Stigma against people with HIV/AIDS in rural Ethiopia, 2005 to 2011: signs and predictors of improvement

How does a social norms-based intervention affect behaviour change? Interim findings from a cluster randomised controlled trial in Odisha, India

BACKGROUND

Behaviour change interventions targeting social norms are burgeoning, but researchers have little guidance on what they look like, and which components affect behaviour change. The Reduction in Anaemia through Normative Innovations (RANI) project designed an intervention to increase iron folic acid (IFA) consumption in Odisha, India.

OBJECTIVE

This paper examines the effect of the intervention at midline to understand which components of the RANI intervention affect uptake.

METHODS

Using a cluster randomised controlled design, we collected baseline data and midline data 6 months later from women of reproductive age in the control and treatment arms (n=3800) in Angul, Odisha, India. Using nested models, we analysed data from three different intervention components, monthly community-based testing for anaemia, participatory group education sessions, and videos, to determine the extent to which exposure to each of these components accounted for the overall intervention effect on haemoglobin and self-reported IFA use.

RESULTS

Overall, residing in a treatment as opposed to control village had little effect on midline haemoglobin, but increased the odds of taking supplements by 17 times. Exposure to each of the intervention components had a dose-response relationship with self-reported IFA use. These components, separately and together, accounted for most of the overall effect of treatment assignment on IFA use.

CONCLUSIONS

All intervention components increased iron supplement use to differing degrees of magnitude. It appears that a social norms-based approach can result in improving IFA uptake, though improvements in haemoglobin counts were not yet discernible.

Levels of HIV/AIDS stigma and associated factors among sexually active Ethiopians: analysis of 2016 Ethiopian Demographic and Health Survey Data

Background

Stigma and discrimination have fueled the transmission of the disease and dramatically increased its negative public health impact. Even though the disease has extremely ravaged human life, stigma, and discrimination attached to it are not well addressed in Ethiopia at the country level. The reduction of stigma and discrimination in a population are important indicators of the success of programs that target HIV prevention and control. This study aimed to assess the level of HIV-related stigma and its determinants among sexually active Ethiopians.

Methods

A public domain data were obtained from 2016 Ethiopian Demographic and Health Survey in which two-stage cross-sectional stratified cluster sampling was applied. A total of 28,371 sexually active Ethiopians were interviewed from both rural and urban parts of Ethiopia. Descriptive Statistics and multilevel ordinal logistic regression (proportional odds model) were used to summarize data and to investigate correlates of HIV-related stigma.

Results

Only 5.1% (95% CI: 4.5%, 5.8%) of sexually active Ethiopians did not have a stigmatizing attitude, whereas, 59.2% (95% CI: 57.3%, 61.1%) and 35.65% (95% CI: 33.5%, 37.9%) of them had a moderate and high level of stigma respectively. Regression results show that residence (AOR = 1.82, 95% CI:1.46, 2.27), education (AOR = 0.65,95% CI: 0.50,0.84), owning mobile (AOR = 0.63,95% CI:0.55,0.72), HIV-testing (AOR = 0.77, 95% CI:0.70,0.84), age (AOR = 0.81, 95% CI: 0.73, 0.91), religion (AOR = 1.53,95% CI:1.33,1.76), and marital status (AOR = 1.38, 95% CI:1.19, 1.61) were significantly associated with HIV-related stigma (p < 0.0001).

Conclusion

Regardless of all efforts put in a place to prevent and control HIV, a significant proportion of sexually active Ethiopians have stigmatizing attitudes. Residence, educational level, owning mobile, HIV test uptake, age, religion, and marital status were determinants of HIV-related stigma. Expanding mobile coverage, promoting HIV counseling and tests, promoting HIV education, and working with religious leaders, among other strategies could be used to minimize the stigma attached to the disease to best prevent and control it.

Measurement characteristics and correlates of HIV-related stigma among adults living with HIV: a cross-sectional study from coastal Kenya

OBJECTIVE

We studied the psychometric properties of the 12-item short version of the Berger HIV stigma scale and assessed the correlates of HIV-related stigma among adults living with HIV on the Kenyan coast.

DESIGN

Cross-sectional study.

SETTING

Comprehensive Care and Research Centre in the Kilifi County Hospital.

PARTICIPANTS

Adults living with HIV on combination antiretroviral therapy were recruited and interviewed between February and April 2018 (n=450).

MAIN OUTCOME MEASURES

HIV-related stigma.

RESULTS

450 participants with a median age of 43 years (IQR=36-50) took part in the study. Of these, 356 (79.1%) were female. Scale reliability and validity were high (alpha=0.80, test-retest reliability intraclass correlation coefficient=0.92). Using confirmatory factor analysis, we observed that the 12-item short version of the HIV stigma scale had a good fit for its hypothesised model (Comparative Fit Index=0.966, Tucker Lewis Index=0.955, root mean square error of approximation=0.044). Multigroup confirmatory factor analysis indicated measurement invariance across gender and age groups as ΔCFI was ≤0.01. Multivariate linear regression established that being female (β=2.001, 95% CI: 0.21 to 3.80, p=0.029), HIV status non-disclosure (β=4.237, 95% CI: 1.27 to 7.20, p=0.005) and co-occurrence of depressive and anxiety symptoms (β=6.670, 95% CI: 3.40 to 9.94, p<0.001) were significant predictors of perceived HIV-related stigma and that these variables accounted for 10.2% of the explained variability in HIV-related stigma among adults living with HIV from Kilifi.

CONCLUSIONS

Our results indicate that the 12-item short version of the HIV stigma scale is a valid and reliable measure of HIV stigma in Kenya. Furthermore, our study indicates that interventions aimed at reducing stigma need to take into account gender to address the specific needs of women, people who have not disclosed their HIV status, and those exhibiting symptoms of depression and anxiety, thereby improving their quality of life.

Social Support, Food Insecurity, and HIV Stigma Among Men Living with HIV in Rural Southwestern Uganda: A Cross-Sectional Analysis

BACKGROUND

HIV stigma is one of the major barriers to HIV care due to the fear of disclosure and social discrimination. HIV stigma among men in sub-Saharan countries, including Uganda, has been linked to the fear about how HIV status might affect their status in society. HIV among men in sub-Saharan settings has been associated with feelings of shame, reduced self-worth, and self-blame for their HIV positive status. Information about HIV stigma and its associated factors among men living with HIV in rural Uganda is limited. This study assessed the burden of HIV stigma and its association with social support and food insecurity among men accessing HIV care at a rural health facility in southwestern Uganda.

METHODS

We conducted a clinic-based cross-sectional study and consecutively enrolled 252 adult men accessing HIV care at a rural health centre in southwestern Uganda. We collected information on sociodemographic information, HIV stigma, social support, and food insecurity. We fitted modified Poisson regression models to determine the associations between social support, food insecurity, and HIV stigma.

RESULTS

The mean HIV stigma score of the study participants was 70.08 (SD 19.34) and 75% reported food insecurity 5% of whom were severely food insecure. The risk of HIV stigma was lower among those aged 35 years and above (adjusted risk ratio [ARR]=0.89; 95% CI 0.83-0.96; P=0.003, those who had been on ART for more than 5 years (ARR=0.92; 95% CI=0.84-0.99; P=0.04), and those who had social support (ARR=0.99; 95% CI=0.98-0.99; P=<0.001). Food insecurity was associated with an increased risk of HIV stigma (ARR=1.07; 95% CI 1.00-1.15; P=0.03). Social support moderated the effect of food insecurity on HIV stigma (P=0.45).

CONCLUSION

Stigma is common among men living with HIV in rural Uganda and is significantly associated with food insecurity. Social support moderated the effect of severe food insecurity on HIV stigma among men living with HIV. Interventions to build social support systems and to economically empower men living with HIV should be incorporated into the mainstream HIV care clinics.

HIV voluntary counseling and testing uptake and associated factors among Ethiopian youths: evidence from the 2016 EDHS using multilevel modeling

BACKGROUND

Existing evidence showed that Human Immunodeficiency Virus counselling and testing uptake among Ethiopian youths is low, and factors contributing to it are not well studied. Therefore, this study aims to assess the status of uptake and identify its determinants using the 2016 Ethiopia Demographic and Health Survey data.

METHOD

Data of 10,903 Ethiopian youths were extracted from the 2016 Ethiopian Demographic and Health Survey. The association between the response variable and the predictors was modeled by multilevel binary logistic regression, whereas adjusted odds ratio and confidence intervals were used to measure associations and their statistical significance. The variation in the uptake of counselling and testing of HIV across regions of Ethiopia was quantified by intra-class correlation.

RESULT

The current study revealed that, overall, 34.9% (95% CI: 33.5, 36.2%) Ethiopian youths were ever tested for human immunodeficiency virus. Results show that about 9% of the variation in the probability of being tested for the disease was due to the regional variations. Moreover, having moderate and comprehensive HIV knowledge, being rich, having risky sexual behaviour, having a better educational level, having professional work, being married, owning of mobile, and having access to media were positively associated with human immunodeficiency virus voluntary counselling and testing uptake. On the other hand, being male, following protestant religion, following Muslim religion, and following other religions than orthodox religion were negatively associated with the uptake of human immunodeficiency virus counselling and testing.

CONCLUSION

Voluntary human immunodeficiency virus counselling and testing uptake among Ethiopian youths is very low and varies across the regions which might hamper the ambitious plan of Ethiopia to end the disease as a public health threat by 2030. Emphasis should be given to promoting the youths' HIV-related knowledge through community-based education, encouraging and empowering the youths to participate in professional works by giving due focus to poor youths, and promoting mass media utilization to better achieve the plan.

Perceived HIV stigma and HIV testing among men and women in rural Uganda: a population-based study

BACKGROUND

Stigma is a formidable social structural barrier to HIV testing, and yet the effect of stigma on HIV testing is rarely examined at the community level. We aimed to examine the geospatial relationships of perceived HIV stigma and HIV testing among men and women living in rural Uganda.

METHODS

Women and men (aged ≥18 years or emancipated minor) residing in rural areas of Uganda who self-identified as HIV negative completed interviews that included measures of HIV testing history and how participants perceived HIV stigma. We used geospatial cluster analyses to identify areas of higher perceived stigma and lower perceived stigma and the geographical dispersion of these areas. We used Poisson regression models stratified by gender to test individual-level and community-level perceived stigma in relation to frequency of HIV testing in the previous 2 years.

FINDINGS

Between Nov 25, 2015, and May 26, 2017, we interviewed 9740 participants (4359 [45%] men and 5381 [55%] women]), among whom 940 (9%) had never been tested for HIV, and among those who had been tested, 1131 (12%) had not been tested in the previous 2 years. Men (3134 [72%] of 4359) were less likely to have been tested in the past 2 years than women (4535 [84%] of 5381) were (p<0·001). We used Poisson regression models, reporting B coefficients, to test study hypotheses regarding the effects of individual-level and community-level stigma on HIV testing frequency counts. Multilevel modelling showed that women showed significant individual-level (B=-0·173, p<0·001) and community-level (B=-0·223, p<0·001) associations between lower stigma predicting higher rates of HIV testing. For men, lower individual-level perceived stigma was also associated with higher testing frequency (B=-0·030, p=0·018), whereas higher community-level perceived stigma was associated with higher testing frequency (B=0·077, p=0·008).

INTERPRETATION

Our results suggest that perceived HIV stigma at the community level exerts a differential influence on testing for women and men. HIV testing campaigns that are targeted to men and women in rural Uganda will require gender tailoring to fit local contexts.

FUNDING

US National Institute of Mental Health.

The social network context of HIV stigma: Population-based, sociocentric network study in rural Uganda

RATIONALE

HIV-related stigma profoundly affects the physical and social wellbeing of people living with HIV, as well as the community's engagement with testing, treatment, and prevention. Based on theories of stigma elaborating how it arises from the relationships between the stigmatized and the stigmatizer as well as within the general community, we hypothesized that social networks can shape HIV-related stigma.

OBJECTIVE

To estimate social network correlates of HIV-related stigma.

METHODS

During 2011-2012, we collected complete social network data from a community of 1669 adults ("egos") in Mbarara, Uganda using six culturally-adapted name generators to elicit different types of social ties ("alters"). We measured HIV-related stigma using the 9-item AIDS-Related Stigma Scale. HIV serostatus was based on self-report. We fitted linear regression models that account for network autocorrelation to estimate the association between egos' HIV-related stigma, alters' HIV-related stigma and alters' self-reported HIV serostatus, while adjusting for egos' HIV serostatus, network centrality, village size, perceived HIV prevalence, and sociodemographic characteristics.

RESULTS

The average AIDS-Related Stigma Score was 0.79 (Standard Deviation = 0.50). In the population 116 (7%) egos reported being HIV-positive, and 757 (46%) reported an HIV-positive alter. In the multivariable model, we found that egos' own HIV-related stigma was positively correlated with their alters' average stigma score (b=0.53; 95% confidence interval [CI] 0.42-0.63) and negatively correlated with having one or more HIV-positive alters (b=-0.05; 95% CI -0.10 to -0.003).

CONCLUSION

Stigma-reduction interventions should be targeted not only at the level of the individual but also at the level of the network. Directed and meaningful contact with people living with HIV may also reduce HIV-related stigma.

Exploration of facilitators and barriers to the implementation of a guideline to reduce HIV-related stigma and discrimination in the Ethiopian healthcare settings: A descriptive qualitative study

BACKGROUND

The barriers to uptake of guidelines underscore the importance of going beyound the mere synthesis of evidence to tailoring the synthesized evidence into local contexts and situations. This requires in-depth exploration of local factors. This project aimed to assess contextual barriers and facilitators to the implementation of a guideline developed to reduce HIV-related stigma and discrimination (SAD) in the Ethiopian healthcare setting.

METHODS

A descriptive qualitative research study was conducted using a semi-structured interview guide informed by the Registered Nurses Association of Ontario (RNAO) framework. The interview was conducted among a purposive sample of seven key informants from Jimma University and Jimma Zone HIV Prevention and Control Office. The interviews were transcribed, coded and analysed using Atlas ti version 7.5 software packages.

RESULTS

Guideline attributes, provider-related factors and organizational and practice-related were identified as factors that can potentially affect the implementation of the guideline. The presence of expert patients were identified as agents for guideline implementation, whilst regular health education programs in addition to initiatives related to service quality improvement, were identified as suitable platforms to assist with the implementation of this guideline. Study participants recommended that the guideline should be disseminated through multidisciplinary team (MDT) meetings, gate keepers such as opinion leaders and unit heads, one-to-five networks and mentorship programs, as well as training, workshops and posters. The current study also indicated that continuous monitoring, evaluation and mentorship are critical elements in the integration of the guideline into the system of the hospital.

CONCLUSIONS

This study identified that guideline implementation can make use of existing structures and pathways such as MDT meetings, service quality improvement initiatives, one-to-five networks, training and workshops. Teamwork and partnership with stakeholders should be strengthened to strengthen facilitators and tackle barriers related to the implementation of the guideline. Effective implementation of the guideline also requires establishing an implementation structure. Moreover, indicators developed to track the implementation of stigma reduction guideline should be integrated into mentorship, MDT meetings and evaluation programs of the hospital to improve performance and to assist data collection on implementation experiences.

The Differential Effects of an Opt-Out HIV Testing Policy for Pregnant Women in Ethiopia When Accounting for Stigma: Secondary Analysis of DHS Data

Individual factors associated with HIV testing have been studied across multiple populations; however, testing is not just an individual-level phenomenon. This secondary analysis of 2005 and 2011 Ethiopia Demographic and Health Survey data was conducted to determine the extent to which the 2007 institution of an opt-out policy of HIV testing during antenatal care increased testing among women, and whether effects differed by women's stigmatizing beliefs about HIV. A logit model with interaction between pre-/post-policy year and policy exposure (birth in the past year) was used to estimate the increased probability of past-year testing, which may be attributable to the policy. Results suggested the policy contributed to a nine-point increase in the probability of testing (95% CI 0.06-0.13, p < 0.0001). A three-way interaction was used to compare the effects of exposure to the policy among women holding higher and lower HIV stigmatizing beliefs. The increase in the probability of past-year testing was 16 percentage points greater among women with lower stigmatizing beliefs (95% CI 0.06-0.27, p = 0.002). Women with higher stigmatizing beliefs were less likely to report attending antenatal care (ANC), testing at their last ANC visit, or being offered a test at their last ANC visit. We encourage researchers and practitioners to explore interventions that operate at multiple levels of socio-ecological spheres of influence, addressing both stigma and structural barriers to testing, in order to achieve the greatest results in preventing HIV.

Understanding HIV Transmission and Illness Stigma: A Relationship Revisited in Rural Rwanda

Integrating an understanding of HIV transmission with structural-behavioral prevention approaches remains a priority in low prevalence rural regions in Africa. Many national indicators use categorical survey responses which do not capture the cultural nuances of HIV transmission knowledge that potentially reify stigmatizing treatment of persons living with HIV (PL-HIV). We examined the relationship between quantitative and qualitative measures of HIV knowledge and four forms of stigma (individual attitudes, felt normative, social distance, and stigma perceived by PLHIV) among 200 rural residents in Rwanda. Forty-two percent qualitatively reported concurrent accurate and partial knowledge of HIV transmission. Being more knowledgeable about HIV transmission was associated with less desire for social distancing from PLHIV. Our findings highlight the continued importance of reinforcing an accurate understanding of HIV transmission and correcting misinformation by drawing on quantitative and qualitative assessments of HIV knowledge as critical arms of HIV stigma reduction programs in low prevalence rural regions.

"Protect Your Loved Ones From Fataki": Discouraging Cross-Generational Sex in Tanzania

The Fataki campaign aired in Tanzania via radio from 2008 to 2011 to address cross-generational sex, a major driver of HIV in the region. The campaign sought to incite social disapproval of men who engage in such relationships, generate dialogue around the issue, and encourage community interventions in these relationships through social learning. Using qualitative methods, we explored campaign reactions, use of the term Fataki to describe men in relationships with much younger women, and the nature of discussions spurred by the campaign. We conducted focus group discussions and individual interviews in Iringa and Pwani regions with young women, older men, and community leaders. Results showed that the Fataki term was widely used and had negative connotations reflecting social disapproval of men who participate in such relationships. Dialogue spurred by the campaign, primarily directed toward young women, focused on reasons for avoiding these relationships. We conclude with suggestions for relevant future interventions.

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.

Revisiting the importance of knowledge: from Namibia, a case for promoting knowledge by campaigns to reduce stigma

Reducing stigma against people living with HIV is key to encouraging HIV testing, which in turn is an important component in the treatment-as-prevention approach. We analyzed nationally representative survey data of participants aged 15 years and older in Namibia (N = 4,300) to determine whether knowledge about HIV and self-efficacy to protect against sexually transmitted HIV would be independently and jointly associated with stigma against people living with HIV, after controlling for demographics. Findings indicated that having less knowledge and feeling less self-efficacy were associated with greater stigma. Our key interaction hypothesis was also supported: stigma among those with lower self-efficacy to reduce risk of sexually transmitted HIV infection was particularly sensitive to the effects of increased knowledge about HIV. Results highlight the importance of enriching knowledge about HIV transmission modes, prevention strategies, and support services among those with low self-efficacy in order to reduce stigma against people living with HIV, and has useful implications for designing anti-stigma campaigns.

Health behavior change models for HIV prevention and AIDS care: practical recommendations for a multi-level approach

Despite increasing recent emphasis on the social and structural determinants of HIV-related behavior, empirical research and interventions lag behind, partly because of the complexity of social–structural approaches. This article provides a comprehensive and practical review of the diverse literature on multi-level approaches to HIV-related behavior change in the interest of contributing to the ongoing shift to more holistic theory, research, and practice. It has the following specific aims: (1) to provide a comprehensive list of relevant variables/factors related to behavior change at all points on the individual–structural spectrum, (2) to map out and compare the characteristics of important recent multi-level models, (3) to reflect on the challenges of operating with such complex theoretical tools, and (4) to identify next steps and make actionable recommendations. Using a multi-level approach implies incorporating increasing numbers of variables and increasingly context-specific mechanisms, overall producing greater intricacies. We conclude with recommendations on how best to respond to this complexity, which include: using formative research and interdisciplinary collaboration to select the most appropriate levels and variables in a given context; measuring social and institutional variables at the appropriate level to ensure meaningful assessments of multiple levels are made; and conceptualizing intervention and research with reference to theoretical models and mechanisms to facilitate transferability, sustainability, and scalability.