Individual and community-level risk factors for HIV stigma in 21 Zambian and South African communities: analysis of data from the HPTN071 (PopART) study

James R. Hargreaves, Shari Krishnaratne, Hlengani Mathema, Pamela S. Lilleston, Kirsty Sievwright, Nomtha Mandla, Tila Mainga, Redwaan Vermaak, Estelle Piwowar-Manning, A Schaap, Deborah Donnell, Helen Ayles, Richard J. Hayes, Graeme Hoddinott, Virginia Bond, Anne Stangl, on behalf of the HPTN 071 (PopART Study Team) AIDS, 2018; Read the full paper online

HIV stigma is present whenever HIV infection is linked to negative stereotypes that mark a person living with HIV as different from the rest of the population; a separation of ‘them’ from ‘us.’ This separation then leads to status loss, which can result in negative outcomes for people living with HIV (PLHIV). Stigma experienced by PLHIV can include being gossiped about, insulted or physically assaulted in communities and healthcare settings. Internalized stigma occurs whenever PLHIV apply the same negative feelings to themselves and can have mental health consequences. HIV stigma infringes human rights and can inhibit access to HIV testing and care.

Few studies have compared data both from those whose beliefs and behaviours are thought to drive the stigmatization process and also from those who experience it. The community-level factors that give rise to stigma are under-studied. Stigma theories suggest that the beliefs and behaviours of community members and health workers (HW) are drivers of stigma, but there are few quantitative data to support this. This paper addresses that gap by analysing baseline data from a large cohort study of HIV stigma nested within the HPTN 071 (PopART) trial. 

Key findings

  • In this large study in 21 urban communities across two countries, 35.5% of PLHIV reported some type of stigma.
  • Experienced stigma in the community and internalized stigma were more common in Zambian communities, whereas experienced stigma in healthcare settings was more common in South Afrian communities.
  • There were few individual predictors of internalized stigma, but experienced stigma was associated with sociodemographic and behavioural characteristics.
  • Experienced stigma was more common among those reporting more risk behaviour.
  • Those who has been diagnosed for longer and who had disclosed to others reported more experienced stigma, perhaps reflecting their greater visibility. They also reported less internalized stigma, perhaps reflecting having had a longer period to 'accept' their status.

The results of the study will inform ongoing work addressing the core hypotheses for the nested study: that the HPTN 071 (PopART) intervention may reduce levels of stigma in study communities, that stigma may undermine the effectiveness of efforts to scale up testing and treatment, or that the forms of HIV stigma may change over the period of the trial.

Related resource

Technical Brief: Measuring HIV stigma and discrimination

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