health coverage and “leaving no one behind”. People living with HIV experience a range of stigmatizing experiences and discrimination within society, from social isolation to violence to denial of housing, employment and healthcare. They may also face police harassment or arrest in contexts where HIV transmission or specific behaviours are criminalized, and often confront intersecting stigma and discrimination due to other health conditions or identities, including gender, disability, race/ethnicity and sexuality. Recognizing this, in 2014 the United Nations selected 1 March as Zero Discrimination Day. Admittedly, while governments worldwide have an obligation to eliminate all forms of discrimination stemming from their ratification of human rights treaties as well as constitutional protections and laws, achieving zero discrimination is a tough task. More narrowly, increasing focus has been put on ending discrimination in health settings. The 2016 United Nations Political Declaration on Ending AIDS called on member nations to commit to eliminating stigma and discrimination in healthcare settings [2]. Following this pledge, the Global Partnership for Action to Eliminate All Forms of HIV-Related Stigma and Discrimination was formed with the participation of the United Nations Development Programme (UNDP), the United Nations Entity for Gender Equality and the Empowerment of Women (UN Women), the Global Network of People Living with HIV (GNP+), the Joint UN Programme on HIV/AIDS (UNAIDS) and non-governmental partners [3]. The Global Fund’s Breaking Down Barriers Initiative has also targeted discrimination, funding interventions on stigma and discrimination reduction, training for healthcare providers on human rights and medical ethics, sensitization of law-makers and law enforcement agents, as well as legal literacy, legal services, and law reform [4], interventions identified by UNAIDS as essential for every national AIDS response [5]. A recent review found evidence of the impact of these types of human rights programmes (singly and combined) on HIV-related outcomes for people living with HIV and key and vulnerable populations most at risk of HIV, ranging from decreased HIV risk behaviours to increased HIV testing to reduced incidence [6]. The review examined research published between 2003 and 2015, but evidence of the positive impact of similar interventions both prior to and after these dates have also been published; for example, focusing on the training of health workers to reduce stigma [7–12] and programmes promoting legal literacy and advocacy [13,14]. Advocacy targeting discriminatory laws, policies and practices have also been shown to be effective to removing barriers to HIV services [15], while evidence of the effectiveness of sensitizing law enforcement is increasing [16]. Amon JJ Journal of the International AIDS Society 2020, 23:e25471 http://onlinelibrary.wiley.com/doi/10.1002/jia2.25471/full | https://doi.org/10.1002/jia2.25471

中文翻译：

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结束医疗保健领域的歧视


一月中旬，在加纳北部一个人烟稀少的角落，我遇到了一个名叫汉娜的13岁女孩。我问她在家里的责任和学业以及她对未来的设想。她的反应很快。她说她想成为一名护士。当我问为什么时，她的回答同样迅速。她解释说，几个月前她生病了，被送往一家诊所。她说，那里的护士对病人的态度不好。她想改变这一点。汉娜所经历的患者护理未能达到最佳状态的原因有很多。尽管加纳在增加护士和助产士数量方面投入了大量资金，并且超过了世界卫生组织建议的护士与人口比例，但确保优质护理仍然存在许多挑战，包括对新培训护士的培训和指导[1]。另一个挑战是耻辱和歧视。耻辱和歧视可能是由多种因素造成的，但主要集中在对“他人”的认同及其贬低上。耻辱可能基于对社会角色的期望（例如种族主义）、文化规范（例如恐同）和/或对传染的恐惧（避免传染病）。就艾滋病毒而言，耻辱和歧视可能有多种原因和表现形式。在艾滋病毒应对措施以及寻求扩大获得性健康和生殖健康以及心理健康服务的公共卫生干预措施中，耻辱和歧视已得到广泛讨论。尽管如此，它们仍然是实现全民健康覆盖和“不让任何人掉队”目标的持续障碍。 艾滋病毒感染者在社会上经历了一系列耻辱经历和歧视，从社会孤立到暴力，再到被剥夺住房、就业和医疗保健。在艾滋病毒传播或特定行为被定罪的情况下，他们还可能面临警察的骚扰或逮捕，并且经常因其他健康状况或身份（包括性别、残疾、种族/民族和性取向）而面临交叉的耻辱和歧视。认识到这一点，联合国于 2014 年选定 3 月 1 日为“零歧视日”。诚然，虽然世界各国政府有义务消除因批准人权条约以及宪法保护和法律而产生的一切形式的歧视，但实现零歧视是一项艰巨的任务。更狭义地说，人们越来越关注消除卫生环境中的歧视。 2016 年《联合国终止艾滋病政治宣言》呼吁成员国致力于消除医疗保健环境中的耻辱和歧视 [2]。根据这一承诺，在联合国开发计划署（UNDP）、联合国促进性别平等和增强妇女权能署（联合国妇女署）的参与下，成立了“消除一切形式艾滋病毒相关耻辱和歧视全球行动伙伴关系”。 ）、全球艾滋病毒感染者网络 (GNP+)、联合国艾滋病毒/艾滋病联合规划署 (UNAIDS) 和非政府合作伙伴 [3]。 全球基金的“打破障碍倡议”还针对歧视，资助针对耻辱和减少歧视的干预措施，对医疗保健提供者进行人权和医学道德培训，提高立法者和执法人员的认识，以及法律素养、法律服务、和法律改革 [4]，联合国艾滋病规划署确定干预措施对每个国家的艾滋病应对措施至关重要 [5]。最近的一项审查发现，有证据表明，这些类型的人权计划（单独和组合）对艾滋病毒感染者以及最容易感染艾滋病毒的关键和弱势群体的艾滋病毒相关结果产生了影响，包括减少艾滋病毒危险行为到增加艾滋病毒进行测试以降低发病率[6]。该审查审查了 2003 年至 2015 年期间发表的研究，但在这些日期之前和之后类似​​干预措施的积极影响的证据也已发表；例如，重点关注对卫生工作者的培训以减少耻辱感[7-12]以及促进法律扫盲和宣传的计划[13,14]。针对歧视性法律、政策和做法的宣传也被证明可以有效消除艾滋病毒服务的障碍[15]，同时越来越多的证据表明提高执法意识的有效性[16]。阿蒙·JJ 国际艾滋病协会杂志 2020 年，23:e25471 http://onlinelibrary.wiley.com/doi/10.1002/jia2.25471/full | https://doi.org/10.1002/jia2。25471