HIV stigma starts young, but can be corrected, African schoolchildren's study shows

A study conducted among nearly 40,000 school students aged 12 to 14 in nine southern African countries shows that in some countries over a fifth of students would “avoid or shun” a friend who revealed they had HIV and that in three countries over a third of students believe that children living with HIV should not be allowed to continue to attend school.

These attitudes were most strongly associated with rural rather than urban living, poverty, having inaccurate beliefs about HIV and especially that HIV can be caught by casual contact, and lack of specific HIV education. Girls and older children were slightly less likely to have these discriminatory opinions, but not to the extent, the researchers comment, that gender-specific HIV education is indicated.

Discouragingly, schoolchildren were somewhat more likely to have discriminatory attitudes if they knew someone who had HIV. However, the questionnaire could not discover who these HIV-positive people were and the relationship they had to the children.

The study - attitudes

The researchers circulated a questionnaire to 39,664 children in 1807 schools in Botswana, Lesotho, Malawi, Mozambique, Namibia, South Africa, Swaziland, Zambia and Zimbabwe. Most of them were aged 12-14 and equal numbers were boys and girls. Somewhat more (59%) lived in rural rather than urban areas. Underlining the toll of both AIDS and other illness in Africa, one-third of children had experienced the death of either one or both parents. Thirty-eight per cent said that they knew a person who had HIV.

The questionnaire asked how the students would behave towards a close friend who disclosed they had HIV. From 8.2% (in Malawi) to 23.4% (in Lesotho) of students said they would ‘avoid or shun’ that friend; more than 20% would also do this in Mozambique and Zimbabwe.

It also asked if they believed that children living with HIV should be allowed to attend school. Here from 12% (in Malawi) to 42% (in Zimbabwe) of students said ‘no’ and in Lesotho and Zambia more than a third of respondents also answered ‘no’.

Slightly more boys than girls held discriminatory attitudes, but this difference was rarely statistically significant and in the least-prejudiced country, Malawi, boys were more open-minded than girls.

There were highly significant differences in most countries between rural and urban environments and between richer and poorer students and in every country except Mozambique and Malawi, between twice and four times as many students in rural as opposed to urban areas said they would avoid or shun an HIV-positive friend. The urban-rural difference was not quite so pronounced with the attending-school question in most countries, except in Zimbabwe, where fully 50% of rural schoolchildren thought children living with HIV should be banned from school but only 17% of urban students.

There was a similar difference between poorer and richer children, with children from poor families two to five times more likely to avoid or shun a friend and a similar difference seen in the attending-school question, apart from Malawi and Swaziland.

The study - beliefs

The questionnaire also sought to discover correct and erroneous knowledge about HIV transmission. It asked about sexual risks and here children’s knowledge was relatively good, with 71% answering ‘yes’ correctly to a list of sexual-contact ways HIV could be spread, only failing on the one question where the correct answer was ‘no’ (“Having sex only with people who look healthy is one way to prevent HIV”).

It also asked about a list of casual contacts ranging from using a toilet seat to mosquito bites to wearing an HIV-positive person’s clothes and asked if any of them could spread HIV. Twenty-four per cent of children answered ‘yes’ to at least one of these, with a maximum of 35% in Lesotho. More than 25% of all respondents and over 40% in Botswana, Lesotho, South Africa and Zimbabwe believed that coughing could spread HIV – though this may have been influenced by confusing HIV with TB.

In all countries other than Malawi – where children were most likely to give the correct answers – correct HIV transmission knowledge was significantly associated with fewer discriminatory opinions, and incorrect beliefs about casual contact were strongly and significantly associated with discriminatory attitudes everywhere but Swaziland. Children who had incorrect beliefs about casual contact were more than twice as likely to have discriminatory attitudes as ones with correct beliefs in six out of nine countries and interestingly, the minority of Malawians who did believe HIV was spread casually were nearly five times as likely to harbour prejudices, suggesting that the prejudices could be fuelling incorrect beliefs as much as the other way round. 

The researchers also asked if someone who had AIDS was ‘bewitched’ or cursed by others, a common cultural belief in Africa, but although a quarter of children believed this was the case, this was not associated with discriminatory attitudes.

The study - knowledge

In seven of nine countries, personal acquaintance with someone with HIV was associated with slightly more likelihood of having discriminatory attitudes, though only in South Africa did this reach statistical significance; here children who said they know someone with HIV were 27% more likely to espouse prejudice.

Reading level and school exam scores were associated with less discriminatory attitudes in most countries, showing that attitudes towards people living with HIV are not too deeply engrained to be correctable with education.

The two countries with the lowest scores for discriminatory attitudes, Malawi and to a lesser extent Swaziland, are small countries with high HIV prevalence that have mounted particularly strong public awareness campaigns and more recently have concentrated on providing access to antiretroviral therapy and, in the case of Malawi, especially to testing.

The researchers comment: “Our study points towards the need for early interventions (age 13 or before) to reduce stigma and discrimination among children, especially in schools in rural and poorer areas. In particular, interventions should aim to correct misconceptions that HIV can be transmitted via casual contact with people living with HIV.”