More research is needed for understanding predictors of internalized stigma among people living with HIV

Predictors of internalised HIV-related stigma: a systematic review of studies in sub-Saharan Africa.

Pantelic M, Shenderovich Y, Cluver L, Boyes M. Health Psychol Rev. 2015 Jan 3:1-45. [Epub ahead of print]

Objective: This systematic review aims to synthesize evidence on predictors of internalised HIV stigma amongst people living with HIV in sub-Saharan Africa.

Method: PRISMA guidelines were used. Studies were identified through electronic databases, grey literature, reference harvesting and contacts with key researchers. Quality of findings was assessed through an adapted version of the Cambridge Quality Checklists.

Results: A total of 590 potentially relevant titles were identified. Seventeen peer-reviewed articles and one draft book chapter were included. Studies investigated socio-demographic, HIV-related, intra-personal and inter-personal correlates of internalised stigma. Eleven articles used cross-sectional data, six articles used prospective cohort data and one used both prospective cohort and cross-sectional data to assess correlates of internalised stigma. Poor HIV-related health weakly predicted increases in internalized HIV stigma in three longitudinal studies. Lower depression scores and improvements in overall mental health predicted reductions in internalized HIV stigma in two longitudinal studies, with moderate and weak effects respectively. No other consistent predictors were found.

Conclusion: Studies utilizing analysis of change and accounting for confounding factors are necessary to guide policy and programming but are scarce. High-risk populations, other stigma markers that might layer upon internalised stigma, and structural drivers of internalised stigma need to be examined.

Abstract access  [1]

Editor’s notes: Internalized stigma can act as a barrier to HIV prevention and treatment. It can occur when a person living with HIV endorses negative attitudes associated with HIV and accepts these attitudes as applicable to themselves. Few stigma reduction programmes exist for people living with HIV. However, two recent studies have illustrated that internalized stigma reduction may be feasible through programmes targeting individual level factors. This paper systematically reviewed the evidence on predictors of internalized stigma among people living with HIV. The review included 18 papers looking at 13 unique studies in South Africa, Lesotho, Malawi, United Republic of Tanzania, Swaziland, Mozambique, Uganda, Kenya and Burkina Faso. All included studies were observational including prospective cohort and cross-sectional study designs. In all studies, participants were recruited through health facilities. Most included studies did not report on sampling methods.

All included studies defined internalized stigma as a negative self-perception due to HIV status and the resultant feelings of shame, difficulties around disclosure and self-exclusion. Only one study looked at the effect of antiretroviral therapy (ART) use on internalized stigma and found no evidence of an association. There was weak evidence across three studies that improved physical health (measured as improved physical functioning and fewer HIV-associated symptoms) lead to reductions in internalized HIV stigma. Two studies found some evidence that lower depression scores and improvements in overall mental health predicted reductions in internalized HIV stigma. There were inconsistent findings on whether time on ART had any association with internalized stigma. No other associations with socio-demographic or interpersonal factors were found. This is a field of new and emerging research and no implications for practice can be drawn given the inconsistent findings across studies. The cross-sectional nature of most of the included studies means that it is not possible to assess long-term associations. Further research is needed to understand the factors associated with internalized stigma and how these might change over time. Future research should use rigorous study methods and should focus on key populations, HIV transmission, and structural drivers of HIV.

Africa [7]
Burkina Faso [8], Kenya [9], Lesotho [10], Malawi [11], Mozambique [12], South Africa [13], Swaziland [14], Uganda [15], United Republic of Tanzania [16]
  • [17]