Construction, urban planning and stigma reduction to ensure access to medicine for people living with HIV are not obviously linked. Yet in one part of South Sudan, space and the layout of buildings may in fact be key for enabling more people to test and receive the life saving treatment they need if diagnosed positive for HIV.

I listened today to a healthcare worker talk about the sites where a potential client at his facility – in one of the regions of South Sudan – may experience stigma or discrimination during a typical journey to test for HIV. 

The healthcare worker described a fictional story of Mary, a young woman aged 25, who would travel from her home on the outskirts of the city into a local clinic for a routine HIV test.

This is where urban planning and stigma reduction surprisingly overlap. If Mary was to test positive for HIV at the local clinic, she would then travel to another hospital to receive a confirmatory diagnostic test. If that second test came back also positive, it is at this hospital where Mary would receive her antiretroviral treatment.

Back at the local clinic, the lab that tests for HIV is separate from those that test for Malaria and other illnesses. The exit from the lab that tests for HIV is visible from the road, and known to the pool of waiting motorbike drivers (known as Boda Bodas) who are waiting there well positioned to provide local transport. If someone like Mary was to come out from that particular lab and seek to travel to the hospital on the back of a Boda Boda, it is almost as clear as a broadcast that the lab test has come back as HIV positive. In other words, it is a subtle and indirect form of forced disclosure about their newly diagnosed HIV positive status.

As Mary arrives at the hospital, she literally meets a gatekeeper, who is stationed at the entrance to the hospital to direct clients to the services they seem to need. To take another HIV test, voluntarily, Mary is directed to a building to the right of the gate that specialises on HIV counselling and testing. If her second test also comes back as positive and confirms her HIV positive diagnosis, Mary is then directed back past the gatekeeper to a different room on the left of the gate to a building that is specifically for providing antiretroviral treatment. This is the space where Mary will start on the life saving antiretroviral drugs that are recommended for people start as soon as hearing an HIV positive diagnosis. The space is located just next to the out patient services that provide maternal and child health services, where a number of Mary’s friends may be attending with their new born babies and infants for a range of services such as immunization, nutrition support and infant weighing, and family planning.

As the healthcare worker today finished off his description of Mary’s journey through the clinic, he explained how Mary may face judgement or unintentional disclosure of her new HIV positive status from others as she walked between the buildings and past the gate of the hospital.

There is also a separate building, just next to the dispensary of antiretroviral treatment, where food and nutritional support is provided at the hospital explicitly for people who are living with HIV. South Sudan and other parts of the region are experiencing severe famine and food insecurity at the moment, and priority support has been allocated to help people with a compromised immunity due to their HIV status.

It was with one simple drawing of a map, and a clear description of the journey of a client seeking an HIV test, that the link between urban planning, hospital construction, and HIV related stigma became unexpectedly clear.

Reducing stigma related to HIV does involve a change in attitudes and beliefs for all of us – including those who are living with HIV, those who are not, and those who do not know their status. That is well known. But perhaps less well known are the literally concrete changes that can be made to reduce stigma in very practical ways in different settings… when diverse and complimentary skills are brought together for thoughtful and collaborative action. Thank you to the healthcare worker today for giving us such a simple and clear picture of a practical way in South Sudan – and in many settings around the world – where an unusual collaboration of people with different skillsets can reduce sites where stigma thrives.

Lucy Stackpool-Moore