Experiences and perceptions of HIV/AIDS-related stigma amongst people on antiretroviral treatment in Khayelitsha, South Africa

HIV/AIDS-related stigma is a recognised problem for people living with HIV/AIDS (PLWHA) yet little research on experiences of stigma has been conducted in sub-Saharan Africa, the epicentre of the disease.? This paper employs quantitative analysis to measure the extent and nature of stigma experienced by 242 people on antiretroviral treatment in Khayelitsha (an urban African community in Cape Town, South Africa). This research draws an important distinction between experienced stigma and perceived stigma (i.e. perceptions of stigma in the community). The results show that while relatively few respondents (17%) reported experiencing a lot of stigma, the majority (75%) had experienced some stigma. Experiences of stigma within households were found to be rare (thus adding to the emerging evidence of general support for PLWHA from family members). Although some reported no experiences of stigma, almost all individuals reported perceived stigma (i.e. believed they lived in a stigmatising environment). Both experienced stigma and perceived stigma were related to inconsistent condom use, fear of disclosure, depression/anxiety and lack of self-efficacy/confidence. As expected, experienced stigma influenced perceived stigma and those affiliated to a religious organisation were shown to manifest more perceived stigma.? Health-related problems and the clinic where treatment was obtained (which could be a proxy for different social contexts) were significant determinants of experienced stigma. This indicates the importance of the biophysical manifestations of HIV/AIDS and community-level variables in shaping PLWHA's experiences and fears of stigma

Quantifying Stigma in the Adult Population of Cape Town

This paper builds on previous analyses of HIV/AIDS-related stigma among young adults (aged 15-23) in the Cape Metropolitan Area by using a representative sample of adults from the same area. It compares the findings from both surveys, and assesses whether the differences between the findings amongst young adults and previous national studies were due to the different age profiles of the samples. Findings show that age is not an important determinant of stigma, indicating similar levels of stigma for all ages, and AIDS education should target all age groups, not just young adults. As was the case with earlier research conducted with young adults only, the prevalence and magnitude of HIV/AIDS-related stigma in Cape Town was found to be significantly greater than stigma levels measured in previous national surveys. Most surveys measure stigma by focussing on behavioural intentions towards people living with HIV/AIDS, often concentrating on behavioural intentions towards family or friends. This paper measures behavioural intentions as well as three attitudinal components of HIV/AIDS-related stigma: instrumental (i.e. indicating fear of infection), symbolic (holding negative attitudes based on values) and resource-based (holding negative attitudes based on resources). Behavioural intentions are deconstructed into (1) intentions towards family/friends and (2) intentions towards strangers. Results show that behavioural intentions are less negative to family/friends with HIV than to strangers with HIV, and that if stigma is measured as symbolic stigma or instrumental stigma, then a higher degree of stigma is evident. Levels of resource-based stigma are very low. Instrumental stigma is a significant predictor of negative behavioural intentions towards people living with HIV/AIDS. This highlights the importance of HIV education. General bigotry and symbolic stigma also influence different dimensions of stigma. This suggests that although education is a necessary component for stigma alleviation, it is by no means sufficient. Racial differences are salient in predicting the determinants of the different dimensions of stigma. This highlights the necessity of considering cultural and environmental aspects in understanding stigma

Measuring HIV/AIDS Stigma

This paper develops indices to measure HIV/AIDS stigma and explores potential determinants of this stigma. Indices are designed to measure the different dimensions of HIV/AIDS stigma. Findings show that levels of stigma vary depending on the measure of stigma used. Furthermore, despite stigma not being expressed consistently in each stigma index, the majority of respondents do exhibit HIV/AIDS stigma in some form. Judgemental attitudes and fear of infection are expressed with greater prevalence than intentions to discriminate against people living with HIV/AIDS (PLWHA). The respondents’ understanding of HIV transmission is found to have the greatest impact on predicting levels of HIV/AIDS stigma, providing evidence for the importance of education campaigns. Racial differences are also salient in predicting both the magnitude of HIV/AIDS stigma and its determinants. This suggests that cultural and environmental aspects need to be considered when addressing HIV/AIDS stigma

Changes in HIV-related stigma among young adults in Cape Town, South Africa

Background: Stigma is a recognised problem for effective prevention, treatment and care of HIV/AIDS.? However, few studies have measured changes in the magnitude and character of stigma over time. This paper provides the first quantitative evaluation in Africa of the changing nature of stigma and the potential determinants of these changes. More specifically, it evaluates the dynamic relationship between stigma and (1) increased personal contact with people living with HIV/AIDS (i.e., the contact hypothesis) and (2) knowing people who died of AIDS. Methods: Panel survey data collected in 2003 and 2006 for 1074 young adults (54% women, 46% men) is used to evaluate changes in three distinct dimensions of stigma: behavioural intentions towards people living with HIV/AIDS, instrumental stigma (inflated fear of infection) and symbolic stigma (expressions of negative moral judgement). Individual fixed effects regression models are used to evaluate factors that influence stigma over time. Results: Each dimension of stigma increased in the population as a whole, and for all racial and gender sub-groups. Symbolic stigma increased most significantly, followed by instrumental stigma, while negative behavioural intentions showed a modest increase.? Knowing someone who died of AIDS was significantly associated with an increase in instrumental stigma (p < 0.01) and symbolic stigma (p < 0.001).? Increased personal contact with people living with HIV/AIDS was not significantly associated with changes in stigma. Importantly, increases in instrumental stigma (p < 0.001) predicted increases in negative behavioural intentions. Conclusion: Stigma increased despite interventions, such as public sector provision of HAART (which some hoped would have reduced stigma), and among a sample highly targeted with HIV-prevention messages. These findings emphasise that changes in stigma are difficult to predict and thus important to monitor. They also indicate an imperative for renewed efforts to reduce stigma, perhaps through interventions to weaken the association between HIV/AIDS and death, to reduce fear of HIV/AIDS, and to recast HIV as a chronic manageable disease

Sexual behaviour of men and women within age-disparate partnerships in South Africa: implications for young women's HIV risk

BACKGROUND: Age-disparate partnerships are hypothesized to increase HIV-risk for young women. However, the evidence base remains mixed. Most studies have focused only on unprotected sex among women in the partnership. Consequently, little is known about other risky behaviours, such as transactional sex, alcohol use, and concurrency, as well as the behaviours of the men who partner with young women. We therefore examined differences in various sexual behaviours of both young women and their male partners by partnership age difference. METHODS: We used nationally representative data from South Africa (2012) on partnerships reported by 16-24 year old black African women (n = 818) and by black African men in partnerships with 16-24 year old women (n = 985). We compared sexual behaviours in age-disparate partnerships and age-similar partnerships, using multiple logistic regression to control for potential confounders and to assess rural/urban differences. RESULTS: Young women in age-disparate partnerships were more likely to report unprotected sex than young women in similar-aged partnerships (aOR:1.51; p = 0.014; 95%CI:1.09-2.11). Men in partnerships with young women were more likely to report unprotected sex (aOR:1.92; p<0.01; 95%CI:1.31-2.81), transactional sex (aOR:2.73; p<0.01; 95%CI:1.64-4.56), drinking alcohol before sex (aOR:1.60; p = 0.062; 95%CI:0.98-2.61), and concurrency (aOR:1.39; p = 0.097; 95%CI:0.94-2.07) when their partners were five or more years younger. The association between age-disparate partnerships and transactional sex (aOR:4.14; p<0.01; 95%CI: 2.03-8.46) and alcohol use (aOR:2.24; p<0.013; 95%CI:1.20-4.19) was only found in urban areas. CONCLUSIONS: Results provide evidence that young women's age-disparate partnerships involve greater sexual risk, particularly through the risky behaviours of their male partners, with the risk amplified for young women in urban areas

Ties that Bind: HIV-Disclosure as Consequence and Catalyst of Stigma and Support in Households

Disclosure positions the HIV-positive individual at the juncture of stigma and support. This paper explores some of the factors that prompt HIV-positive individuals to disclose to members of their household through a close appraisal of disclosure as a consequence and catalyst of stigma and support for people living with HIV. The paper draws on both quantitative and qualitative research conducted between 2004 and 2008 in Cape Town, South Africa. The quantitative data come from two longitudinal surveys conducted in Khayelitsha, a township on the eastern periphery of Cape Town: a panel study conducted with a cohort of HIV-positive people on antiretroviral treatment and a second panel conducted with a control group comprising a matched sample of residents. The qualitative research includes participant observation and in-depth narrative interviews with thirty key informants and health care providers. The findings centre on two key aspects of disclosure within households: the process of disclosure, and the dynamics? of disclosure, stigma and support. The quantitative findings indicate high levels of disclosure within households; we propose that this is a consequence of high levels of support and low levels of perceived stigma within families, notwithstanding higher levels of perceived stigma in the general population. The qualitative findings problematise some of the quantitative findings and indicate that disclosure was not only met with positive and supportive responses from household members, but that it has also catalysed stigmatising responses, particularly from parents within the household. These initial responses, however, shifted over time as individuals became more aware of the prevalence of HIV, and started to dissociate the virus from conceptions of promiscuity and death. The respondents in the qualitative study indicated a concern that disclosure would threaten supportive relationships among co-residential kin; in order to garner support and mitigate against stigma within their household, the respondents in? the qualitative study first 'tested out' responses by disclosing to extended family on the periphery of their close social networks. This points to the nature of disclosure as an incremental process, rather than a once-off event. This paper argues that relationships within households are dynamic and change over time, and therefore that the catalysts of disclosure also take new form within relationships in households, and in the broader community

Concurrent sexual partnerships among individuals on HAART in South Africa: an opportunity for HIV prevention

Concurrent sexual partnerships, a common form of sexual partnering in much of southern Africa, play an important role in HIV transmission dynamics. This study examines the prevalence of concurrency and condom use among the general population and a sample of HAART patients in Cape Town, South Africa. The prevalence of reported concurrency was relatively high among a sample of HAART patients and in the general population (24% and 18% respectively) and reported consistent condom use was significantly higher among HAART patients compared to the general population (58% versus 20%);? perceived concurrency among the study populations' sexual partners was higher among HAART patients (35% versus 20%). Individuals on HAART report higher and more consistent use of condoms than the general population but the prevalence of concurrent relationships remains worryingly high. Greater programmatic attention should be given to promoting risk awareness of and behaviour change around concurrency both in the general population and amongst people living with HIV

Inequality and Diversity in Cape Town: An Introduction and User's Guide to the 2005 Cape Area Study

The 2005 Cape Area Study comprises a survey of aspects of diversity and inequality in the South African city of Cape Town. The survey was designed as both part of an ongoing study of Cape Town (that includes a series of surveys) and part of an international, multi-city study of aspects of urban life. This report provides an introduction to the survey for prospective users as well as important information for actual users, for example details of sample design and fieldwork

Disability grants and individual and household welfare among HAART patients in South Africa

Objective: To examine whether the loss of disability grants creates perverse incentives to forego treatment and negatively impacts health and economic welfare among individuals on highly active antiretroviral therapy (HAART) in South Africa. Design: Three-year panel study of a sample of individuals in Khayelitsha (a large poor, black township in Cape Town, South Africa) on HAART. Methods: Descriptive cross-tabulations and multivariate individual fixed effects regressions using self-reported health status, adherence to treatment, individual and household incomes and employment status as dependent variables and a binary indicator of disability grant status as the main independent variable. Results: We found no statistically significant association between grant receipt and adherence to treatment, self-reported health status, or side effects from HAART. None of the individuals in the sample reported that they would be willing to forego treatment to remain eligible for grants and all respondents reported perfect or near perfect adherence to treatment. However, a loss of a disability grant was associated with substantial decreases ion individual and household incomes, respectively. Conclusion: While we found no evidence of people trading off their health for income, there still appears to be a large financial burden associated with disability grant loss, which could increase the salience of perverse incentives, especially among those who are unable to find employment. Future research should examine alternative social welfare programs for AIDS-sick individuals that minimize incentives to trade-off health for economic security