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

In 30 seconds

This cluster randomized controlled trial assessed whether enhanced stigma-reduction training improved healthcare worker (HCW) attitudes and client experiences in Malawi’s HIV index case testing program. Across 33 clusters in southeastern Malawi, all HCWs received standard training, while enhanced clusters also received tablet-based and in-person learning. The study enrolled 305 HCWs, 341 people living with HIV, and 194 sexual partners. Stigma was low and respectful-care ratings were high in both arms; adjusted differences showed no improvement with enhanced training, including an HCW stigma difference of -0.1 at one month (p = 0.3) and 0.0 at one year (p = 1.0).

Key findings

• Mean HCW stigma scores were 0.8 at one month and 0.7 at one year; adjusted between-arm differences were -0.1 (p = 0.3) and 0.0 (p = 1.0), respectively.
• Anticipated stigma means were 0.1 for both index and contact clients, with adjusted between-arm differences of 0.0 (p = 0.9 and p = 0.7, respectively).
• Respectful-care means were 4.0 for index clients and 4.2 for contact clients; adjusted between-arm differences were 0.0 (p = 0.9) and -0.1 (p = 0.3), respectively.

Why it matters

Stigma and perceptions of respectful care can affect participation in HIV prevention services. In this trial, enhanced training did not improve measured HCW or client stigma-related outcomes, despite generally low stigma and high care ratings. The findings highlight the need to evaluate approaches that address stigma and client experience in index testing, while interpreting the absence of observed benefit in the context of the low baseline levels reported.

What to keep in mind

Stigma was low and respectful-care ratings were high across arms, which may limit the ability to detect improvement. Client outcomes were assessed in a subset through exit interviews.