A comparison of HIV stigma and discrimination in five international sites: the influence of care and treatment resources in high prevalence settings

How does HIV-related stigma correlate with HIV prevalence in African countries? Distinct perspectives from individuals living with and living without HIV

BACKGROUND

Population-level research evaluating HIV-related stigma among countries with varied national HIV prevalence is scarce. To better understand HIV-related stigma and mitigate its potential negative effects, it is necessary to evaluate its relationship with HIV prevalence, as well as the mechanisms that influence it. This study aimed to analyze how HIV-related stigma correlates with subnational HIV prevalence in three African countries with varied HIV epidemics.

METHODS

This paper used data from the nationally representative Population-based HIV Impact Assessment (PHIA) surveys conducted from 2015-2017 in Malawi, Zambia, and Tanzania. Each country's sub-national geographic divisions were used to categorize them as low (0-5.4%), middle (5.5-11.2%), and high (11.3-17.1%) HIV prevalence regions in the main analysis. Questions from the survey stigma module were used to measure HIV-related stigma. Logistic regression and multilevel models were performed to assess the associations between the level of sub-national HIV prevalence and HIV-related stigma measures among persons living with, and without, HIV.

RESULTS

The results show that the odds of people living without HIV expressing stigmatizing behavior towards PLWH was significantly lower in regions of middle (OR = 0.80, 90%CI = (0.68-0.96)) and high (OR = 0.65, 90%CI = (0.53-0.80)) HIV prevalence when compared to low prevalence regions. The odds of reporting discriminatory attitudes were also lower for those in middle (OR = 0.87, 90%CI = (0.78-0.98)) and high (OR = 0.64, 90%CI = (0.56-0.73)) HIV prevalence regions compared to others. Living in middle and high HIV prevalence regions was associated with lower odds of expressing prejudice toward PLWH (OR = 0.84, 90%CI = (0.71-0.99) and OR = 0.60, 90%CI = (0.45-0.80), respectively) among people living without HIV. Notably, PLWH living in high prevalence regions had higher odds of reporting internalized stigma (OR = 1.48, 90%CI = (1.02-2.14)) compared to those living in low prevalence regions.

CONCLUSIONS

The results indicate that among people not living with HIV, subnational HIV prevalence was negatively associated with discriminatory attitudes and prejudice towards PLWH, but HIV prevalence was positively associated with self-reported internalized stigma among PLWH. These results provide insight on how resources could be invested to reduce HIV related stigma among both PLWH and those not living with HIV.

Differences in Reasons for Late Presentation to HIV Care in Uganda Among Men and Women

Late presentation to HIV care, i.e., presenting with < 200 CD4 cells/mL, is associated with higher mortality and worse outcomes. Despite that, a quarter of people living with HIV in Uganda still present late to care. We surveyed Ugandans living with HIV who enrolled in clinic ≤ 90 days prior. We compared groups who presented 'late' with CD4 < 200 and 'early' with CD4 > 350, stratifying by sex. We found men who presented late had higher externalized stigma than early presenters. Thirty-six percent of the entire cohort were depressed. Social support was stronger in late presenters versus early, although weak overall. Social support was inversely correlated with depression, with social support dropping as depression increased. Interventions to improve clinic privacy, reduce stigma, improve social support, and help women disclose their HIV status to male partners are needed to reduce late presentation to HIV care.

They call us goor-jigeen: a qualitative exploration of the experiences of Senegalese Muslim men who have sex with men living with HIV

Men who have sex with men living with HIV in majority Muslim communities face discrimination based on multiple forms of stigma at socio-cultural and legislative levels. This study aimed to explore qualitatively the experiences of men who have sex with men living with HIV in Dakar, Senegal. In-depth individual interviews were conducted with 30 Senegalese men aged 18 to 55 years, who self-reported as same-sex practising, Muslim, and receiving HIV treatment at health centres in Dakar. Interview data were analysed using an ethnographic phenomenological approach to explore their life experiences. Primary themes included: the self-discovery process; the social, religious and health ramifications of being same-sex practising; and stigma. Within the theme of stigma issues described included shame, blame (of self and others), and violence resulting from being a man who has sex with other men and/or being HIV seropositive. Those with undetectable viral load reported how HIV related stigma and burden diminished as their health improved. Disclosure of being men who have sex with men and/or HIV status, whether voluntary or not, affected experiences of violence and/or isolation. Addressing stigma at healthcare institutions and improving access to HIV treatment can help mitigate the burden of stigma affecting such men. Interventions to address their physical and psychosocial wellbeing require the engagement of multiple stakeholders, including religious and political leaders.

Development, Implementation, and Scale Up of the National Furaha Yangu Campaign to Promote HIV Test and Treat Services Uptake Among Men in Tanzania

Evidence has demonstrated that immediate HIV treatment initiation upon a positive HIV test, referred to as Test and Treat, can help people living with HIV live longer, healthier lives and prevent HIV transmission. Although Tanzania adopted the evidence-based Test and Treat strategy since 2016, men were not being adequately reached for HIV services. A national campaign was launched to promote the new HIV services with a focus on men. To inform the development and implementation of the campaign, we conducted formative audience insights-gathering (AIG) sessions to assess facilitators and barriers to accessing HIV Test and Treat services and inform the concepts and materials for the campaign. Qualitative AIG interviews and focus group discussions were conducted with 54 people who were unaware or aware of their HIV status and currently or not currently on treatment, as well as health workers. Facilitators and barriers included a fear of testing positive, the desire to belong, control their narratives, and reinvent themselves to achieve their dreams and live a happy life. The campaign played off a My Happiness! creative concept to position antiretroviral therapy (ART) as a solution to fears around what life would be like after a positive HIV diagnosis. The development and implementation of the campaign were informed by the AIG sessions and national stakeholders, leading to strong partners’ buy-in that supported the scale-up of the ongoing campaign from 12 to 26 regions via the collaborative efforts of government, donors, and implementing partners.

Magnitude of optimal adherence and predictors for a low level of adherence among HIV/AIDS-infected adults in South Gondar zone, Northwest Ethiopia: a multifacility cross-sectional study

OBJECTIVES

This study aims to identify levels of adherence to antiretroviral therapy (ART) drugs and factors associated with them in Northwest Ethiopia. We hypothesise that in the era of COVID-19, there would be suboptimal adherence to ART drugs.

DESIGN

An observational cross-sectional study was conducted. Factors associated with the level of adherence were selected for multiple logistic regressions at a p value of less than 0.2 in the analysis. Statistically significant associated factors were identified at a p value less than 0.05 and adjusted OR with a 95% CI.

SETTING

The study was conducted in one specialised hospital and three district hospitals found in the South Gondar zone, Northwest Ethiopia.

PARTICIPANTS

About 432 people living with HIV/AIDS receiving highly active ART in South Gondar zone public hospitals and who have been on treatment for more than a 3-month period participated in the study.

PRIMARY AND SECONDARY OUTCOME MEASURES

Levels of adherence to ART drugs and their associated factors.

RESULTS

Among 432 study participants, 81.5% (95% CI: 78% to 85.2%) of participants were optimally adherent to ART drugs. Determinants of a low level of adherence: stigma or discrimination (OR=0.4, p=0.016), missed scheduled clinical visit (OR=0.45, p=0.034), being on tuberculosis treatment (OR=0.45, p=0.01), recent CD4 cell count less than 500 cells/mm³ (OR=0.3, p=0.023) and patients who had been on WHO clinical stage III at the time of ART initiation (OR=0.24, p=0.027) were factors significantly associated with adherence to ART drugs.

CONCLUSIONS

Level of adherence was relatively low compared with some local studies. The intervention targeted to reduce discrimination, counselling before initiation of treatment and awareness regarding compliance is advised to improve adherence to antiretroviral regimens.

Living With a Stigmatized Identity; Perceptions of Disclosure, Coping, and Medication Adherence Among Adolescent Boys and Young Men in Chiredzi-Zimbabwe

There is limited research on adolescent boys and young men (ABYM)'s initial and onward HIV seropositive status disclosure, coping strategies and treatment adherence journeys especially in Zimbabwe. This qualitative exploratory study employed in-depth individual interviews at Chiredzi General Hospital in Zimbabwe to explore the dynamics of disclosure, coping and treatment adherence among ABYM. Twenty-one HIV positive ABYM with ages ranging from 14 to 21 were recruited from their scheduled visit to collect medication at the hospital. Findings indicate that ABYM disclosure journeys began with shock, confusion or misunderstanding and ended in a positive life outlook. Treatment adherence among ABYM was very poor due to poverty, erratic food supply, feeling sick after taking medication, forgetfulness and the public nature of medication collection centers. The study concluded that ABYM maintained secrecy in order to be accepted by their peers but also to protect themselves from stigma and isolation.

HIV Stigmatizing Attitudes Among Men Accompanying Their Partners to Antenatal Care in Tanzania: A Mixed-Method Study

This mixed-method study aimed to describe HIV stigmatizing attitudes, identify factors associated with stigmatizing attitudes, and explore the broader context of HIV stigma among men accompanying their pregnant female partners to antenatal care in Tanzania. The study recruited 480 men who were attending a first antenatal care appointment with their pregnant female partners. Participants completed a structured survey; a subset of 16 men completed in-depth interviews. The majority of participants endorsed at least one of the stigmatizing attitudes; the most common attitude endorsed was the perception that HIV is a punishment for bad behaviour. In a multivariable logistic analysis, men were more likely to endorse stigmatizing attitudes if they were younger, less educated, Muslim, did not know anyone with HIV, or reported less social support. In the qualitative interviews, men discussed how HIV was antithetical to masculine identities related to respect, strength, independence, and emotional control. Future studies should develop and test interventions to address HIV stigmatizing attitudes among men, taking advantage of settings of routine HIV testing. These programs should be tailored to reflect masculine ideals that perpetuate stigma.

Therapeutic Borderlands: Austerity, Maternal HIV Treatment, and the Elusive End of AIDS in Mozambique

"End of AIDS" requires ambitious testing, treatment, and adherence benchmarks, like UNAIDS' "90-90-90 by 2020." Mozambique's efforts to improve essential maternal/infant antiretroviral treatment (ART) exposes how austerity-related health system short-falls impede public HIV/AIDS service-delivery and hinder effective maternal ART and adherence. In therapeutic borderlands-where household impoverishment intersects with health-system impoverishment-HIV+ women and over-worked care-providers circumnavigate scarcity and stigma. Worrisome patterns of precarious use emerge-perinatal ART under-utilization, delayed initiation, intermittent adherence, and low retention. Ending HIV/AIDS requires ending austerity and reinvesting in a public sector health workforce to ensure universal health coverage as household and community safety nets.

Prevalence and Correlates of HIV Stigma Among Women Living with HIV in Metro Vancouver, Canada

This study elucidated the prevalence and correlates of four types of HIV stigma among women living with HIV (WLWH). Data were drawn from 2 years (September 1/15 to August 31/17) of follow-up from a longitudinal community-based open cohort of 215 cisgender or transgender WLWH who lived and/or accessed care in Metro Vancouver, Canada (2014-present). Bivariate and multivariable cumulative logistic regression using generalized estimating equations for repeated measures were used to examine correlates of HIV stigma, including: (1) anticipated; (2) enacted; (3) internalized; and (4) perceived stigma. In multivariable analysis, disclosure of HIV status without consent was significantly associated with heightened: anticipated; enacted; and perceived stigma. Verbal and/or physical violence related to HIV status was significantly associated with heightened enacted, internalized and perceived stigma. Negative physical effects/symptoms of HIV was significantly associated with all stigma outcomes. Results suggest a need to support safe disclosure of HIV status and address social and structural violence against WLWH.

Daily emotional inertia and long-term subjective well-being among people living with HIV

OBJECTIVE

The aim of this study was to verify if subjective well-being (SWB) modifies the autoregressive effect of daily emotions and if this emotional inertia predicts long-term changes in SWB among people living with HIV (PLWH).

METHODS

The 131 participants had medically confirmed diagnoses of HIV and were undergoing antiretroviral therapy. They assessed their SWB (satisfaction with life, negative affect, positive affect) twice with an interval of one year. They also took part in a five-day online diary study six months from their baseline SWB assessment and reported their daily negative and positive emotions.

RESULTS

Results showed that baseline SWB did not modify the emotional carryover effect from one to another. Additionally, after control for baseline SWB, emotional inertia did not predict SWB one year later. However, such an effect was noted for the mean values of daily reported emotions, indicating their unique predictive power over SWB itself.

CONCLUSIONS

This may suggest that emotional inertia does not necessarily provide better information than more straightforward measures of affective functioning.

Psychometric Validation of a Scale to Assess Culturally-Salient Aspects of HIV Stigma Among Women Living with HIV in Botswana: Engaging "What Matters Most" to Resist Stigma

Perceived stigma deters engagement in HIV care and is powerfully shaped by culture. Yet few stigma measures consider how cultural capabilities that signify "full personhood" could be engaged to resist stigma. By applying a theory conceptualizing how culturally-salient mechanisms can worsen or mitigate HIV stigma in relation to "what matters most" (WMM), we developed the WMM Cultural Stigma Scale for Women Living with HIV in Botswana (WMM-WLHIV-BW) and psychometrically evaluated it among 201 respondents with known and unknown HIV status. The two subscales, Cultural Factors Shape Stigma (CFSS) and Cultural Capabilities Protect against Stigma (CCPS) were reliable (both [Formula: see text]). Among WLHIV, the CFSS Subscale showed initial construct validity with depressive symptoms (r = .39, p = .005), similar to an established HIV stigma scale, whereas the CCPS Subscale showed initial construct validity with self-esteem (r = .32, p = .026) and social support number (r = .29, p = .047), suggesting that achieving local cultural capabilities mitigates stigma and is linked with positive psychosocial outcomes. This culturally-derived scale could help WLHIV in Botswana experience improved stigma-related outcomes.

Temporal and cross-national comparisons of young Africans' HIV-related narratives from five countries, 1997-2014

Little is known about how young Africans have made sense of the dramatic ways in which the HIV epidemic has evolved, and how that sense-making varies across countries with different epidemiological and sociocultural profiles. Symbolic representations of HIV and people living with HIV influence prevention, stigma, treatment-seeking, and illness experience. We compared social representations of HIV among young people from Senegal, Burkina Faso, Nigeria (South-East), Kenya, and Swaziland between 1997 and 2014. From a pool of 32,759 HIV-themed creative narratives contributed by 10-24 year-olds to scriptwriting competitions at eight time points (1997, 2000, 2002, 2005, 2008, 2011, 2013, and 2014), we randomly sampled 1937 narratives, stratified by author's sex, age, and rural/urban residence. We quantified components of each narrative and calculated descriptive statistics and adjusted odds ratios, controlling for year, country, and author demographics. From 2005 onwards, representations of death, treatment access, and hopefulness improved significantly. Representations of death reached their lowest point in 2013, while biomedical treatment and hope peaked in 2011 and 2008, respectively, then declined. Narratives increasingly focused on female protagonists. Nigerian texts had significantly higher odds of death and blame, and lower odds of hope. A focus on life post-infection and representations of support for characters living with HIV increased with country HIV prevalence. Narratives by older authors were less blaming and more hopeful, supportive, and prevention-focused. While aggregate social representations in the narratives from 2005 to 2008-11 reflect increased optimism fostered by access to antiretroviral therapy (ART), positive developments are not sustained at this level. Stigmatizing representations persist, particularly in Nigeria. The hope-promoting and stigma-reducing influence of the advent of ART access may have partially run its course by 2011/2013. However, significant temporal and cross-national differences point to opportunities to reframe HIV in more constructive ways and contribute to improved education, communication, and stigma-reduction efforts.

LOWER PERCEIVED-STIGMATIZATION BY HEALTH WORKERS AMONG HIV-AIDS PATIENTS OF KEY POPULATION BACKGROUNDS

The stigma of people living with HIV-AIDS (PLWHA) by health workers may have a broad impact, so it is necessary to identify the factors that influence the occurrence of stigma. Identification of factors that cause a decrease in stigmatization by health workers will have an impact on improving the quality of life of people with HIV, increasing compliance with medication, and ultimately reducing the incidence of HIV infection itself. The purpose of this study was to analyze factors related to PLWHA’s perception of stigma among health workers in the community health center.  This research applied a cross-sectional design using interviews. Ninety-four patients from the Infectious Disease Intermediate Care of Dr. Soetomo Hospital Surabaya, a tertiary level hospital, were interviewed. The stigma perception was assessed using a questionnaire modified from the Standardized Brief Questionnaire by Health Policy Project with Cronbach’s Alpha of 0.786. The data were simultaneously analyzed with binary multiple regressions on IBM SPSS Statistics 22.0 for Windows software. There were 30 out of 94 patients with key population backgrounds, and most population was injecting drug users (IDUs) and female sex workers (FSWs). PLWHA perceived most stigmatized community health workers when they drew blood, provided care, and considered they were involved in irresponsible behavior. There were relationships between age(p=0.008), marital status(p=0.013), and the history of key population (p=0.006)to people living with HIV-AIDS (PLWHA)’s perception of stigma among health workers in East Java community health center. Future research on factors influencing HIV-related stigma is needed to improve patients’ quality of life.

Patient-reported reasons for declining same-day antiretroviral therapy initiation in routine HIV care settings in Lusaka, Zambia: results from a mixed-effects regression analysis

INTRODUCTION

In the current "test and treat" era, HIV programmes are increasingly focusing resources on linkage to care and same-day antiretroviral therapy (ART) initiation to meet UNAIDS 95-95-95 targets. After observing sub-optimal treatment indicators in health facilities supported by the Centre for Infectious Disease Research in Zambia (CIDRZ), we piloted a "linkage assessment" tool in facility-based HIV testing settings to uncover barriers to same-day linkage to care and ART initiation among newly identified people living with HIV (PLHIV) and to guide HIV programme quality improvement efforts.

METHODS

The one-page, structured linkage assessment tool was developed to capture patient-reported barriers to same-day linkage and ART initiation using three empirically supported categories of barriers: social, personal and structural. The tool was implemented in three health facilities, two urban and one rural, in Lusaka, Zambia from 1 November 2017 to 31 January 2018, and administered to all newly identified PLHIV declining same-day linkage and ART. Individuals selected as many reasons as relevant. We used mixed-effects logistic regression modelling to evaluate predictors of citing specific barriers to same-day linkage and ART, and Fisher's Exact tests to assess differences in barrier citation by socio-demographics and HIV testing entry point.

RESULTS

A total of 1278 people tested HIV positive, of whom 126 (9.9%) declined same-day linkage and ART, reporting a median of three barriers per respondent. Of these 126, 71.4% were female. Females declining same-day ART were younger, on average, (median 28.5 years, interquartile range (IQR): 21 to 37 years) than males (median 34.5 years, IQR: 26 to 44 years). The most commonly reported barrier category was structural, "clinics were too crowded" (n = 33), followed by a social reason, "friends and family will condemn me" (n = 30). The frequency of citing personal barriers differed significantly across HIV testing point (χ2 p = 0.03). Significant predictors for citing ≥1 barrier to same-day ART were >50 years of age (OR: 12.59, 95% CI: 6.00 to 26.41) and testing at a rural facility (OR: 9.92, 95% CI: 4.98 to 19.79).

CONCLUSIONS

Given differences observed in barriers to same-day ART initiation reported across sex, age, testing point, and facility type, new, tailored counselling and linkage to care approaches are needed, which should be rigorously evaluated in routine programme settings.

Investigation of Relationship between Family Social Support and the Level of Stigma Perceived by PLWHA in Iran

This study is aimed to investigate the relationship between family social support and the level of stigma perceived by people living with HIV (PLWHA). The methodology is cross-sectional and the sample population includes 163 individuals (54% males, 46% females) who were randomly selected from the counseling centers for behavioral disorders of Medical Sciences of Tehran University. The average age of the sample was 37.48 ± 10.29 years old and the main cause of HIV infection was the sexual intercourse with spouse/non-spouse. The results of this study indicate that there is a significant and inverse relationship between general social stigma with the duration of HIV infection (r = -0.31, P < .05). There is also a positive and significant relationship between the general family social support and its subscales (information support, seeking support, instrumental support) with the duration of the infectious disease (r = +0.20, P < .05), which means that with increasing duration of the disease, the level of family social support increases. The general social stigma score with the general family social support showed a significant correlation (inverse) (r = -0.43, P < .05). It seems that the design and implementation of appropriate psychosocial interventions to increase family social support and reduce social stigma associated with HIV/AIDS are important in Iranian society and societies that are family-oriented and the family institution continues its protective and supportive functions.

Association between HIV knowledge and stigmatizing attitudes towards people living with HIV in Afghanistan: findings from the 2015 Afghanistan Demographic and Health Survey

BACKGROUND

Afghanistan has witnessed a dramatic increase in HIV infections. Public health officials have responded with campaigns to educate the public about HIV prevention and transmission. We examine the association between HIV prevention and transmission knowledge and stigma towards people living with HIV (PLHIV) in Afghanistan.

METHODS

We conducted a secondary analysis of cross-sectional data (n=11 930) from the 2015 Afghanistan Demographic and Health Survey. Hierarchical linear regression analysis was used to examine the effects of accurate HIV knowledge related to safer sex and local misconceptions about the virus's transmission (e.g. mosquitos and witchcraft) on two stigma outcomes, namely, stigma towards public others with HIV (teachers and food vendors) and stigma towards close family members with HIV.

RESULTS

Stigmatizing attitudes were highly prevalent and HIV knowledge varied widely. Multivariate analyses show that correct knowledge related to local misconceptions about HIV prevention and transmission is significantly associated with lower stigma towards public others (ΔR2adjusted=0.07); however, knowledge had little and contradictory influence in the model predicting stigma towards close family members with HIV (ΔR2adjusted=0.005).

CONCLUSIONS

These findings suggest that it would be worthwhile designing interventions that dispel local misconceptions about HIV. This may be helpful in reducing stigma towards PLHIV in public positions but not towards family members, which calls for alternative strategies for reducing HIV-related stigma.

HIV knowledge mediates the relationship between HIV testing history and stigma in college students

OBJECTIVE

HIV-related stigma is one of the strongest barriers to prevention and treatment. HIV prevalence in U.S. college students is estimated around 0.02%, but is thought to be drastically underreported. We examined the influence of HIV knowledge on the relationship between HIV testing history and stigma in college students.

PARTICIPANTS

A random sample of 2343 students, over the age of 18, attending a large university in the southeastern United States completed the survey in January 2016.

METHODS

A mediation model was constructed in regression framework to explore the relationship between HIV testing history, knowledge, and stigma.

RESULTS

HIV testing history was associated with higher knowledge scores (a path: B = 4.08, p < .001) and higher knowledge scores were associated with lower stigma (b path: B = .01, p < .001). These results suggest that HIV knowledge partially mediates the relation between HIV testing history and stigma in college students.

CONCLUSIONS

HIV testing history may decrease stigma by increasing knowledge. Results can be used to inform college health promotion practice on developing programs and services.

Designing robot-assisted neurorehabilitation strategies for people with both HIV and stroke

There is increasing evidence that HIV is an independent risk factor for stroke, resulting in an emerging population of people living with both HIV and stroke all over the world. However, neurorehabilitation strategies for the HIV-stroke population are distinctly lacking, which poses an enormous global health challenge. In order to address this gap, a better understanding of the HIV-stroke population is needed, as well as potential approaches to design effective neurorehabilitation strategies for this population. This review goes into the mechanisms, manifestations, and treatment options of neurologic injury in stroke and HIV, the additional challenges posed by the HIV-stroke population, and rehabilitation engineering approaches for both high and low resource areas. The aim of this review is to connect the underlying neurologic properties in both HIV and stroke to rehabilitation engineering. It reviews what is currently known about the association between HIV and stroke and gaps in current treatment strategies for the HIV-stroke population. We highlight relevant current areas of research that can help advance neurorehabilitation strategies specifically for the HIV-stroke population. We then explore how robot-assisted rehabilitation combined with community-based rehabilitation could be used as a potential approach to meet the challenges posed by the HIV-stroke population. We include some of our own work exploring a community-based robotic rehabilitation exercise system. The most relevant strategies will be ones that not only take into account the individual status of the patient but also the cultural and economic considerations of their respective environment.

Factors that Motivated Otherwise Healthy HIV-Positive Young Adults to Access HIV Testing and Treatment in South Africa

The World Health Organization recommends early initiation of HIV antiretroviral therapy (ART) for all those infected with the virus at any CD4 count. Successfully reaching individuals with relatively high CD4 counts depends in large part on healthy individuals seeking testing and treatment; however, little is known about factors motivating this decision. We conducted a qualitative study to explore this issue among 25 young HIV-positive adults (age 18-35) with a CD4 count >350 cells/mm³ who recently started or made the decision to start ART in Gugulethu, South Africa. Using an inductive content analytical approach, we found that most individuals sought testing and treatment early in the disease progression because of a desire to appear healthy thereby avoiding stigma associated with AIDS. Other factors included social support, responsibilities and aspirations, normalcy of having HIV, and accessible services. These findings suggest that maintenance of physical appearance should be included in the development of novel testing and treatment interventions.

Living with HIV, disclosure patterns and partnerships a decade after the introduction of HIV programmes in rural South Africa

Prevention of mother-to-child Transmission and HIV Treatment programmes were scaled-up in resource-constrained settings over a decade ago, but there is still much to be understood about women's experiences of living with HIV and their HIV disclosure patterns. This qualitative study explored women's experiences of living with HIV, 6–10 years after being diagnosed during pregnancy. The area has high HIV prevalence, and an established HIV treatment programme. Participants were enrolled in a larger intervention, “Amagugu”, that supported women (n = 281) to disclose their HIV status to their children. Post-intervention we conducted individual in-depth interviews with 20 randomly selected women, stratified by clinic catchment area, from the total sample. Interviews were entered into ATLAS.ti computer software for coding. Most women were living with their current sexual partner and half were still in a relationship with the child's biological father. Household exposure to HIV was high with the majority of women knowing at least one other HIV-infected adult in their household. Eighteen women had disclosed their HIV status to another person; nine had disclosed to their current partner first. Two main themes were identified in the analyses: living with HIV and the normalisation of HIV treatment at a family level; and the complexity of love relationships, in particular in long-term partnerships. A decade on, most women were living positively with HIV, accessing care, and reported experiencing little stigma. However, as HIV became normalised new challenges arose including concerns about access to quality care, and the need for family-centred care. Women's sexual choices and relationships were intertwined with feelings of love, loyalty and trust and the important supportive role played by partners and families was acknowledged, however, some aspects of living with HIV presented challenges including continuing to practise safe sex several years after HIV diagnosis.

Change in HIV-related stigma in South Africa between 2004 and 2016: a cross-sectional community study

A critical component of an AIDS-free generation is to reduce HIV-related stigma. Previous research predicted that stigma would decline over time with increased contact with PLWH, understanding of the disease and availability of treatment. The aim of the research was to explore change in stigma over a 12-year period, by comparing data collected from two large cross-sectional samples from South African communities in 2004 (before the roll-out of antiretroviral treatment (ART)) and in 2016. Students recruited respondents according to criteria related to age, gender, race and area of living. A survey assessing moral judgement and interpersonal distance was used to assess personal and perceived community stigma. Responses to ten identical items used in the 2004 and 2016 data collection were compared. Personal stigma attached to HIV decreased significantly over time, except in respect of having close contact with PLWH, such as dating and befriending. Perceived community stigma remained high in all subgroups. It is argued that perceived community stigma contributes to high levels of internalised stigma among PLWH. Interventions should focus on helping PLWH to cope with perceived stigma and strategies to address stereotyping, which contributes to perceived community stigma.

Dynamic of HIV-testing after arrival in France for migrants from sub-Saharan Africa: The role of both health and social care systems

Objective

HIV testing is an important tool in the management of the HIV epidemic among key populations. We aimed to explore the dynamic of first-time HIV testing in France for sub-Saharan migrants after their arrival.

Methods

ANRS-Parcours is a retrospective life-event survey conducted from 2012 to 2013 in healthcare facilities in the Paris region, among 926 sub-Saharan HIV-infected migrants and 763 non-infected migrants. After describing the time to first HIV test in France and associated circumstances, we performed a discrete-time logistic regression to analyze the influence of socioeconomic position, contact with the healthcare system and sexual behaviors, on first-time HIV testing in France in migrants who arrived after 2000.

Results

Median first-time HIV testing occurred during the second year spent in France for non-infected men and women in both groups, and during the first year for men of the HIV group. The probability of testing increased with hospitalization and pregnancy for women of both groups. For non-infected men unemployment and absence of a residence permit were associated with an increased probability of HIV testing [respectively, OR = 2.2 (1.2–4.1) and OR = 2.0 (1.1–3.5)]. Unemployment was also associated with an increased probability of first-time HIV-testing for women of the HIV group [OR: 1.7 (1.0–2.7)]. Occasional and multiple sexual relationships were associated with an increased probability of first-time testing only for HIV-infected women [OR: 2.2 (1.2–4.0) and OR = 2.4 (1.3–4.6)].

Conclusion

Access to first HIV testing in France is promoted by contact with the health care system and is facilitated for unemployed and undocumented migrants after arrival.However, testing should be offered more systematically and repeated in order to reduce time between HIV infection and diagnosis, especially for deprived people which are particularly vulnerable regarding HIV infection.

High HIV prevalence predicts less HIV stigma: a cross-national investigation

Despite substantial global efforts to reduce HIV-related stigma, stigma and discrimination remain widespread and are among the most poorly understood aspects of the epidemic. However, there has been little research on whether HIV stigma in a country is associated with HIV prevalence. This article offers a socioecological perspective for understanding HIV stigma in a context of HIV prevalence. Using two international data sets (the UNAIDS 2009 HIV Epidemiological Report and the World Values Survey), we investigated whether and how HIV prevalence is associated with individual- and country-level HIV stigma. Results showed that in countries with higher HIV prevalence, people reported less HIV stigma (Studies 1 & 2). HIV knowledge mediated the relationship between HIV prevalence and stigma (Study 2). People in countries with higher HIV prevalence reported more knowledge about HIV transmission, which reduced their stigmatizing attitudes. These findings suggest that stigma-reduction programs should incorporate a socioecological perspective and consider the roles of prevalence rate of and knowledge of the disease.

Changing forms of HIV-related stigma along the HIV care and treatment continuum in sub-Saharan Africa: a temporal analysis

OBJECTIVES

Stigma remains pervasive for people living with HIV (PLHIV) in sub-Saharan Africa, undermining care engagement. Using everyday, biographical and epochal temporalities, we explored the manifestation of stigma at different stages of the HIV care continuum in seven health and demographic surveillance sites in Eastern and Southern Africa.

METHODS

Between 2015 and 2016, we conducted qualitative in-depth interviews with 264 PLHIV, 54 health providers and 48 family members of people who had died from HIV. Topic guides explored experiences of HIV testing, care and treatment services. Data were analysed thematically, aided by NVivo 10.

RESULTS

In everyday time across these communities, stigma was evident in the presence of gossiping and the relative absence of supportive interpersonal discourse, which fuelled judicious disclosure. This was especially disruptive at testing, counselling and early antiretroviral therapy adherence stages of care. Biographical time framed everyday stigma events, highlighting the dilemma of disclosure in relation to sexual relationship norms, as well as the interfacing of age and healthcare continuum points. Epochal patriarchal relations gave a structural context to everyday and biographical stigma dynamics. Historical shifts to social acceptance of PLHIV within these communities, while positive, were complicated by stigma in everyday life and in respect of biographical goals like having a family. Moreover, low community-level resistance to HIV-related stigma jeopardised stigma reduction strategies.

CONCLUSIONS

Despite improvements to HIV care services, stigma remains pervasive across the HIV care continuum in these sites. Context-specific interventions are needed to address stigma and discrimination of PLHIV within the community and in health services, and greater reflection is required to ensure policies aiming to expand HIV treatment do not exacerbate stigma and result in negative HIV outcomes.

'They say God punishes people with HIV': experiences of stigma and discrimination among adults with HIV in Dili, Timor-Leste

Little is known about the experiences of people with HIV in the small island nation of Timor-Leste. This study explored the HIV-related stigma experiences of adults aged between 18 and 40 living with HIV in Dili, Timor-Leste. Participants were interviewed on topics related to living with HIV, both as key informants describing the experience of others with HIV known to them, and also with respect to their own personal experiences. Findings suggest that people with HIV in Timor-Leste face stigma and discrimination in various contexts. In this predominantly Catholic country, perceptions of HIV and attitudes towards people with HIV appear to be commonly shaped by religious beliefs. In families and communities, participants encountered gossip, social exclusion and threats of violence. In health settings, participants experienced discrimination from health providers in the form of failing to maintain confidentiality and inappropriate treatment. The impact of stigma was profoundly negative and influenced participants' decision to disclose their status to others. Participants attributed stigma to a lack of information about HIV among the general public. Unless stigma reduction interventions also address the Church's role in shaping perceptions of HIV, education campaigns are unlikely to be effective in reducing HIV-related stigma.

Development of a Novel Tablet-based Approach to Reduce HIV Stigma among Healthcare Staff in India

Although stigma is considered to be one of the major barriers to reducing the AIDS epidemic in India, efforts to reduce stigma have not been sufficiently examined. In response, a partially computer-administered three-session stigma reduction intervention was developed and is currently being tested. This paper describes the technological design, development, implementation, and management of these in-person tablet-administered assessment and intervention sessions that are being used to evaluate the efficacy of this innovative stigma reduction intervention among nursing students and ward attendants in India.

Willingness by people living with HIV/AIDS to utilize HIV services provided by Village Health team workers in Kalungu district, central Uganda

BACKGROUND

Less than one quarter of people in need have access to HIV services in Uganda. This study assessed willingness of people living with HIV/AIDS (PLWHAs) to utilize HIV services provided by Village Health Teams (VHTs) in Kalungu district, central Uganda.

METHODS

A cross-sectional study conducted in two health facilities providing anti-retroviral therapy enrolled 312 PLWHAs. Pre-tested semi-structured questionnaires were administered to participants at household level. A forward fitting logistic regression model computed the predictors of willingness of PLWHAs to utilize services provided by VHTs.

RESULTS

Overall, 49% were willing to utilize HIV services provided by VHTs increasing to 75.6% if the VHT member was HIV positive. PLWHAs who resided in urban areas were more likely to utilize HIV services provided by VHTs (AOR 0.24, 95%CI 0.06-0.87). Barriers to utilizing HIV services provided by VHTs were: income level > 40 USD (AOR 6.43 95%CI 1.19-34.68), being a business person (AOR 8.71 95%CI 1.23-61.72), peasant (AOR 7.95 95%CI 1.37-46.19), lack of encouragement from: peers (AOR 6.33 95%CI 1.43-28.09), spouses (AOR 4.93 95%CI 1.23-19.82) and community leader (AOR 9.67 95%CI 3.35-27.92).

CONCLUSION

Social support could improve willingness by PLWHAs to utilize HIV services provided by VHTs for increased access to HIV services by PLWHA.

A Livelihood Intervention to Reduce the Stigma of HIV in Rural Kenya: Longitudinal Qualitative Study

The scale-up of effective treatment has partially reduced the stigma attached to HIV, but HIV still remains highly stigmatized throughout sub-Saharan Africa. Most studies of anti-HIV stigma interventions have employed psycho-educational strategies such as information provision, counseling, and testimonials, but these have had varying degrees of success. Theory suggests that livelihood interventions could potentially reduce stigma by weakening the instrumental and symbolic associations between HIV and premature morbidity, economic incapacity, and death, but this hypothesis has not been directly examined. We conducted a longitudinal qualitative study among 54 persons with HIV participating in a 12-month randomized controlled trial of a livelihood intervention in rural Kenya. Our study design permitted assessment of changes over time in the perspectives of treatment-arm participants (N = 45), as well as an understanding of the experiences of control arm participants (N = 9, interviewed only at follow-up). Initially, participants felt ashamed of their seropositivity and were socially isolated (internalized stigma). They also described how others in the community discriminated against them, labeled them as being "already dead," and deemed them useless and unworthy of social investment (perceived and enacted stigma). At follow-up, participants in the treatment arm described less stigma and voiced positive changes in confidence and self-esteem. Concurrently, they observed that other community members perceived them as active, economically productive, and contributing citizens. None of these changes were noted by participants in the control arm, who described ongoing and continued stigma. In summary, our findings suggest a theory of stigma reduction: livelihood interventions may reduce internalized stigma among persons with HIV and also, by targeting core drivers of negative attitudes toward persons with HIV, positively change attitudes toward persons with HIV held by others. Further research is needed to formally test these hypotheses, assess the extent to which these changes endure over the long term, and determine whether this class of interventions can be implemented at scale.

A livelihood intervention to improve economic and psychosocial well-being in rural Uganda: Longitudinal pilot study

HIV and poverty are inextricably intertwined in sub-Saharan Africa. Economic and livelihood intervention strategies have been suggested to help mitigate the adverse economic effects of HIV, but few intervention studies have focused specifically on HIV-positive persons. We conducted three pilot studies to assess a livelihood intervention consisting of an initial orientation and loan package of chickens and associated implements to create poultry microenterprises. We enrolled 15 HIV-positive and 22 HIV-negative participants and followed them for up to 18 months. Over the course of follow-up, participants achieved high chicken survival and loan repayment rates. Median monthly income increased, and severe food insecurity declined, although these changes were not statistically significant (P-values ranged from 0.11 to 0.68). In-depth interviews with a purposive sample of three HIV-positive participants identified a constellation of economic and psychosocial benefits, including improved social integration and reduced stigma.

Social Network Characteristics Moderate the Association Between Stigmatizing Attributions About HIV and Non-adherence Among Black Americans Living with HIV: a Longitudinal Assessment

BACKGROUND

Stigma may contribute to HIV-related disparities among HIV-positive Black Americans.

PURPOSE

We examined whether social network characteristics moderate stigma's effects.

METHODS

At baseline and 6 months post-baseline, 147 HIV-positive Black Americans on antiretroviral treatment completed egocentric social network assessments, from which we derived a structural social support capacity measure (i.e., ability to leverage support from the network, represented by the average interaction frequency between the participant and each alter). Stigma was operationalized with an indicator of whether any social network member had expressed stigmatizing attributions of blame or responsibility about HIV. Daily medication adherence was monitored electronically.

RESULTS

In a multivariate regression, baseline stigma was significantly related to decreased adherence over time. The association between stigma and non-adherence was attenuated among participants who increased the frequency of their interactions with alters over time.

CONCLUSIONS

Well-connected social networks have the potential to buffer the effects of stigma.

Barreiras e fatores promotores do consumo de frutas e hortaliças entre usuários do Programa Academia da Saúde

RESUMO Objetivo: Investigar barreiras e fatores promotores do consumo de frutas e hortaliças entre usuários do Programa Academia da Saúde. Métodos: Estudo qualitativo conduzido em seis polos do Programa Academia da Saúde em Belo Horizonte, Minas Gerais. Foram realizadas entrevistas semiestruturadas com 62 usuários. A análise de conteúdo foi desenvolvida com auxílio dosoftware NVivo10. Resultados: As principais barreiras identificadas foram: comércio inadequado, baixo poder aquisitivo, preço, carência de iniciativas públicas, falta de tempo, preguiça, fruta ser considerada apenas uma alternativa alimentar e não realizar o jantar. Os fatores promotores mais citados foram: saúde, prevenção/controle de doenças, gostar, hortaliça ser considerada como parte da refeição, criação e origem familiar, melhoria da situação financeira, comércio próximo e estratégias de compra. Conclusão: É necessário ampliar o acesso às frutas e às hortaliças por meio do fortalecimento das iniciativas públicas para aumento da produção e diminuição dos preços desses alimentos e ampliação do comércio local. As intervenções educativas devem focar a construção de outros sentidos para o consumo que não se restrinjam ao discurso saúde-doença e soluções viáveis que facilitem o consumo de frutas e hortaliças no cotidiano, seja pela proposição de estratégias de aquisição de frutas e hortaliças ou pela ampliação de habilidades culinárias para preparações mais práticas.

Why increasing availability of ART is not enough: a rapid, community-based study on how HIV-related stigma impacts engagement to care in rural South Africa

BACKGROUND

Stigma is a known barrier to HIV testing and care. Because access to antiretroviral therapy reduces overt illness and mortality, some scholars theorized that HIV-related stigma would decrease as treatment availability increased. However, the association between ART accessibility and stigma has not been as straightforward as originally predicted.

METHODS

We conducted a "situational analysis"--a rapid, community-based qualitative assessment to inform a combination HIV prevention program in high prevalence communities. In the context of this community-based research, we conducted semi-structured interviews and focus groups with 684 individuals in four low-resource sub-districts in North West Province, South Africa. In addition to using this data to inform programming, we examined the impact of stigma on the uptake of services.

RESULTS

Findings suggested that anticipated stigma remains a barrier to care. Although participants reported less enacted stigma, or hostility toward people living with HIV, they also felt that HIV remains synonymous with promiscuity and infidelity. Participants described community members taking steps to avoid being identified as HIV-positive, including avoiding healthcare facilities entirely, using traditional healers, or paying for private doctors. Such behaviors led to delays in testing and accessing care, and problems adhering to medications, especially for men and youth with no other health condition that could plausibly account for their utilization of medical services.

CONCLUSIONS

We conclude that providing access to ART alone will not end HIV-related stigma. Instead, individuals will remain hesitant to seek care as long as they fear that doing so will lead to prejudice and discrimination. It is critical to combat this trend by increasing cultural acceptance of being seropositive, integrating HIV care into general primary care and normalizing men and youths' accessing health care.

'The mercurial piece of the puzzle': Understanding stigma and HIV/AIDS in South Africa

Although stigma and its relationship to health and disease is not a new phenomenon, it has not been a major feature in the public discourse until the emergence of HIV. The range of negative responses associated with the epidemic placed stigma on the public agenda and drew attention to its complexity as a phenomenon and concept worthy of further investigation. Despite the consensus that stigma is one of the major contributors to the rapid spread of HIV and the frequent use of the term in the media and among people in the street, the exact meaning of 'stigma' remains ambiguous. The aim of this paper is to briefly re-visit some of the scholarly deliberations and further interrogate their relevance in explaining HIV-related stigma evidenced in South Africa. In conclusion a model is presented. Its usefulness--or explanatory potential--is that it attempts to provide a comprehensive framework that offers insights into the individual as well as the social/structural components of HIV-related stigma in a particular context. As such, it has the potential to provide more nuanced understandings as well as to alert us to knowledge-gaps in the process.

'We keep her status to ourselves': experiences of stigma and discrimination among HIV-discordant couples in South Africa, Tanzania and Ukraine

In HIV-discordant relationships, the HIV-negative partner also carries the burden of a stigmatised disease. For this reason, couples often hide their HIV-discordant status from family, friends and community members. This perpetuates the silence around HIV-discordant relationships and impacts on targeted HIV prevention, treatment and counselling efforts. This article reports on experiences of stigma and discrimination among HIV-discordant couples in South Africa, Tanzania and Ukraine. During 2008, HIV-discordant couples who had been in a relationship for at least one year were recruited purposively through health-care providers and civil society organisations in the three countries. Participants completed a brief self-administered questionnaire, while semi-structured interviews were conducted with each partner separately and with both partners together. Interviews were analysed using thematic content analysis. Fifty-one couples were recruited: 26 from South Africa, 10 from Tanzania, and 15 from Ukraine. Although most participants had disclosed their HIV status to someone other than their partner, few were living openly with HIV discordance. Experiences of stigma were common and included being subjected to gossip, rumours and name-calling, and HIV-negative partners being labelled as HIV-positive. Perpetrators of discrimination included family members and health workers. Stigma and discrimination present unique and complex challenges to couples in HIV sero-discordant relationships in these three diverse countries. Addressing stigmatisation of HIV-discordant couples requires a holistic human rights approach and specific programme efforts to address discrimination in the health system.

HIV/AIDS-related stigma in South African alcohol-serving venues and its potential impact on HIV disclosure, testing and treatment-seeking behaviours

Alcohol-serving venues in South Africa are sites for high-risk behaviours that may lead to HIV transmission. Prevention and treatment interventions are sorely needed in these settings, but HIV-related stigma may limit their effectiveness. This study explored expressions of stigma among alcohol-serving venue patrons in Cape Town and examined the potential impact of stigma on HIV disclosure, testing and treatment-seeking behaviours. A total of 92 in-depth interviews with male and female, black and coloured patrons were conducted. Transcripts were analysed via memo-writing and diagramming techniques. Many participants mentioned knowing other patrons living with HIV/AIDS (PLWH), and this visibility of HIV impacted expressions of HIV-related stigma. Participants discussed four forms of HIV-related stigma in the venues: fearing PLWH, fearing HIV acquisition, blaming others for spreading HIV and isolating PLWH. HIV visibility and expressions of HIV-related stigma, particularly fear of isolation, influenced participants' willingness to disclose their status. HIV-related stigma in the venues also appeared to indirectly influence testing and treatment-seeking behaviour outside the venue. Results suggest that efforts to change norms and reduce expressions of HIV-related stigma in alcohol-serving venues are necessary to successfully deliver tailored HIV prevention interventions and increase uptake of HIV testing and care in this important social setting.

HIV in Harare: the role and relevance of social stigma

HIV is a significant social, political and economic problem in Zimbabwe. However, few researchers have explored peoples' experiences of living with HIV in that country. Drawing on 60 qualitative interviews conducted with Zimbabweans living in Harare in 2010, this paper focuses on how people from four different urban communities cope with HIV-related social stigma. To provide theoretical context to this issue, we utilised the ideas of Erving Goffman for exploring the individual experience of stigma and the concept of structural violence to understand stigma as a social phenomenon. This paper considers the relevance and role of stigma in the context of a country undergoing significant social, political and economic crisis. We investigated the strategies adopted by the Zimbabwean state and the influence of traditional and religious interpretations to appreciate the historical roots of HIV-related stigma. We took into account the ways in which the articulation of HIV with gender has caused women to experience stigma differently than men, and more intensely, and how grassroots activism and biomedical technologies have transformed the experience of stigma.

Antiretroviral Therapy Availability and HIV Disclosure to Spouse in Rakai, Uganda: A Longitudinal Population-Based Study

BACKGROUND

A decade after the rollout of antiretroviral therapy (ART) in sub-Saharan Africa, the effects of this structural change on social aspects of HIV, such as rates of HIV disclosure to partners, remain largely unmeasured. We evaluated whether the introduction of ART was associated with disclosure of HIV diagnosis to spouses in Rakai, Uganda, using longitudinal, population-based data.

METHODS

We identified individuals in marital/cohabitating unions who were newly diagnosed with HIV in Rakai Community Cohort Study surveys between 2000 and 2008, where ART was introduced in mid-2004. Using discrete-time survival analysis, we assessed the hazard of self-reported HIV disclosure to spouse after diagnosis pre-ART and post-ART rollout, adjusting for individual and union characteristics. Disclosure in the ART period was further stratified by ART initiation.

RESULTS

The analysis included 557 married adults, 264 of whom were diagnosed with HIV before ART was available (2000-2004), and 293 diagnosed after ART was introduced (2005-2008). The cumulative incidence of self-reported disclosure was 75.2% in the post-ART period, compared with 58.3% before ART availability [P < 0.001, adjusted hazard ratio: 1.46 (95% confidence interval: 1.16 to 1.83)]. In the post-ART period, observed disclosure rates were 39% (72 of 184) among those not in HIV care, 65% (82 of 126) among those in pre-ART care, and 85% (64 of 75) among persons on ART (P < 0.001).

CONCLUSIONS

Treatment availability and use, especially ART initiation, was associated with increased self-disclosure of HIV diagnosis to partners. ART access may facilitate the prevention of transmission to uninfected partners and linkage to treatment for infected couples.

The causal effect of education on HIV stigma in Uganda: Evidence from a natural experiment

RATIONALE

HIV is highly stigmatized in sub-Saharan Africa. This is an important public health problem because HIV stigma has many adverse effects that threaten to undermine efforts to control the HIV epidemic.

OBJECTIVE

The implementation of a universal primary education policy in Uganda in 1997 provided us with a natural experiment to test the hypothesis that education is causally related to HIV stigma.

METHODS

For this analysis, we pooled publicly available, population-based data from the 2011 Uganda Demographic and Health Survey and the 2011 Uganda AIDS Indicator Survey. The primary outcomes of interest were negative attitudes toward persons with HIV, elicited using four questions about anticipated stigma and social distance.

RESULTS

Standard least squares estimates suggested a statistically significant, negative association between years of schooling and HIV stigma (each P < 0.001, with t-statistics ranging from 4.9 to 14.7). We then used a natural experiment design, exploiting differences in birth cohort exposure to universal primary education as an instrumental variable. Participants who were <13 years old at the time of the policy change had 1.36 additional years of schooling compared to those who were ≥13 years old. Adjusting for linear age trends before and after the discontinuity, two-stage least squares estimates suggested no statistically significant causal effect of education on HIV stigma (P-values ranged from 0.21 to 0.69). Three of the four estimated regression coefficients were positive, and in all cases the lower confidence limits convincingly excluded the possibility of large negative effect sizes. These instrumental variables estimates have a causal interpretation and were not overturned by several robustness checks.

CONCLUSION

We conclude that, for young adults in Uganda, additional years of education in the formal schooling system driven by a universal primary school intervention have not had a causal effect on reducing negative attitudes toward persons with HIV.

The Stigma Complex

Since the beginning of the twenty-first century, research on stigma has continued. Building on conceptual and empirical work, the recent period clarifies new types of stigmas, expansion of measures, identification of new directions, and increasingly complex levels. Standard beliefs have been challenged, the relationship between stigma research and public debates reconsidered, and new scientific foundations for policy and programs suggested. We begin with a summary of the most recent Annual Review articles on stigma, which reminded sociologists of conceptual tools, informed them of developments from academic neighbors, and claimed findings from the early period of "resurgence." Continued (even accelerated) progress has also revealed a central problem. Terms and measures are often used interchangeably, leading to confusion and decreasing accumulated knowledge. Drawing from this work but focusing on the past 14 years of stigma research (including mental illness, sexual orientation, HIV/AIDS, and race/ethnicity), we provide a theoretical architecture of concepts (e.g., prejudice, experienced/received discrimination), drawn together through a stigma process (i.e., stigmatization), based on four theoretical premises. Many characteristics of the mark (e.g., discredited, concealable) and variants (i.e., stigma types and targets) become the focus of increasingly specific and multidimensional definitions. Drawing from complex and systems science, we propose a stigma complex, a system of interrelated, heterogeneous parts bringing together insights across disciplines to provide a more realistic and complicated sense of the challenge facing research and change efforts. The Framework Integrating Normative Influences on Stigma (FINIS) offers a multilevel approach that can be tailored to stigmatized statuses. Finally, we outline challenges for the next phase of stigma research, with the goal of continuing scientific activity that enhances our understanding of stigma and builds the scientific foundation for efforts to reduce intolerance.

Hepatitis-related stigma in chronic patients: A qualitative study

BACKGROUND

Hepatitis is one of health problems throughout the world. It has numerous consequences on patients' life. Stigma, depression, social marginalization and financial problems are some of the challenges in these patients.

AIM

The purpose of this qualitative study was to examine hepatitis-related stigma and discrimination in patients living with chronic hepatitis in Iranian society.

METHODS

This present study was designed as a qualitative method, and this article shows up the results of a qualitative research study undertaken with patients living with hepatitis in Iran. The study uses a content analysis method. A purposive sample of 18 patients was chosen. Data were collected through a semi-structured interview and field note that the researchers will take during participants' observation. Data analysis process was performed on the texts which were generated from verbatim transcripts of the participants interviews.

RESULTS

Participants were between 18 and 61 years old. The main theme, Stigma, emerged from three themes during the process data analysis in this study. These themes were including fear to lose of family and social support, fear to present in public and fear of transmission.

CONCLUSIONS

This research indicates that stigma presents major challenges not only for patients living with chronic hepatitis but also for nurses, other healthcare practitioners, family and social networks, institutions and society. The researcher suggests that interventions to reduce or eliminate stigma should require individual, structural, cultural thought, society and systemic changes.

The influence of antiretroviral treatment on willingness to test: a qualitative study in rural KwaZulu-Natal, South Africa

Previous quantitative studies suggest a mutually reinforcing relationship between HIV counselling and testing (HCT) and antiretroviral treatment (ART). HCT is the entry into ART, and access to ART appears to increase HIV-testing uptake in settings with historically low uptake. Adopting a qualitative approach, this study examined the influence of ART on willingness to test for HIV, in a rural community in South Africa. Ninety-six in-depth interviews from a large community-based HIV-prevention trial were analysed. The data provide insight into the community members' views, perceptions and experiences regarding ART, and how they draw on these in making decisions about HIV testing. Several key factors that supported a positive relationship between ART and HIV testing were noted. These included the beliefs that ART brings hope and that it prolongs life; the powerful positive effect of witnessing the recovery of someone on treatment; and that ART encourages early HIV-testing behaviour. A few negative factors that could potentially weaken the effects of this positive relationship between ART and HCT uptake were the disclosure difficulties experienced by those enrolled in treatment, beliefs that ART does not cure HIV disease, and the travel distance to testing and treatment facilities from where people live and work. HIV/AIDS-service providers and programme planners should actively draw on these observations, to encourage increased HIV testing in communities and to ensure that the maximum number of people get the HIV treatment and care services that they require.

Perceptions of HIV/AIDS leaders about faith-based organisations' influence on HIV/AIDS stigma in South Africa

The extent of the HIV pandemic-particularly in the hardest-hit countries, including South Africa-has prompted a call for greater engagement of all groups, including faith-based organisations (FBOs). Although FBOs are known to play a substantial role in providing care and support to those affected by HIV and AIDS, empirical evidence in regard to their actions in the broader context of stigma is limited. A qualitative, key-informant survey was conducted in South Africa as part of a six-country international study to examine perceptions of how FBOs have contributed to reduction in HIV risk, vulnerability and related impacts. The special emphasis of this paper is the influence of FBOs on stigma and discrimination. In-depth interviews were held with 34 senior-level key informants who act as key decision-makers in the response to HIV and AIDS in South Africa. Secular and faith-based respondents shared their perceptions of the faith-based response, including FBOs' actions in relation to HIV/AIDS stigma and discrimination. Our study revealed that while FBOs were perceived as taking some action to address stigma in South Africa, FBOs were also thought to contribute to HIV/AIDS- discrimination through conflating issues of sexuality and morality, and through associating HIV and AIDS with sin. The interviewees indicated a number of internal and external challenges faced by FBOs to deal effectively with stigma, including lack of information and skills, the difficulty of maintaining confidentiality in health services, and self-stigmatisation which prevents HIV-infected persons from revealing their status. Findings from this study may help both faith-based and secular groups capitalise on the perceived strengths of FBOs as well as to elucidate their perceived weaknesses so that these areas of concern can be further explored and addressed.

Socioeconomic gradients in internalized stigma among 4,314 persons with HIV in sub-Saharan Africa

The stigma attached to HIV is a major public health problem given its adverse impacts on HIV prevention and on the psychosocial wellbeing of persons with HIV. In this study, I apply a novel method to data from the Demographic and Health Surveys to identify persons with HIV who were aware of their seropositivity at the time of the survey. The pooled dataset includes 4,314 persons with HIV in Cameroon, Ethiopia, Gabon, Kenya, Lesotho, Malawi, Rwanda, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe. My findings indicate that nearly one-fifth of study participants provided survey responses consistent with internalization of stigmatizing beliefs. Furthermore, in multivariable regression models, striking socioeconomic gradients in internalized stigma were observed. A clear implication of my findings is that the adverse health and psychosocial impacts of HIV stigma are likely concentrated among those with the fewest socioeconomic resources for managing and resisting it.

HIV stigma experienced by young men who have sex with men (MSM) living with HIV infection

Stigma can compromise the health of persons living with HIV. Although HIV is increasingly affecting young men who have sex with men (MSM), little is known about their experiences with HIV stigma. We used narrative data to examine HIV stigma experienced by young MSM living with HIV. Data came from 28 qualitative interviews with young MSM. We used inductive content analysis to identify themes across these interviews. Participants commonly discussed negative perceptions and treatment of persons living with HIV. Stigma could result in nondisclosure of HIV status, internalized stigma, and avoidance of HIV-related things. Some men discussed strategies that might combat stigma. Findings suggest that HIV stigma might challenge young MSM's health by undermining health-conducive resources (e.g., social support) and contributing to HIV vulnerability. Interventions that counteract HIV stigma may help to create environments that promote well-being among young MSM living with HIV.