Introduction
Stigma, and the discrimination that flows naturally from it, collectively are major barriers to public health action against the HIV/AIDS epidemic in the Caribbean, as indeed many places globally.
This is because the phenomenon of stigma and discrimination is pervasive in its impact on the continuum of action – from primary prevention to testing to care, treatment and support of both those infected and affected by the virus. And HIV/AIDS itself is also so pervasive that it could be said that ALL people are in fact living with HIV/AIDS.

The campaign, having identified with the pain stigma and discrimination inflicts, seeks a change from the cruelty of rejection to a greater sense of acceptance and tolerance. Therefore it appeals for this type of behaviour change, not only on the part of people at the general community level, but also, more specifically, to health care workers and the private sector. Further, there are products aimed specifically at People Living with HIV/AIDS dealing with such issues as Human Rights and Living with HIV.

To all audiences the campaign advises that stigma and discrimination does not protect against HIV. Rather it hurts. In reinforcing this message, the campaign also puts a human face to some of these targetted groups. They include the HIV infecte d person who is demoralised by isolation and rejection; the young person who must harbour living with HIV as a dark secret in order to develop or maintain a relationship; the doctor, nurse and other health care provider whose professional environment, instead of being a font Condom Use or Abstinence can Protect.

The Target Audience
The campaign is targeted primarily at Health Care Providers, People Living with HIV/AIDS (PLWA), the general public, and subsets of it. Since efforts to reduce stigma and discrimination will have a positive effect on their respective environments, other vulnerable groups such as Men who Have Sex with Men (MSM) and Sex Workers (SWs) would be secondary beneficiaries of the campaign.

Specific Action/Behaviours
Overall, therefore, the campaign seeks to get people to think differently about people living with HIV/AIDS, invite introspection, widen debate on the issue, help the audience to internalise messages and overcome fears and prejudices and, ultimately, minimise stigma and discrimination against persons living with HIV and AIDS. The call for action is for the individuals to use condoms or abstain to protect themselves

Key Theme:
Our natural, instinctive reaction to pain is: OUCH! The pain that Stigma and Discrimination causes could be far worse than the infection itself. Simply put then, stigma hurts. Discrimination hurts. Consequently, we are all hurt. As important, though, is the notion that individuals must take personal responsibility for protecting themselves, rather than discriminating against PWAs.

All of this then is at the heart of CAREC’s campaign against stigma and
discrimination. And the adoption of a theme rooted in the natural vocal human reflex to pain, OUCH IT HURTS, is meant to capture the impact of stigma and discrimination. But Discrimination Does Not Protect against HIV.

The communication objective is to get the target audiences to accept that Stigma and Discrimination can hurt them and their loved ones personally – in addition to People Living with HIV/AIDS and people from other vulnerable groups.

Rationale:
The phenomenon of Stigma and Discrimination as a major barrier everywhere:
· demoralises and dehumanises people living with HIV and AIDS.
· Creates isolation and ostracism.
· Robs people of their basic human rights
· Stimulates fear.
· Prevents people from using condoms for fear of arousing suspicion
· Forces some people to display heterosexual behaviour publicly, while
privately engaging in homosexual behaviour, and in this scenario, condom
use is often absent or sporadic at best.

Additional impacts include:
· A lack of compassion for persons living with HIV and AIDS
· The fear of ostracism felt by HIV positive persons, which often results in
non-disclosure and denial of their health status.
· The public health impact and implications of stigma and discrimination
driving people underground, thus reducing the reach of care, treatment and
prevention programmes. This in turn is reflected by underreporting in
Surveillance data, compromising planning efforts when public health
authorities are unable to estimate the true burden of the epidemic.

The Messages
The messages address problems of HIV/AIDS related stigma and the ways and situations in which stigma and discrimination are manifested. They also focus on the factors that contribute to low knowledge, negative attitudes, intention and behaviour. It is on this basis that the following key issues have been identified:

· Insensitivity to the realities of stigma and discrimination
· Impact of stigma and discrimination on the HIV/AIDS epidemic – connection between stigma and discrimination and public health
· Stigma and discrimination as a human rights issue
· Attitudes of health care workers in the delivery of care and treatment of
persons living with HIV and AIDS
· insufficient knowledge of rights by persons living with HIV and AIDS and the implications for self-stigma
· Stigma and discrimination as manifested in the workplace
· Prejudices which lead to stigma by association
· The perception that early death is the only likely outcome of HIV/AIDS
· Lack of commitment at the highest levels (political, corporate and labour)
nationally
· The need for increased community involvement
· The need to promote testing and counselling as an effective prevention
strategy

The campaign is also intended to be a guide for countries who are encouraged to use the material as templates which can be replicated to develop national versions. Additionally, although the campaign is regional in its approach from the CAREC end, we encourage countries to use their relationships with the mass media to promote transmission/publication of the radio, television and print materials free of cost or at   reduced/subsidised rates.

The Campaign Reach
There are specific messages/products to reach:
· Health care workers
· People Living with HIV and AIDS (PLWHA)
· The general community
· Family/Caregivers of PLWHA
· NGOs; Faith-based communities; Service Organisations
· Business sector/Employers /Insurance Sector
· Labour Unions/ Workers
· Government leaders and Policy makers

HOW TO USE THE COMMUNICATION PRODUCTS
The campaign seeks to exploit the power of the mass media to reach a wide and varied audience. It also acknowledges the more powerful role of interpersonal intervention to bring about health behaviour change. Consequently, we have produced a comprehensive and varied package.

There are products specifically for mass media (radio, television, and the print media) in the form of radio and television spots and print ads, as well as complementary print products in the form of booklets, a cartoon, leaflet,
booklets, posters, and print ads.

The complementary print products are designed for placement and use in
environments where health care is provided and where PLWHA access
HIV/AIDS related services, and in the mass communication media. We
recommend that the materials be used as well to support a range of
interpersonal communication activities in various settings, for example, in
sensitisation sessions with various groups such as Chambers of Industry and Commerce, Employers Associations and Trade Unions, Church Leaders and Non-Government Organisations.

Television
Three spots are available:

Radio
Two spots are available:

Spot #1 (Duration 30 secs) Download Spot #1
This spot identifies the consequences of fear and ignorance about HIV, and corrects some commonly held beliefs (myths) about how HIV and AIDS can be transmitted.

Spot #2 (Duration 30 secs) Download Spot #2
This spot targets the prospective employer and pointedly seeks to find out whether, despite success and lofty ideals, he would employ someone who is living with HIV.

Press Ads

Four press ads are available , covering issues that fuel rejection and isolation of PLWHA.

Press Ad #1: FEAR appeals against using fear of contracting HIV to reject and discriminate against infected persons.

Press Ad #2 : KNOWLEDGE promotes the value of knowing how HIV/AIDS is transmitted as a prerequisite for protecting one’s self against infection rather than as a reason to stigmatise and discriminate against persons living with HIV/AIDS.

Press Ad #3 deals specifically with HIV STIGMA as one of the main reasons why people are reluctant to get tested, leading to the possibility of infected persons, with no knowledge of their HIV status, having unprotected
sexual relationships.

Press Ad #4 highlights the impact of DISCRIMINATION against PLWHA in the work place, and appeals for understanding by people in the business
environment that HIV positive persons can and do lead long and productive
lives – with our support.

Posters: (Size: 24 inches by 18 inches)

Horizontal Layout
Eight posters have been developed: four Horizontal, and four Vertical ones.
The posters address: PLWHA rights; Confidentiality; Condom Use or Abstinence are recommended as protection, rather than discriminating against PLWHA;

Poster One
promotes confidentiality as the right of the HIV positive person and the duty of the health care worker in the provision of services to persons living with HIV/AIDS

Poster Two
pledges health care professionals to uphold the right of the person living with HIV/AIDS to confidentiality and to proper treatment.

Poster Three
again pledges confidentiality among health care workers for persons living with HIV/AIDS, this time embracing the concept of the providers working as a team to protect the rights of the HIV positive patient.

Poster Four
targets general audiences, advocating condom use or abstinence or safer sex as protection against HIV rather than stigma and discrimination against people living with HIV/AIDS.

Posters: (Size: 18 inches by 24 inches)

Vertical Layout

Poster One

The signature poster introduces to general audiences the OUCH Motif and the key message behind the campaign:

DISCRMINATION DOES NOT PROTECT AGAINST HIV – IT HURTS.

Poster Two

Targets health care workers and does some soul searching on whether they
regard their surgical gear as UNIVERSAL PRECAUTION, or use it as a form of
DISCRIMINATION against HIV positive patients. An additional benefit would be for PLWHA themselves to recognise that when Health Care Providers use masks and gloves, they do so to protect their patients as well.

Poster Three and Four target people in the workplace, placing HIV positive persons in various
settings and with a call for support so that PLWHA can access medication to live long and
productive lives.

Cartoon Booklet [pdf] (20 pages)
This publication highlights a wide range of issues including risk of transmission, the need for us to be supportive of PLWHA, and some of the absurdities of stigmatisation. These messages are backed by a call to all individuals to protect themselves either through condom use or abstinence because Stigma and Discrimination does not protect against HIV.

The “OUCH” Leaflet
This leaflet is for distribution to general audiences. It puts stigma and discrimination into its true perspective. It addresses the roots and outlines what is meant by HIV stigma and give concrete examples of discrimination. It reinforces the messages that stigma and discrimination hurts and could also lead to further spread of HIV.

The “RIGHTS” Booklet [pdf] (16 pages)
This is a personal booklet that People Living with HIV and AIDS can use as a tool for advocating that they be active in their own cause. It treats with a wide range of issues and behaviours pertaining to living positively with HIV/AIDS, including advice on skills to cope with infection. It also outlines fundamental rights of the HIV positive person to work, to confidentiality and to quality health care services.

Sensitisation Booklet [pdf] (20 Pages)
This publication provides a number of stories for a clearer understanding of HIV - related Stigma and Discrimination and could well serve to support counselling on each item discussed. The stories speak to such issues as fear and denial, an HIV positive diagnosis, HIV and the family, Gossip, HIV and homosexuality, and HIV and the Workplace.

The Ouch! T-Shirt
An attractive hook for our campaign. The Ouch! motif is powerfully displayed in Red on a Black T-Shirt.

The Ouch Pouch!
A few years ago, CAREC-SPSTI introduced the message pouch for carnivals and festivals, filled with condoms and HIV prevention literature. This item has now become popular among both men and women in many countries of the region, not only as a public health education vehicle, but to carry money, passports and other important documents as well. Its primary use is for hanging around the shoulder/neck, particularly during major outdoor events
RECOMMENDED USAGE AND APPROACH

Radio and Television Spots and Print Ads
The public service vehicles, primarily for mass media placement, could be
economically booked through partnerships with the media establishment
themselves and through sponsorship from private sector partnerships. National AIDS Programmes and planners are advised, therefore, to deepen their relationships to secure mass dissemination at no or relatively low cost.

All materials
All the products are intended to complement and support interpersonal, small group and community interventions – in addition to mass media usage.
Because stigma is often – but not always - based on ignorance, fear, and personal values, it is important that these interventions be directed at providing opportunities for stimulating interaction and discussion between PLWA and the wider community. We recommend, therefore, that the products be used as triggers for dialogue and action.

The opportunities should be facilitated by the following:

Partnering with radio and television or seeking private sector sponsorships for the production of talk shows, features, documentaries and other electronic media format for discussion of issues related to stigma and discrimination.

· Contributing to or encouraging special articles especially in the value-added sections of newspapers, magazines, e-zines, websites, newsletters etc for more in-depth treatment as against news coverage of stigma and discrimination issues. The latter, of course, should not be ruled out.

Piggy backing on, or creating special functions and events at the level of government, private sector and non-government organisations including service clubs etc that can bring together such primary groups including health care providers, community leaders, professional organisations, and People Living with HIV/AIDS. etc

In all of these, we recommend the following approach:

The focus should not be merely on vulnerable groups. This in itself could foster discrimination. The discussions should emphasise that everyone is at risk.
The emphasis should also be on risk behaviour and not on risk groups, themselves which again can reinforce negative attitudes against people, whereas risky behaviour could be attributable to all groups.

· The discussion must return to some of the basics of HIV/AIDS/STI prevention and control including modes and the science of transmission, testing, counselling, condom use etc.
· Efforts should be made to provide in-depth information on the determinants of stigma and discrimination, including how certain select groups that are vital to the mitigation process either unwittingly or deliberately engage in acts that discriminate against persons living with HIV/AIDS.
· Because a major consequence of stigma and discrimination is the erosion of the rights of persons living with HIV/AIDS, human rights and advocacy for those rights should be emphasised in the dialogue.
· People Living with HIV/AIDS must be very prominent in the entire approach and be presented as people who can be very productive and can survive for many years once given the chance and provided with the kind of supportive environment that enables them to live as normal a life as
possible.

MONITORING
We recommend use of a simple monitoring tool to track dissemination and use of the materials, by target population. We have provided a sample tool below for adaptation. Some countries/organisations might wish to apply a monitoring tool that they already use regularly in their programme.

MONITORING THE “OUCH” CAMPAIGN

FEEDBACK AVAILABILITY
This entire brief, including copies of the material, will be placed on the

CAREC websites at:

http://www.carec.org
http:// www.catin.org

For further information, kindly contact:
Ms Cheryl O’Neil at oneilche@carec.paho.org;
Ms Agnes Thomas at thomasag@carec.paho.org