Stigma and HIV – the continuing challenge

Persistent HIV-related stigma in rural Uganda during a period of increasing HIV incidence despite treatment expansion.

Chan BT, Weiser SD, Boum Y, Siedner MJ, Mocello AR, Haberer JE, Hunt PW, Martin JN, Mayer KH, Bangsberg DR, Tsai AC. AIDS. 2014 Sep 27. [Epub ahead of print]

Objective: Programme implementers have argued that the increasing availability of antiretroviral therapy (ART) will reduce the stigma of HIV. We analyzed data from Uganda to assess how HIV-related stigma has changed during a period of ART expansion.

Design: Serial cross-sectional surveys.

Methods: We analyzed data from the Uganda AIDS Rural Treatment Outcomes study during 2007-2012 to estimate trends in internalized stigma among people living with HIV (PLHIV) at the time of treatment initiation. We analyzed data from the Uganda Demographic and Health Surveys from 2006 to 2011 to estimate trends in stigmatizing attitudes and anticipated stigma in the general population. We fitted regression models adjusted for sociodemographic characteristics, with year of data collection as the primary explanatory variable.

Results: We estimated an upward trend in internalized stigma among PLHIV presenting for treatment initiation [adjusted b = 0.18; 95% confidence interval (CI), 0.06-0.30]. In the general population, the odds of reporting anticipated stigma were greater in 2011 compared with 2006 [adjusted odds ratio (OR) = 1.80; 95% CI, 1.51-2.13], despite an apparent decline in stigmatizing attitudes (adjusted OR = 0.62; 95% CI, 0.52-0.74).

Conclusion: Internalized stigma has increased over time among PLHIV in the setting of worsening anticipated stigma in the general population. Further study is needed to better understand the reasons for increasing HIV-related stigma in Uganda and its impact on HIV prevention efforts.

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Editor’s notes: This paper provides very useful insights on HIV and stigma. The authors caution that the results may only apply to Uganda, a country where incidence has risen in recent years. However, contrary to their concern, the findings are likely to be more generalizable. As the authors note, social desirability bias may have affected the way people reported potentially stigmatising attitudes: people were sensitised to know what the correct answer was. Or it may be that while an individual may have changed their own attitude, they believe that stigmatising attitudes are prevalent in the wider society. Thus anticipated stigma, fear of disclosure for example, had increased. Many people had believed that the roll-out of antiretroviral therapy would mean an end to HIV stigma, instead we have people fearing that treatment is hiding people living with HIV from public view. This valuable paper describes these processes and highlights the very complex nature of HIV-related stigma; a timely reminder of the continuing challenges in ‘the era of ART expansion’. 

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