Stigma,AIDS, and HIV Prevention in Africa: Reports from Community Organizations Providing Prevention Services

ABSTRACT

The AIDS epidemic in Africa remains a serious health crisis. Nongovernmental organizations (NGOs) in Africa play a critical role in the delivery of HIV prevention services. An important barrier to their HIV prevention efforts is stigma directed at persons living with HIV/AIDS. In order to understand how stigma affects HIV prevention programming, we conducted in-depth qualitative interviews with NGO directors in 29 African countries. Qualitative analytic approaches were used to identify key themes. Substantial discrimination and stigmatization of HIV-positive persons was reported. HIV-positive women were particularly likely to suffer negative social and economic consequences. The stigma associated with HIV interfered with disclosure of HIV status, risk-reduction behaviors, and HIV testing, creating significant barriers to HIV prevention efforts.

Interventions to reduce AIDS-related stigma in Africa are urgently needed. Reducing the burden of stigma is critical to fighting the epidemic in Africa and could play an important role in global HIV reduction.     

The Second Closet: A Qualitative Study of HIV Stigma Among Seropositive Gay Men in a Southern U.S. City

ABSTRACT

Objectives: Stigma connected with HIV/AIDS has decreased considerably since the early epidemic yet affects those living with HIV in many ways. Little research, particularly qualitative research, concerning HIV stigma from the perspective of gay men has emerged. The present qualitative study aimed to fill this evidence gap by examining how HIV stigma is perceived and experienced by gay men who have become HIV-infected and how they respond to this stigma. Methods: Thematic analysis of 19 gay men's narratives identified six main themes. Results: Encountering HIV stigmatization was common and was linked to the physical stigmata identifying respondents as HIV-positive. Overwhelmingly, they found stigmatization to be most intensely felt within gay communities. One profound theme was internalized HIV stigma, referring to respondents’ internalized negative feelings about their HIV status. A related theme was the closeted nature of HIV. Lastly, regarding how the men dealt with the HIV diagnosis and experiences of HIV stigma, a theme of adaptation became clear. Conclusions: Although exploratory, the results can serve as a beginning framework for understanding and assisting seropositive gay men who experience HIV stigma. The findings are important because it is realistic to expect that in a climate in which HIV has become increasingly invisible and closeted and in which infections are on the rise, gay and bisexual men will be increasingly affected and infected by HIV.     

Why do People Disclose their HIV Status? Qualitative Evidence from a Group of Activist Women in Khayelitsha

Abstract

This study explores the bio-psychosocial context of HIV/AIDS in which eleven HIV-positive activist women from Khayelitsha negotiated the process of disclosing their HIV-positive status to significant others, specifically biological household members. The study is based on the narratives of a group of HIV-positive peer-educators in Cape Town, South Africa. The results suggest that community perceptions of HIV/AIDS are shaped by a wide variety of factors particular to the socio-cultural and political context of HIV/AIDS in South Africa. The process and outcomes of disclosure to others occurs within this shifting web of meanings, and in turn, reshapes them as people respond to the person who has just disclosed. Eight out of the eleven women disclosed to a close biological household member as these significant-others provided, or had the potential to provide, the appropriate support. Six of the eleven participants disclosed during the symptomatic phases of HIV/AIDS, while five were asymptomatic at the time. Four of the five who disclosed when asymptomatic were diagnosed while pregnant and had never experienced severe opportunistic infections. Additionally, these same four disclosed some time after diagnosis (nine months > t < two years). Of the six who disclosed in a state of ill-health, five disclosed immediately after diagnosis in order to access health-related social support. At this time, concerns regarding health and mortality superseded fears of rejection and discrimination due to AIDS-related stigma. The perceived potential benefits (social and health-related support) outweighed the perceived risks (stigmatisation and discrimination). When participants had never experienced serious illness, they disclosed in order to educate loved-ones, gain emotional support or challenge false popular perceptions of HIV/AIDS.     

The dimensionality of stigma: a comparison of its impact on the self of persons with HIV/AIDS and cancer

Does the impact of stigma on the self differ by illness type? This study focuses on a comparison of the effects of the stigma associated with HIV/AIDS and cancer on self-esteem, body image, and personal control. We test the hypothesis that individuals' perceptions of stigma account for significant differences in the impact of an illness on the self. We examine four dimensions of perceived stigma: social rejection, internalized shame, social isolation, and financial insecurity. In turn, we consider how these dimensions medicate the effects of HIV/AIDS and cancer. Our sample includes 130 persons with HIV/AIDS and 76 persons with cancer. We control for illness severity by including a measure of functional health status that is based on participants' subjective perspectives of the severity of their symptomatology. Our findings provide additional support for modified labeling theory; however, our findings also point to the dimensionality of stigma and its differential negative impact on particular elements of the self, regardless of illness type.     

Stigma Management Among Gay/Bisexual Men with HIV/AIDS

People with HIV infection are subjected to prejudice, discrimination and hostility related to the stigmatization of AIDS. To manage the stigma of their disease, they mount complex coping strategies. This paper reports results from a qualitative study that examined gay/bisexual men's experiences of living with HIV infection. Unstructured interviews from a diverse sample of 139 men were analyzed to examine how men coped with AIDS-related stigma. We discerned a variety of stigma management strategies that could be arranged along a continuum from reactive to proactive based on the extent to which they implicitly accepted or challenged the social norms and values that underlie the stigmatization of HIV/AIDS. Reactive strategies to cope with stigma involve defensive attempts to avoid or mitigate the impact of stigma, but imply acceptance of the underlying social norms and values that construct the stigma. Examples of reactive strategies include hiding one's HIV status, presenting one's illness as a less stigmatizing one (e.g., cancer), or distancing one's self from more damaging aspects of AIDS-stigma (e.g., attributing infection to blood transfusion). Proactive strategies challenge the validity of the stigma and imply disavowal and resistance of the social norms and values that underlie the stigma. Examples of proactive strategies include engaging in public educational efforts that address misperceptions about HIV transmission and social activism to change the social and political conditions that affect PWA/HIV.     

Developing a community-level anti-HIV/AIDS stigma and homophobia intervention in new York city: The project CHHANGE model

HIV/AIDS stigma and homophobia are associated with significant negative health and social outcomes among people living with HIV/AIDS (PLWHA) and those at risk of infection. Interventions to decrease HIV stigma have focused on providing information and education, changing attitudes and values, and increasing contact with people living with HIV/AIDS (PLWHA), activities that act to reduce stereotyped beliefs and prejudice, as well as acts of discrimination. Most anti-homophobia interventions have focused on bullying reduction and have been implemented at the secondary and post-secondary education levels. Few interventions address HIV stigma and homophobia and operate at the community level. Project CHHANGE, Challenge HIV Stigma and Homophobia and Gain Empowerment, was a community-level, multi-component anti-HIV/AIDS stigma and homophobia intervention designed to reduce HIV stigma and homophobia thus increasing access to HIV prevention and treatment access. The theory-based intervention included three primary components: workshops and trainings with local residents, businesses and community-based organizations (CBO); space-based events at a CBO-partner drop-in storefront and “pop-up” street-based events and outreach; and a bus shelter ad campaign. This paper describes the intervention design process, resultant intervention and the study team’s experiences working with the community. We conclude that CHHANGE was feasible and acceptable to the community. Promoting the labeling of gay and/or HIV-related “space” as a non-stigmatized, community resource, as well as providing opportunities for residents to have contact with targeted groups and to understand how HIV stigma and homophobia relate to HIV/AIDS prevalence in their neighborhood may be crucial components of successful anti-stigma and discrimination programming.     

HIV/AIDS stigma manifestations during clinical interactions with MSM in Puerto Rico

HIV/AIDS stigma can have detrimental effects on physician/patient interactions when manifested by health professionals. Unfortunately, HIV/AIDS stigma is usually manifested in an intersectional manner with other preexisting stigmas, including stigma toward men who have sex with men (MSM). Therefore, our study aimed to examine the behavioral manifestations of HIV/AIDS stigma among physicians in training during simulated clinical interactions with MSM, and explore the interrelation between HIV/AIDS stigma attitudes and behaviors. We implemented an experimental design using Standardized Patient simulations with a sample of 100 physicians in training in Puerto Rico. Results show a significant difference in the two groups’ means (p?<?.001), with a higher number of stigma behaviors in the HIV MSM patient condition (M?=?6.39) than the common cold control condition (M?=?5.20). Results evidence that stigma manifestations toward MSM with HIV may continue to be an obstacle for public health in Puerto Rico, and that medical training to prevent stigma is still needed.     

Issues Related to HIV Stigma in Nepal

ABSTRACT

We conducted a qualitative study to understand and describe experiences of people living with HIV and AIDS with regard to HIV-associated stigma in Nepal. The study has revealed four key themes associated with HIV stigma: a hierarchy of stigma (sexual transmission and women stigmatized more than injecting-drug transmission and men); exclusion and rejection (denial of care services, rejection from family); death as a form of punishment (untimely death is seen as a punishment for something done wrong in the past); and Mumbaiya disease (caught from working in “other places”). Cultural contexts are the best ways to understand HIV stigma in Nepal along with socially and culturally established gender roles. This study has confirmed that stigma manifests at different levels: individual, social, and structural, with denial and rejection being a key mechanism of stigma.     

Healthy children in families affected by AIDS: Epidemiological and psychosocial considerations

Traditional means of conceptualizing the psychosocial impact of AIDS have emphasized infected individuals out of their natural context AIDS occurs not simply within hospitals but within families. A secondary morbidity occurs within a family system when one of its members is infected. Clinical experience suggests that non-infected children within families with AIDS are at significant risk for poor developmental outcomes as a consequence of the skewing of familial resources. Children living in families who have a member infected by HIV are impacted by isues such as stigma, isolation, abandonment, and death. This article explores the epidemiology of this child population and risk factors that render them vulnerable. Social workers are in a unique position to identify and serve these children in such diverse settings as schools, welfare agencies, and hospitals. Suggested interventions based on the developmental stage of the child are discussed as are implications for policy formation and program development.     

Community reaction to persons with HIV/AIDS and their parents: an analysis of recent evidence from Thailand

We systematically examine community reaction to persons living with HIV/AIDS (PHAs) and their older parents in Thailand. We focus on parents as well as PHAs because parents are major providers of care for their ill adult children. Our analyses are based on several sources of recently collected survey and qualitative data from a wide range of perspectives. We find important variations in community reaction to PHAs and their families, but overall these reactions are much more positive than is widely assumed. We conclude that much existing research on community reaction to AIDS neglects both a rich body of social theory on stigma and a strong tradition of population-based empirical research in sociology. Much existing research also fails to adequately distinguish between key aspects of the social settings where most AIDS cases occur and the social settings where most of the stereotypes surrounding AIDS-related stigma have originated. A closer marriage between empirical and theoretical approaches to social stigma is required to advance our understanding of this critically important dimension of the AIDS epidemic.     

Aids prevention,Stigma and migrant status

This article discusses how stigma has been applied to disease and also to foreigners, especially during epidemics. Foreigners, or migrants, fit particularly well into AIDS stigma, being both objects and originators of the generalised reaction: ‘it's somebody else's problem’. Material is presented from a European Community Concerted Action assessing AIDS/HIV prevention which surveyed programmes for short‐ and long‐term guest populations and ethnic minorities in twelve European countries. It is shown how the potential for stigmatisation seriously hindered the establishment of AIDS prevention efforts directed towards migrants. Basic shifts of programme focus which help overcome stigmatisation problems concerning migrants are defined, including: 1) making fine differentiations amongst migrant groups rather than considering ‘migrants’ as a generalised ‘other’, 2) basing programmes on a universal right to know rather than on the notion of risk group, and 3) working in real and effective collaboration with minority communities rather than imposing top down programmes.     

“She Got Spoilt”: Perceptions of Victims of Child Sexual Abuse in Ghana

ABSTRACT

International research has commented on social stigma as a key reason for nondisclosure of child sexual abuse. However, the actual components of this social stigma frequently remain unexplored. The present study deals with perceptions of consequences of child sexual abuse among professionals and laypeople in Ghana (N = 44), employing a bystander perspective. As a qualitative study using a grounded theory framework, it considers these consequences in light of their underlying beliefs about child and adolescent development, particularly in relation to gender-based expectations placed on girls and boys. Consequences of child sexual abuse could be divided into sexual health consequences, beliefs about “destroyed innocence” and beliefs about a “destroyed future,” which were strongly related to the sexual nature of the violence perpetrated. These perceived consequences of child sexual abuse hold implications for what surviving child sexual abuse means on a social level. Implications for practice are discussed on the basis of the data analysis.     

From Acute Palliation to Chronic Care: Using the Narratives of Two Gay Caregivers to Explore Experiences of Providing HIV Support Across Sociohistorical Contexts

Despite the longstanding shift in conceptualizing HIV/AIDS as a site of chronic care, versus one of acute palliation, few attempts have been made to examine caregiving in the context of this change. This study constitutes a preliminary attempt at exploring the evolving nature of HIV/AIDS caregiving among sexual minorities, primarily by comparing the narratives of two partnered caregivers of HIV-positive gay men whose stories are located in disparate sociohistorical contexts. Whereas one caregiver provided support during an era in which HIV/AIDS was primarily conceptualized as acutely life-limiting, the other did so in the contemporary period of chronic HIV care. Although similarities are noted across the stories, distinctions are also apparent in how the caregivers encounter expressions of homophobia and HIV stigma, and negotiate these realities distinctly as a function of sociohistorical context. In particular, despite the salience of these systemic barriers across the two narratives, these expressions of marginalization appear to occur more routinely and indefinitely in the context of chronic care. This article concludes with implications of the study's findings on theory, research, policy, and practice.     

HIV and AIDS: unexpected lessons for Save the Children

SUMMARY. HIV and AIDS training is a sensitive area in which experience is all recent. Previous articles in Children & Society (issues 1. 1, 1.2 and 2.4) have looked at major concerns for children's services. This paper reports on an imaginative approach to staff training in one child care agency — Save the Children Fund. The authors' frankness about problems as well as benefits will help others to identify lessons for their organisations., particularly for those in management     

Gendered Economic,Social, and Cultural Challenges to HIV/AIDS Prevention and Intervention for Chinese Women

ABSTRACT

China is experiencing the most rapidly expanding HIV prevalence in the world, with the percentage of Chinese women living with HIV/AIDS also increasing significantly. Chinese women's risk of HIV infection is heavily influenced by patriarchal cultural beliefs, Confucian doctrines, and rapid social and economic changes in China. Chinese women generally have a low level of awareness of HIV/AIDS. With inherent inferior social status and economic disadvantage, their vulnerability to HIV infection is heightened by adverse impacts of massive rural-to-urban migration, explosion of the commercial sex industry, and prevalence of gender-based violence. In order to target HIV/AIDS prevention and treatment programs for Chinese women, their specific needs and gendered obstacles must be addressed and tackled. These include strategies that aim to fight against poverty, improve education, enhance HIV/AIDS awareness, facilitate new life-skills acquisition and behavior change, make available woman-centered services for testing and treatment of HIV, and eradicate gender-based discrimination and violence. There is also an urgent need to further develop various public health infrastructure in China, especially in remote and rural areas. The pool of gender experts in China should also be expanded to conduct a thorough gender analysis and design a national response to address the evolving HIV/AIDS epidemic in Chinese women.     

Economic versus psychological forecasting. Evidence from consumer confidence surveys

Permanent and widespread psychological biases affect both the subjective probability of future economic events and their retrospective interpretation. They may give rise to a systematic gap between (over-critical) judgments and (over-optimistic) expectations – the “forecast” error. When things go bad, then, psychology suggests that people tend to become particularly bullish, amplifying the forecast error. Also, psychology argues that personal/future conditions are systematically perceived to be better than the aggregate/past ones. All this sharply contrasts with standard economic assumptions. Evidence from a unique dataset covering 10 European countries over 22 years confirms the presence of structural psychologically driven distortions in people’s judgments and expectations formation.     

Reasons for the adoption of celibacy among older men and women living with HIV/AIDS

The reasons for becoming celibate following diagnosis with HIV/AIDS were examined using focused interviews with 63 infected older adults (ages 50 ‐ 68). Forty‐eight percent reported they were currently celibate or had been celibate following diagnosis with HIV/AIDS. Women reported celibacy (78%) more than men (36%). Although men and women reported some similar reasons for celibacy, most notably fear of infecting others and fear of reinfection, we also found gender differences in the reasons for celibacy. Additional reasons offered by women included loss of interest in sex, anger and distrust of men, and desire to focus on themselves rather than men. Other reasons offered by men included fear of rejection or stigma‐tization, difficulty with sexual performance, and negative body image. The prevalence of celibacy and the finding that many reasons for celibacy are related to fear, anger, and distrust suggests that older adults may have difficulty resuming healthy sexual relationships following diagnosis with HIV/AIDS.     

The development of Maisha,a video-assisted counseling intervention to address HIV stigma at entry into antenatal care in Tanzania

HIV stigma has a profound impact on clinical outcomes and undermines the quality of life of people living with HIV (PLWH). Among HIV-negative individuals, misinformation and prejudicial attitudes about HIV can fuel stigma and contribute to discrimination against PLWH. Antenatal care (ANC), with its focus on universal HIV testing, provides a unique entry point to address HIV stigma. This study describes the development of a counseling intervention to address HIV stigma among women and their partners attending a first ANC appointment in Tanzania. Formative work to inform the intervention consisted of qualitative interviews with 32 pregnant and postpartum women (both women living with HIV and HIV-negative women) and 20 healthcare workers. Data were analyzed iteratively, using a thematic analysis approach, to identify intervention targets. The resulting intervention, Maisha (Swahili for “Life”), includes three sessions informed by the HIV Stigma Framework and Cognitive-Behavioral Therapy: a video and brief counseling session prior to HIV testing and, for those who test seropositive for HIV, two additional sessions building on the video content. A pilot test of the intervention is in process. Addressing HIV stigma at the first ANC visit can help individuals living with HIV to overcome stigma-related barriers to the initiation and maintenance of HIV care, and can reduce stigmatizing attitudes among those who test negative for HIV.     

Determinants Influencing Male Condom use Among University Students in Portugal

ABSTRACT. A self-administered questionnaire was carried out among university students in Portugal, with the aim to examine determinants influencing male condom use, according to the information–motivation–behavioral skills model (J. Fisher & Fisher, 1992). Students’ levels of information, motivation, and behavioral skills regarding preventive sexual behavior (male condom use) were ascertained and were used to determine their association with condom use among 880 male and 1,807 female students aged 18 to 35 years old. Although 86.9% of respondents indicated that they used a condom during their first sexual intercourse, only 32.8% used a condom always during sexual intercourse in the last 12 months. Most young people, especially women, had a good level of information regarding HIV/AIDS transmission/prevention. They also showed reasonable positive attitudes and had positive subjective norms and intentions toward HIV/AIDS preventive behaviors. Men presented a higher perceived difficulty and a lower perceived effectiveness of HIV/AIDS preventive behavior, therefore reporting higher risk acceptance. A path analysis revealed that preventive sexual behavior did not depend directly on information level but on motivation and behavioral skills (especially among men). Information about HIV prevention/transmission was not significantly associated with condom use. The finding that motivation and behavioral skills were the strongest determinants of condom use suggested that these may be important factors in effective sexually transmitted infection-prevention programs.     

Chapter 12. Families Caring for Persons with HIV/AIDS

SUMMARY

The extent to which family members are willing and able to assist with daily activities and provide emotional support can greatly affect the quality of life for persons with chronic illness. In the case of HIV/AIDS, the burdens of symptom management and medication are amplified by social stigma. This chapter provides a summary of the physical, psychological, social, and spiritual issues associated with HIV/AIDS along with approaches to assessment and treatment.