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HIV stigma decreases with scale-up of HIV treatment
Roger Pebody, 2015-06-30 07:40:00
In high-prevalence countries of sub-Saharan Africa, the
scale-up of HIV treatment appears to have resulted in a lessening of
stigmatising attitudes in the general population, according to an analysis
published online by the American Journal
of Public Health.
Studies have previously shown that people who hold
stigmatising beliefs are more likely to have risky sexual behaviour and less
likely to test for HIV. People with HIV who have internalised stigmatising
beliefs are less likely to disclose their HIV status, more likely to be
depressed and less likely to adhere well to HIV treatment.
For the new analysis, researchers examined data from 43 surveys,
conducted in 18 African countries between 2003 and 2013. The surveys used
(Demographic and Health Surveys and AIDS Indicator Surveys) are nationally representative,
population-based surveys which ask four standardised questions to gauge HIV
- “If a member of your family became sick with AIDS, would you
be willing to care for her or him in your own household?”
- “Would you buy fresh vegetables from a shopkeeper or vendor
if you knew that this person had the AIDS virus?”
- “In your opinion, if a female teacher has the AIDS virus but
is not sick, should she be allowed to continue teaching in the school?”
- “If a member of your family got infected with the AIDS
virus, would you want it to remain a secret or not?”
The surveys showed that stigmatising attitudes were very
widely shared. In the earliest surveys included in the analysis, 84% of men and
91% of women gave a stigmatising response to at least one of these questions.
But those figures did decline a little over the decade that followed, to 81%
and 88% respectively.
That decade was a period of significant scale-up of HIV
treatment in many African countries, thanks to Global Fund and PEPFAR funding. At the time of
the earliest surveys in 2003 to 2006, just 2% of people living with HIV in the
countries studied were receiving HIV treatment. During the period of analysis,
coverage increased by an average of 17% in these countries, with some countries making better progress than others.
The data suggest a link between improving antiretroviral
coverage and decreasing HIV stigma. For example, surveys were conducted in
Zimbabwe in 2005 and 2010, a period in which treatment coverage increased
by 23%. Comparing the second survey to the first, 28% fewer men and 23% fewer
women expressed stigmatising views.
Looking at all 18 countries together – and making
statistical adjustments for other factors that could influence the results –
there was a statistically significant association between the proportion of people
living with HIV receiving HIV treatment and the percentage of the general
population endorsing HIV-related stigma.
For each 10% increase in HIV treatment coverage, 2.8% fewer
men and 2.3% fewer women gave stigmatising responses to at least one of the
The impact was clearest in the countries with a higher
prevalence of HIV included in the study (Cameroon, Kenya, Lesotho, Mozambique,
Nigeria, Rwanda, Tanzania, Uganda and Zimbabwe). Here, for each 10% increase in
HIV treatment coverage, 4.3% fewer people gave stigmatising answers.
When countries with an HIV prevalence lower than 2.8% were
analysed together, there were no statistically significant associations between
treatment coverage and stigma.
“Our findings suggest
that an additional important benefit of antiretroviral therapy scale-up may be
the diminution of HIV-related stigma in the general population,” the authors
conclude. They note that there are few data to show that other stigma-reduction
interventions are effective.
They suggest that because treatment improves the physical
health of people living with HIV and allows them to contribute economically to
society, treatment undermines one source of HIV stigma. This effect would be
most apparent in higher prevalence countries.
Nonetheless, the reductions in HIV stigma seen were
modest, with stigma remaining deeply entrenched in many African countries.