Factors associated with HIV-related stigma in three African countries (Project ACCLAIM)
Background: In 2013, the Elizabeth Glaser Pediatric AIDS Foundation (EGPAF) undertook a baseline knowledge, attitudes and beliefs (KAPB) household survey as part of a three-arm, community-based randomized trial to improve the uptake and retention of women in MCH and PMTCT services in Swaziland, Uganda and Zimbabwe. EGPAF also assessed social and behavioral factors including HIV-related stigma using eight selected validated stigma scales for community and individual attitude measures. In this analysis, we present factors associated with stigma in the three countries.
Methods: We surveyed randomly selected households using a structured questionnaire with data entered into a database on laptops. One adult (male or female) per household was randomly selected from eligible (18-60 years) adults. We analyzed demographic, socioeconomic and HIV testing factors in relation to the mean values of the stigma scales using generalized estimating equations with a binomial distribution, a logit link function and the compound symmetry correlation structure. We used principal component analysis to identify the most discriminating stigma measures. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated along with p-values.
Results: Over 3,000 respondents were surveyed; 1099 in Swaziland, 1140 in Uganda, 1079 in Zimbabwe. Of the eight stigma measures, two were the most discriminating: “HIV/AIDS is the result of sinning”, and “It would be foolish to marry someone who is living with HIV or AIDS”. After adjustment for the covariates of age, gender, marital status, education, occupation and HIV testing, “country” was found to be significantly associated (p< 0.001) with agreement with the statement “HIV/AIDS is the result of sinning”, with ORs of 12.4 (95% CIs: 9.3, 16.6), for Uganda, and 0.52 (95% CIs: 0.39, 0.68) for Swaziland relative to Zimbabwe. Women were less likely than men to have stigmatizing attitudes (OR: 0.79, p< 0.02), as were those tested for HIV (OR: 0.69, p< 0.001). Higher levels of education, (ORs: primary, 0.66, p< 0.003, secondary, 0.34, p< 0.001, tertiary, 0.22, p< 0.001) were associated with less stigma, while formal employment with more stigma (OR: 1.64, p< 009).
Conclusions: High levels of HIV stigma persist in the community. Evidence-informed approaches to prevent and mitigate stigma are needed.
G. Woelk1, M.P. Kieffer2, D. Mpofu3, N. Herrera4, D. Walker5, H. Hoffman4, The ACCLAIM Study Group
1Elizabeth Glaser Pediatric AIDS Foundation, Research Department, Washington, United States, 2Elizabeth Glaser Pediatric AIDS Foundation, Program Innovation and Policy, Lilongwe, Malawi, 3Elizabeth Glaser Pediatric AIDS Foundation, Program Innovation and Policy, Mbabane, Swaziland, 4George Washington University, Epidemiology and Biostatistics, Washington, United States, 5United States Agency for International Development, Bureau for Global Health, Office of HIV/AIDS, Washington, United States