HIV-related stigma: Adapting a theoretical framework for use in India

Department of Medicine, Center for AIDS Prevention Studies, University of California, San Francisco, CA 94105, USA.
Social Science & Medicine (Impact Factor: 2.89). 08/2008; 67(8):1225-35. DOI: 10.1016/j.socscimed.2008.05.032
Source: PubMed


Stigma complicates the treatment of HIV worldwide. We examined whether a multi-component framework, initially consisting of enacted, felt normative, and internalized forms of individual stigma experiences, could be used to understand HIV-related stigma in Southern India. In Study 1, qualitative interviews with a convenience sample of 16 people living with HIV revealed instances of all three types of stigma. Experiences of discrimination (enacted stigma) were reported relatively infrequently. Rather, perceptions of high levels of stigma (felt normative stigma) motivated people to avoid disclosing their HIV status. These perceptions often were shaped by stories of discrimination against other HIV-infected individuals, which we adapted as an additional component of our framework (vicarious stigma). Participants also varied in their acceptance of HIV stigma as legitimate (internalized stigma). In Study 2, newly developed measures of the stigma components were administered in a survey to 229 people living with HIV. Findings suggested that enacted and vicarious stigma influenced felt normative stigma; that enacted, felt normative, and internalized stigma were associated with higher levels of depression; and that the associations of depression with felt normative and internalized forms of stigma were mediated by the use of coping strategies designed to avoid disclosure of one's HIV serostatus.

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    • "Typically this subjective awareness is assessed among persons with HIV and is sometimes termed " felt stigma " (Scambler and Hopkins, 1986) or " anticipated stigma " (what Link (1987) described as " expectations of rejection " ). However , anticipated stigma can also be assessed among persons in general population samples (irrespective of HIV serostatus) using parallel questions (Steward et al., 2008; Visser et al., 2008). The remaining three questions elicit respondents' willingness to interact with persons with HIV under hypothetical scenarios. "
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    ABSTRACT: HIV is highly stigmatized in sub-Saharan Africa. This is an important public health problem because HIV stigma has many adverse effects that threaten to undermine efforts to control the HIV epidemic. The implementation of a universal primary education policy in Uganda in 1997 provided us with a natural experiment to test the hypothesis that education is causally related to HIV stigma. For this analysis, we pooled publicly available, population-based data from the 2011 Uganda Demographic and Health Survey and the 2011 Uganda AIDS Indicator Survey. The primary outcomes of interest were negative attitudes toward persons with HIV, elicited using four questions about anticipated stigma and social distance. Standard least squares estimates suggested a statistically significant, negative association between years of schooling and HIV stigma (each P < 0.001, with t-statistics ranging from 4.9 to 14.7). We then used a natural experiment design, exploiting differences in birth cohort exposure to universal primary education as an instrumental variable. Participants who were <13 years old at the time of the policy change had 1.36 additional years of schooling compared to those who were ≥13 years old. Adjusting for linear age trends before and after the discontinuity, two-stage least squares estimates suggested no statistically significant causal effect of education on HIV stigma (P-values ranged from 0.21 to 0.69). Three of the four estimated regression coefficients were positive, and in all cases the lower confidence limits convincingly excluded the possibility of large negative effect sizes. These instrumental variables estimates have a causal interpretation and were not overturned by several robustness checks. We conclude that, for young adults in Uganda, additional years of education in the formal schooling system driven by a universal primary school intervention have not had a causal effect on reducing negative attitudes toward persons with HIV. Copyright © 2015 Elsevier Ltd. All rights reserved.
    Social Science [?] Medicine 08/2015; 142:37-46. DOI:10.1016/j.socscimed.2015.08.009 · 2.89 Impact Factor
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    • "HIV-related stigma was measured by a validated scale developed in Indian, measuring enacted, felt, vicarious, and internalized stigma ; [5] 50% of participants did not respond to a sufficient number of enacted stigma items. Hence, we only focused on felt, vicarious, and internalized stigma in this study. "

    8th IAS, Vancouver, Canada; 07/2015
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    • "Likewise, stigmatization of PLHIV, which may impair opportunity for housing, employment, income, quality of social relationships, and health-care treatment (Hatzenbuehler, Phelan, & Link, 2013) may have a direct role in the depressive symptoms and decreased QoL observed here. Among PLHIV, women experience more stigma (Murphy , Austin, & Greenwell, 2006; Steward et al., 2008; Subramanian, Gupte, Dorairaj, Periannan, & Mathai, 2009), have lower emotional support (Gordillo et al., 2009; Zierler et al., 2000), poorer QoL (Mahalakshmy, Premarajan, & Hamide, 2011; Reis, Santos, & Gir, 2012), and CART adherence (Hanif et al., 2013) and lower incomes and employment leading to greater socioeconomic burden (Charles et al., 2012), possibly contributing to their greater depression. "
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    ABSTRACT: Depression is the most common psychiatric co-morbidity among people living with HIV (PLHIV), with prevalence rates ranging from 25% to 36%. Depression impacts negatively upon adherence and response to combined antiretroviral therapy (CART) and the transmission of HIV infection through increased sexually risky behavior. This cross-sectional study presents data from a reference HIV-outpatient service in Dourados (Brazil) that evaluated the association between depressive symptoms, health-related quality of life, and clinical, socioeconomic, and demographic factors in newly diagnosed HIV/AIDS patients. Using the Beck Depression Inventory (BDI), the prevalence of depressive symptoms was 61% with a predominance of self-deprecating and cognitive-affective factors. Depressive symptoms were associated with lower income (p = 0.019) and disadvantaged social class (p = 0.005). Poorer quality of life was related to depressive symptoms (p < 0.0001), low educational level (p = 0.05), and lower income (p = 0.03). These data suggest that socioeconomic factors, including level of income and education, are mediating the risk of depression and poor quality of life of PLHIV. Possible explanations for this effect are discussed, including the possible role of stigma.
    AIDS Care 03/2015; 27(8):1-7. DOI:10.1080/09540121.2015.1017442 · 1.60 Impact Factor
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