In a rural town and surrounding villages where HIV care and treatment is being rapidly scaled up, we found that components of HIV stigma are still common. Those who had more negative attitudes about PLWH were more likely to believe that HIV can be spread through casual contact or mosquitoes, and to lack knowledge about the natural history of HIV, as well as ART and its benefits. Personally knowing a PLWH was associated with fewer negative attitudes.
Health related stigma has been characterized as a process of social disqualification of individuals and populations identified with particular health problems, associated with exclusion, rejection, blame or devaluation . Stigma can reflect and perpetuate existing inequalities and marginalization of socially disenfranchised groups .
Stigma was recognized early in the AIDS epidemic as a barrier to HIV prevention, treatment and support. Manifestations of HIV stigma include: negative judgments about PLWH (such as shame or blame-associated judgments); avoidance or discriminatory behaviors (enacted stigma) in family, community or institutional settings; discriminatory laws or policies; and self (internalized) stigma.
The focus of this analysis was HIV stigma in the community setting. Ethiopia, like many countries in SSA, is strongly grounded in the belief, especially in rural settings, that what happens to one person concerns the whole community; therefore, negative judgments and exclusion by the community can have devastating effects [1, 33].
In terms of attitudes towards PLWH, we found both positive and negative beliefs. On the one hand, 80% agreed with one or more negative judgments about PLWH that reflected shame or blame, and 41% agreed with actions reflecting distancing from PLWH. On the other hand, over 85% felt that PLWH deserved compassion and support from their communities. This seeming contradiction has been previously noted in Ethiopia and other African countries . Even when PLWH are believed to have morally transgressed, a strong sense of community responsibility can lead people to believe that PLWH should still be cared for and treated with compassion [15, 17].
Our finding of a significant correlation between HIV knowledge and negative attitudes towards PLWH is consistent with other studies linking poor knowledge about HIV/AIDS (including HIV transmission) with increased HIV stigma [2, 3, 34, 35]. Knowledge gaps associated with stigma in our analysis included an incomplete understanding about how HIV is not transmitted (especially through casual contact), the natural history of HIV infection (which can initially be asymptomatic), ART (including its potential benefits), and MTCT (including prevention of perinatal transmission). It is concerning that 33% of women did not know that HIV could be transmitted perinatally, and that 51% were unaware that there are ways to reduce MTCT. In 2009, only 35% of all pregnant African women received an HIV test, and only 54% of HIV-positive women received ART to prevent MTCT .
Although knowledge about sexual transmission was not statistically associated with stigma, it is concerning that although over 90% knew that HIV could be transmitted sexually and that having one uninfected faithful partner was protective, 23% were uncertain or did not believe that people could protect themselves from HIV by consistent and correct condom use. Lack of awareness or belief in the benefits of condom use jeopardizes one important strategy in a comprehensive HIV prevention program [37, 38].
In our analysis, personally knowing a PLWH was a significant predictor of lower stigma. Other studies have also found that personal acquaintance with a PLWH is associated with less expressed stigma [6, 35]. This supports the involvement of PLWH in both developing and implementing community-based stigma and discrimination-reduction efforts [2, 5, 6], and the importance of PLWH being willing to disclose their status to others.
Our findings of greater negative attitudes among those with lower education are consistent with other studies . Our findings are also consistent with other studies in suggesting that stigma may manifest differently in men and women [1, 17, 33]. Finally, the presence of greater stigma among those living in rural villages is of particular note. Although rural HIV seroprevalence in Ethiopia is lower than in urban settings, over 80% of the Ethiopian population is rural; in 2007, it was estimated that 38% of all PLWH were rural .
Although the focus of this analysis was on stigma in the community setting, stigma may occur in other settings such as health care facilities, may be reflected in laws and policies of governments and other institutions, may be internalized as well as external, and may overlap with additional stigma against marginalized groups such as sex workers or men who have sex with men. This supports the need to evaluate in each local setting how HIV stigma and discrimination are manifested, so that programs to combat it can be most effectively targeted.
There are several cautions in interpreting our results. Although interviewers were trained to ask questions in a nonjudgmental fashion, some participants may have given responses they considered socially desirable, rather than reflecting how they actually felt; if so, the degree of stigma may have been greater than we identified. Second, by design, this survey was conducted in kebeles with larger numbers of PLWH; communities with few or no HIV-infected residents may have had different responses. Third, survey responses will likely differ in other counties, as well as Ethiopian regions with a different cultural, religious or social make-up; results therefore cannot be directly generalized to all other sub-Saharan African rural communities. However, as described above, our finding concerning both the nature and determinants of stigma are consistent with studies from many other countries in SSA.