Trends in HIV-related stigma in the general population during the era of antiretroviral treatment expansion: an analysis of 31 sub-Saharan African countries
Chan BT, Tsai AC.
Background: HIV-related stigma is an important public health problem because it is associated with increased risk-taking behavior, reduced uptake of HIV testing, and decreased adherence to antiretroviral therapy (ART). ART expansion may reduce HIV-related stigma through improvements in physical health among people living with HIV (PLHIV), which lead to economic rehabilitation and social reintegration. However, the extent to which levels of HIV-related stigma in the general population have changed during the current era of ART scale-up in sub-Saharan Africa is unknown.
Methods: Data on HIV-related stigma in the general population, including stigmatizing attitudes and anticipated stigma, were drawn from the Demographic and Health Surveys (DHSs) and AIDS Indicator Surveys (AISs) of 31 sub-Saharan African countries between 2003-2013. We fitted linear regression models with robust standard errors and country fixed effects, specifying stigmatizing attitudes or anticipated stigma as the dependent variable and year as the explanatory variable; all estimates were adjusted for socio-demographic variables and HIV knowledge.
Results: We found a statistically significant negative association between year and stigmatizing attitudes (adjusted b=-0.021; 95% CI, -0.028 to -0.015) but a statistically significant positive association between year and anticipated stigma (adjusted b=0.025; 95% CI, 0.019 to 0.031). Compared to the baseline mean across countries in 2003 (Figure 1), these regression coefficients suggested an approximately 4% reduction in prevalence of stigmatizing attitudes and 4% increase in prevalence of anticipated stigma with each year. Adjustment for HIV knowledge yielded no substantive changes to these findings.
Conclusion: During a period of ART expansion in sub-Saharan Africa, anticipated stigma in the general population increased despite a decrease in stigmatizing attitudes towards PLHIV. Our findings suggest that ART expansion alone is insufficient to reduce HIV-related stigma. Further study is needed to understand the reasons for worsening anticipated stigma in the general population and to develop effective anti-stigma interventions.