Anne Stangl

A systematic review of interventions to reduce HIV-related stigma and discrimination from 2002 to 2013: how far have we come?

HIV‐related stigma and discrimination continue to hamper efforts to prevent new infections and engage people in HIV treatment, care and support programmes. The identification of effective interventions to reduce stigma and discrimination that can be integrated into national responses is crucial to the success of the global AIDS response.

COMBATING HIV STIGMA IN HEALTH CARE SETTINGS: WHAT WORKS?

The purpose of this review paper is to provide information and guidance to those in the health care setting about why it is important to combat HIV-related stigma and how to successfully address its causes and consequences within health facilities. Research shows that stigma and discrimination in the health care setting and elsewhere contributes to keeping people, including health workers, from accessing HIV prevention, care and treatment services and adopting key preventive behaviours.Studies from different parts of the world reveal that there are three main immediately actionable causes of HIV-related stigma in health facilities: lack of awareness among health workers of what stigma looks like and why it is damaging; fear of casual contact stemming from incomplete knowledge about HIV transmission; and the association of HIV with improper or immoral behaviour.To combat stigma in health facilities, interventions must focus on the individual, environmental and policy levels. The paper argues that reducing stigma by working at all three levels is feasible and will likely result in long-lasting benefits for both health workers and HIV-positive patients. The existence of tested stigma-reduction tools and approaches has moved the field forward. What is needed now is the political will and resources to support and scale up stigma-reduction activities throughout health care settings globally.

Reducing Stigma and Discrimination to Improve Child Health and Survival in Low- and Middle-Income Countries: Promising Approaches and Implications for Future Research

The social processes of stigmatization and discrimination can have complex and devastating effects on the health and welfare of families and communities, and thus on the environments in which children live and grow. The authors conducted a literature review to identify interventions for reducing the stigma and discrimination that impede child health and well-being in low- and middle-income countries, with a focus on nutrition, HIV/AIDS, neonatal survival and infant health, and early child development. Despite broad consensus on the importance of stigma and discrimination as barriers to access and uptake of health information and services, the authors found a dearth of research and program evaluations directly assessing effective interventions in the area of child health except in the area of reducing HIV-related stigma and discrimination. While the literature demonstrates that poverty and social exclusion are often stigma-laden and impede adult access to health information and services, and to education relevant to family planning, child rearing, nutrition, health promotion, and disease prevention, the child health literature does not document direct connections between these known mediators of child health and the stigmatization of either children or their caregivers. The child health field would greatly benefit from more research to understand and address stigma as it relates to child health and well-being. The authors suggest applying a framework, adapted from the HIV stigma field, to direct future research and the adaptation of existing strategies to reduce HIV-related stigma and discrimination to address social and health-related stigmas affecting children and their families.

Individual and community-level risk factors for Hiv stigma in 21 Zambian and South African communities: analysis of data from the Hptn071 (popart) study

Objective: To describe the prevalence and determinants of HIV stigma in 21 communities in Zambia and South Africa. Design: Analysis of baseline data from the HPTN 071 (PopART) cluster-randomized trial. HIV stigma data came from a random sample of 3859 people living with HIV. Community-level exposures reflecting HIV fears and judgements and perceptions of HIV stigma came from a random sample of community members not living with HIV (n = 5088), and from health workers (HW) (n = 851). Methods: We calculated the prevalence of internalized stigma, and stigma experienced in the community or in a healthcare setting in the past year. We conducted risk-factor analyses using logistic regression, adjusting for clustering. Results: Internalized stigma (868/3859, prevalence 22.5%) was not associated with sociodemographic characteristics but was less common among those with a longer period since diagnosis (P = 0.043). Stigma experienced in the community (853/3859, 22.1%) was more common among women (P = 0.016), older (P = 0.011) and unmarried (P = 0.009) individuals, those who had disclosed to others (P < 0.001), and those with more lifetime sexual partners (P < 0.001). Stigma experienced in a healthcare setting (280/3859, 7.3%) was more common among women (P = 0.019) and those reporting more lifetime sexual partners (P = 0.001) and higher wealth (P = 0.003). Experienced stigma was more common in clusters wherever community members perceived higher levels of stigma, but was not associated with the beliefs of community members or HW. Conclusion: HIV stigma remains unacceptably high in South Africa and Zambia and may act as barrier to HIV prevention and treatment. Further research is needed to understand its determinants.

“My mother told me that I should not ”: a qualitative study exploring the restrictions placed on adolescent girls living with HIV in Zambia

Adolescent girls in sub‐Saharan Africa are disproportionately affected by HIV due to a range of social and structural factors. As they transition to adulthood, they are recipients of increasing blame for HIV infection and ‘improper’ sex, as well as increasing scrutiny, restrictions and surveillance. This study used a qualitative and participatory approach to explore the messaging and restrictions imposed on adolescent girls living with HIV in Zambia.

Predictors of timely linkage-to-ART within universal test and treat in the HPTN 071 (PopART) trial in Zambia and South Africa: findings from a nested case-control study.

HPTN 071 (PopART) is a three‐arm community randomized trial in Zambia and South Africa evaluating the impact of a combination HIV prevention package, including universal test and treat (UTT), on HIV incidence. This nested study examined factors associated with timely linkage‐to‐care and ART initiation (TLA) (i.e. within six‐months of referral) in the context of UTT within the intervention communities of the HPTN 071 (PopART) trial.

Trends in Responses to DHS Questions Should Not Be Interpreted as Reflecting an Increase in "Anticipated Stigma" in Africa.

To the Editors:In sub-Saharan Africa, measurements of change in levels of HIV-related stigma have not been well reported. Years of data have been collected through the Demographic and Health Surveys (DHS) and AIDS Indicator Surveys on responses to questions aimed at determining attitudes toward peop

HIV-Related Stigma and Children

HIV-related stigma affects the health and well-being of children and adolescents at all stages of development, from an expectant mother avoiding antenatal care for fear of getting tested for HIV, to a child skipping her antiretroviral medication when school friends are around for fear of her HIV status being discovered, to a teenager’s worry that his girlfriend will leave him if he discloses his HIV status. In order to ensure a healthy transition to adulthood for children and adolescents living with HIV and to reduce new infections among adolescents, it is critical that we tackle stigma and discrimination. This chapter aims to create a greater understanding of the challenges and needs of this population with regard to HIV-related stigma and discrimination by describing the stigmatization process, demonstrating how stigma impacts children and adolescents living with HIV and their families, summarizing the latest evidence on stigma-reduction interventions, and highlighting several key areas for future research and intervention development.

P14.14 Intersecting stigmas: a framework for data collection and analysis of stigmas faced by people living with hiv and key populations

Introduction Stigma can impede the implementation of HIV prevention and treatment programmes. Many measurement scales have been developed, though few have addressed intersecting stigmas: that is to say, multiple stigmas faced by people living with HIV, and key populations at high risk of HIV. Methods We developed an approach to measure intersecting stigmas nested within the HPTN 071 (PopART) trial, conducted in South Africa and Zambia. We adopted best-practice wording to assess key domains of stigma, building on a process of global consultative indicator harmonisation. We designed nested data collection items in surveys for parallel use among the general population, health workers and people living with HIV (PLHIV) - including health workers living with HIV - to assess the same phenomena from multiple perspectives. We also designed “parallel” assessments of key population stigma within the health care worker survey to compare the attitudes and perceptions of health care workers towards PLHIV, and those at increased risk of HIV infection, such as migrants, sex workers, MSM, young women, and people with disabilities. A core set of seven questions was included in the HPTN071 (PopART) surveys conducted among the general population (over 10,000 individuals), PLHIV (about 4000 individuals) and health care workers (over 1000 individuals). These items assessed two key domains of HIV stigma: drivers of stigma and manifestations of stigma. In the health care worker survey, questions specific to key populations were also included, to assess health care worker attitudes, experiences and perceptions about those at increased risk of HIV as listed above. We developed an approach to visually represent the complex data set using methods based on social-network analysis. We developed an approach to assess intersecting HIV-related stigmas, incorporating data collected from different population groups. Data collection is ongoing. Disclosure of interest statement HPTN 071 is sponsored by the National Institute of Allergy and Infectious Diseases (NIAID) under Cooperative Agreements UM1-AI068619, UM1-AI068617, and UM1-AI068613, with funding from the US President’s Emergency Plan for AIDS Relief (PEPFAR). Additional funding is provided by the International Initiative for Impact Evaluation (3ie) with support from the Bill and Melinda Gates Foundation, as well as by NIAID, the National Institute on Drug Abuse (NIDA) and the National Institute of Mental Health (NIMH), all part of NIH. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIAID, NIMH, NIDA, PEPFAR, 3ie, or the Bill and Melinda Gates Foundation. We have no conflicts of interest to declare.