Optimizing HIV Intervention Through Understanding HIV/AIDS-Related Stigma in South Africa

Introduction:  HIV/AIDS is exacerbated by stigma. HIV-positive individuals often face community-wide discrimination or shame, and may even be outcast from their families or communities. Particularly in Sub-Saharan Africa, where incidence of HIV is high and knowledge about the cause and treatment of HIV is often low, HIV/AIDS-related (HAR) stigma is a pervasive problem. Such stigma is thought to both impede the ability of available health services to prevent new incidence of HIV, as well as to deter HIV-positive individuals from seeking and adhering to treatment.

Despite its important implications for the efficacy of preventive HIV interventions and for the morbidity and mortality of HIV-positive individuals in Sub-Saharan Africa, no studies have simultaneously examined the interrelationships among HAR stigma, barriers to HIV-related health services, and HIV outcomes in this context. Also, despite the theoretical dependence of stigma on community-level and ecological processes, no studies have measured HAR stigma in Sub-Saharan Africa as a community-level construct. This study aims to address these above gaps in the Sub-Saharan African literature.

Methods: The survey data for this study are particularly advantageous to the study of HAR stigma and HIV outcomes because the sample is composed of randomly-selected clusters of households within 24 urban and rural communities in KwaZulu-Natal, South Africa (N = 1961 households). As such, it includes both HIV-positive and non-HIV-positive participants from various socio-demographic backgrounds, and minimizes biases of selection into the sample. The data nest individuals within households within communities, allowing for multi-level analysis.

Results: Preliminary analyses found that higher HAR stigma levels, measured at the community level, significantly predicted more reported barriers to health services at the community level (B=0.153; S.E.=0.005; p < .0005). Community-level HAR stigma also predicted higher community-level HIV prevalence (B=0.110; S.E.=0.517; p < .0005). Finally, more health service barriers at the community level predicted higher community-level HIV prevalence (B=0.105; S.E.=2.309; p < .005).

Conclusions: These findings suggest that understanding HAR stigma in this context can help the prevention field to understand patterns of HIV-positive persons’ utilization of treatment-based health services, to understand patterns of utilization of preventive services among entire communities, and to more accurately estimate the impact such preventive interventions may have on HIV/AIDS incidence. It can therefore help preventionists learn how to maximize implementation efficiency and program accessibility, thereby making greater strides in the reducing new incidence and improving access to care among PLWHA.