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 stigma:
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.
Chan BT et al. HIV Treatment Scale-Up and HIV-Related Stigma in Sub-Saharan Africa: A Longitudinal Cross-Country Analysis. American Journal of Public Health, 2015. (Abstract).
