Scale-up of HIV treatment lessens stigma

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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 a recent analysis. 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 stigma: 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?; and 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 questions. 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.

Abstract
Objectives. We estimated the association between antiretroviral therapy (ART) uptake and HIV-related stigma at the population level in sub-Saharan Africa.
Methods. We examined trends in HIV-related stigma and ART coverage in sub-Saharan Africa during 2003 to 2013 using longitudinal, population-based data on ART coverage from the Joint United Nations Program on HIV/AIDS and on HIV-related stigma from the Demographic and Health Surveys and AIDS Indicator Surveys. We fitted 2 linear regression models with country fixed effects, with the percentage of men or women reporting HIV-related stigma as the dependent variable and the percentage of people living with HIV on ART as the explanatory variable.
Results. Eighteen countries in sub-Saharan Africa were included in our analysis. For each 1% increase in ART coverage, we observed a statistically significant decrease in the percentage of women (b = −0.226; P = .007; 95% confidence interval [CI] = −0.383, −0.070) and men (b = −0.281; P = .009; 95% CI = −0.480, −0.082) in the general population reporting HIV-related stigma.
Conclusions. An important benefit of ART scale-up may be the diminution of HIV-related stigma in the general population.

Aidsmap material
American Journal of Public Health abstract


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