Gender-focused training for HIV providers reduces stigma but implementation proves challenging

“You have to take time with the patient, listen to them, all their stories and baggage…I don’t think we have that environment here. When you have a long line of clients, you aren’t going to give everyone 30 minutes [to] 1 hour listening to all their problems and challenges.”

A gender-sensitivity training programme for HIV healthcare providers in Uganda reduced stigma among clients but failed to improve treatment adherence or satisfaction with care, according to a pilot study published in PLOS Global Public Health.

The training improved providers' knowledge about how gender norms affect HIV care and helped them recognise biases against groups including sex workers, men who drink alcohol, and young women. At six months, trained providers reported increased competence in gender-sensitive care. However, these gains disappeared by 12 months, and clients at intervention clinics reported worse communication quality and lower satisfaction than those at control clinics. The one sustained benefit was a reduction in  the HIV stigma clients expected to face from others at intervention sites.

Background

Gender norms – in other words, social expectations about how men and women should behave – are major drivers of HIV transmission and barriers to care in Uganda and across sub-Saharan Africa.

For women, gender inequality limits autonomy in HIV prevention and treatment decisions, creates economic dependence on men, and increases exposure to gender-based violence, all of which raise HIV risk. For men, masculine norms around strength, self-reliance, and respect combine with HIV stigma to discourage HIV testing and engagement in care.

While community-based programmes that challenge harmful gender norms have shown success in improving HIV outcomes, less attention has been paid to training healthcare providers to deliver gender-responsive care. This is a critical gap, as providers are often the first point of contact for people starting antiretroviral treatment (ART).

Researchers led by Dr Katelyn Sileo from The University of Texas, San Antonio, pilot tested a gender-sensitivity training programme for HIV care providers and clinic staff in Uganda. The goal of the training was to increase HIV care providers’ awareness of how gender norms affect client’s engagement in HIV care, reduce their gender and related biases, build their client-centred communication skills, and build their ability to implement gender-specific and gender-transformative approaches to counselling men and women.

The intervention

Six clinics in central Uganda participated in the study; three received the training (intervention clinics) and three did not (control clinics).

The training consisted of four sessions delivered over several months to 61 healthcare staff at intervention clinics, three-quarters of whom were women. Less than half were certified healthcare workers (clinical officers, nurses, counsellors, etc.), with the remainder being lay workers and other clinic staff (peer educators, linkage facilitators, etc). On average, providers had practised in their current roles for seven years.

Session 1 introduced gender as distinct from biological sex, explaining how gender norms and roles create barriers to HIV care and contribute to disparities between men and women. Session 2 focused on recognising biases and stereotypes – related to gender, HIV status, and marginalised groups – that can undermine quality care. Session 3 reinforced existing Ministry of Health training on gender-based violence, emphasising healthcare workers' role in screening and response, while session 4 was a practical refresher where trainers observed provider-client interactions and provided individualised feedback on applying the training content.

Sessions 1-2 were delivered over two consecutive days, session 3 followed 1-2 weeks later, and session 4 was delivered three months after the initial sessions.

To gather data on outcomes for people living with HIV, the study enrolled 238 clients, 119 at intervention clinics and 119 at control clinics. Eligible clients were struggling with adherence or had recently started ART.

Both healthcare providers and clients completed questionnaires at baseline, 6 months, and 12 months. After the final assessment, 53 providers from intervention clinics (almost 90% of those trained) participated in focus groups or individual interviews.

Results

In provider surveys at six months, the intervention group showed a 4.5% improvement from baseline in gender-sensitive care competence, while the control group declined by 2%. However, by 12 months, the intervention group's score had returned close to baseline (1% improvement), similar to the control group (2% improvement).

Overall, providers who received the training showed significantly greater improvement compared to controls, with the difference significant at six months, but not at 12 months.

The effect was stronger for male providers than female providers, and for lay health workers compared to certified healthcare workers. For lay health workers, the effect was maintained at 12 months, though reduced.

Providers reported increased knowledge about how gender norms affect HIV care and greater confidence responding to gender-based violence:

“People came with GBV-related challenges and we weren’t helping them that much, but, after this training, I realised that I could help these people. They come and tell you that, ‘at home it’s like this and that. My husband beats me. I am in this situation!’ I am now able to counsel them to see that they get helped.”

Many providers (mostly women) reported increased confidence in working with men, based on improved understanding of how gender norms affect men’s communication styles. However, some providers still reinforced gender double standards.

“So, while giving services, I counsel according to the sex I am dealing with. For instance, I may tell a woman to remain faithful to one partner, which may be not easy to tell the men. So, as I discuss with [men], I let them know that it’s not good, but I don’t force it on them.”

Client-centred communication

Providers’ confidence in client-centred communication improved in control clinics but declined in intervention clinics over time (overall p = 0.02), with intervention providers reporting lower confidence than at baseline by 12 months (p = 0.05).

Clients' perceptions of communication quality followed the same pattern, favouring control clinics (overall p < 0.001). By 12 months, clients at intervention clinics reported significantly worse communication quality (p < 0.001).

However, providers at intervention clinics reported increased empathy toward clients at six months (p = 0.04). Both groups of clients reported increased involvement in treatment decisions over time (overall p = 0.02), with men at intervention clinics reporting the strongest improvement.

One provider described learning to recognise non-verbal communication:

“For the men, I came to understand that they respond more with the non-verbal than the verbal. He can respond with the eyes, head. But the woman, she will keep communicating with you [verbally]. For the men, you have to be very attentive and [use] active listening. After the study, I understood that even the non-verbal [cues] are very key in the sessions”

However, providers explained that heavy workloads, time pressure, and lack of privacy made it difficult to implement client-centred approaches.

Recognising and reducing bias

Providers described recognising biases toward clients who drink alcohol, sex workers, young women assumed to be promiscuous, men in general, gender and sexual minorities, drug users, young people, and people with unsuppressed viral loads.

“Aha! That time I had no time for those who wear minis [mini-skirts] - I would give them their drugs and I would not care whether you take it properly or not or even throw it away. I am not concerned because I had it in me that, ‘you are a prostitute and it is up to you.’ But now I take time to interact. When there are things that are not right, we go for counselling sessions, and when there are things which have gone well, we continue to move with the good thing. I now create time and I have time for such people”.

While providers became more aware of stereotypes, some underlying prejudices remained. One provider explained:

“Before this training, I had this feeling that whoever came to the clinic indecently dressed and reacts [to an HIV test] and turns positive, that ‘This one was a commercial sex worker and was selling themselves; that’s why they are HIV positive.’ But after the study, I got to realise that, at times, its one’s personality and how they feel comfortable [dressing], not that they are commercial sex workers.”

Patient outcomes

Both intervention and control clinics saw improvements in ART adherence over the 12-month period, with no significant difference between the two groups (p = 0.28). At six months, adherence was similar in both groups (p = 0.91), and remained similar at 12 months (p = 0.33).

Client satisfaction with HIV care remained stable at control clinics but decreased modestly at intervention clinics, particularly between six and 12 months (overall p < 0.001). There was no difference at six months (p = 0.91), but by 12 months, intervention clients reported significantly lower satisfaction (p < 0.001).

The clearest client benefit was reduced HIV stigma. While there was no difference between groups at six months, by 12 months clients at intervention clinics reported significantly less stigma than those at control clinics, where stigma had increased (p < 0.001). This was mainly due to reduced anticipated stigma – the stigma clients expected to face from others.

Conclusion

The trial demonstrates that gender-sensitivity training can help providers recognise biases, understand how gender norms affect HIV care, and increase empathy toward male clients. Clients reported reduced stigma and providers developed stronger counselling skills. However, the lack of sustained effects and implementation challenges underscore the need for ongoing support and system-level changes to enable providers to apply what they learn. Providers emphasised that building trust and delivering patient-centred care requires time that current clinic structures do not allow.