Experiences of Stigmatization and Discrimination in Accessing Health Care Services Among People Living with HIV (PLHIV) in Akwa Ibom State, Nigeria

Abstract

Background
Recent advances in care and treatment have turned HIV into a “chronic but manageable condition”. Despite this, some people living with HIV (PLHIV) continue to suffer from stigma and discrimination in accessing health care services. This study examined the experience of stigma and discrimination and access to health care services among PLHIV in Akwa Ibom State.

Methods
The Center for Clinical Care and Clinical Research (CCCRN), implementing a USAID-funded Integrated Child Health and Social Services Award (ICHSSA 1) project, conducted a community-based cross-sectional survey in 12 randomly selected local government areas in Akwa Ibom State, Nigeria. A structured quantitative questionnaire was used for data collection. In total, 425 randomly selected PLHIV were interviewed after providing informed consent. Descriptive statistics and bivariate analyses were conducted using the data analytical application Stata 14.

Results
The study revealed that 215 PLHIV (50.4%) had been denied access to health care services, including dental care, because of their HIV status in Akwa Ibom State. Respondents reported being afraid of: gossip (78%), being verbally abused (17%), or being physically harassed or assaulted because of their positive status (13%). Self-stigmatization was also evident; respondents reported being ashamed because of their positive HIV status (29%), exhibiting self-guilt (16%), having low self-esteem (38%), and experiencing self-isolation (36%). Women, rural residents, PLHIV with no education, unemployed, single, young people aged between 19 and 29 years, and older adults were more likely to experience HIV-related stigmatization.

Conclusion
Data from the study revealed that the percentage of PLHIV who experience health-related stigmatization because of their HIV status is high in Akwa Ibom State. This finding calls for the prioritization of interventions to reduce stigma, enhance self-esteem, and promote empathy and compassion for PLHIV. It also highlights the need for HIV education for family and community members and health care providers, to enhance the knowledge of HIV and improve acceptance of PLHIV within families, communities, and health care settings.

Full text

ORIGINAL RESEARCH
Experiences of Stigmatization and Discrimination in
Accessing Health Care Services Among People
Living with HIV (PLHIV) in Akwa Ibom State, Nigeria
Peters Adekoya
1
, Faith D Lannap
1
, Fatima Anne Ajonye
1
, Stanley Amadiegwu
2
, Ifeyinwa Okereke
1
,
Charity Elochukwu
1
, Christopher Ayaba Aruku
1
, Adeyemi Oluwaseyi
1
, Grace Kumolu
1
,
Michael Ejeh
1
, Ayodotun O Olutola
1
, Doreen Magaji
3
1
Centre for Clinical Care and Clinical Research, Abuja, Nigeria;
2
Catholic Relief Services, Abuja, Nigeria;
3
United States Agency for International
Development, Abuja, Nigeria
Correspondence: Faith D Lannap, Email annap@cccr-nigeria.org; faithlannap@gmail.com
Background: Recent advances in care and treatment have turned HIV into a “chronic but manageable condition”. Despite this, some
people living with HIV (PLHIV) continue to suffer from stigma and discrimination in accessing health care services. This study
examined the experience of stigma and discrimination and access to health care services among PLHIV in Akwa Ibom State.
Methods: The Center for Clinical Care and Clinical Research (CCCRN), implementing a USAID-funded Integrated Child Health and
Social Services Award (ICHSSA 1) project, conducted a community-based cross-sectional survey in 12 randomly selected local
government areas in Akwa Ibom State, Nigeria. A structured quantitative questionnaire was used for data collection. In total, 425
randomly selected PLHIV were interviewed after providing informed consent. Descriptive statistics and bivariate analyses were
conducted using the data analytical application Stata 14.
Results: The study revealed that 215 PLHIV (50.4%) had been denied access to health care services, including dental care, because of
their HIV status in Akwa Ibom State. Respondents reported being afraid of: gossip (78%), being verbally abused (17%), or being
physically harassed or assaulted because of their positive status (13%). Self-stigmatization was also evident; respondents reported
being ashamed because of their positive HIV status (29%), exhibiting self-guilt (16%), having low self-esteem (38%), and experien-
cing self-isolation (36%). Women, rural residents, PLHIV with no education, unemployed, single, young people aged between 19 and
29 years, and older adults were more likely to experience HIV-related stigmatization.
Conclusion: Data from the study revealed that the percentage of PLHIV who experience health-related stigmatization because of
their HIV status is high in Akwa Ibom State. This nding calls for the prioritization of interventions to reduce stigma, enhance self-
esteem, and promote empathy and compassion for PLHIV. It also highlights the need for HIV education for family and community
members and health care providers, to enhance the knowledge of HIV and improve acceptance of PLHIV within families, commu-
nities, and health care settings.
Keywords: orphans and vulnerable children, household, stigmatization, discrimination, people living with HIV, health-related stigma
Introduction
Globally, about 40 million people were estimated to be living with human immunodeciency virus (HIV) in 2021, and
since the beginning of the epidemic, more than 84.2 million people have been infected and about 40.1 million people
have died of HIV.
1
Nigeria ranks third among the countries with the highest burden of HIV infection in the world, with
more than two million people living with HIV (PLHIV) as at 2019 and approximately 45,000 AIDS-related deaths in the
country.
2,3
The advances in care and treatment have turned HIV into a “chronic but manageable condition”. Regardless,
PLHIV continue to suffer from stigmatization and discrimination from their families, communities, and health care
providers.
4
As a result, HIV/AIDS is increasingly being recognized as not merely a medical problem, but also a social
problem.
5
Erving Goffman dened stigma as “the phenomenon whereby an individual with an attribute which is deeply
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Open Access Full Text Article
Received: 7 November 2023
Accepted: 1 February 2024
Published: 19 February 2024

discredited by his or her society is rejected as a result of that attribute”, and the results of stigma, which include
prejudice, shame, isolation, rejection, and discrimination, are directed at people believed to have that illness or trait.
6,7
Stigmatization emanates from a lack of understanding of the illness (ignorance and misinformation), and also because
some people have negative attitudes towards or negative beliefs about it.
8
HIV-related stigmatization can be described as a process of devaluing people who live with or are connected with the
disease.
9
Discrimination is one mechanism through which stigma is manifested, and refers to discriminatory behaviors
perpetuated by HIV-uninfected individuals towards HIV-infected people.
10,11
HIV stigma is primarily due to a fear of
HIV, ie fear of contracting the disease, and a lack of knowledge about how HIV transmission occurs.
12
Stigmatization
manifests in the form of negative attitudes by the public towards those affected, as well as through negative experiences
of those living with HIV.
13,14
HIV is transmitted predominantly through sexual intercourse. Therefore, in many countries,
including Nigeria, HIV is perceived as a consequence of immoral sexual behavior.
15
Previous studies have found that
women and girls between the ages of 18 to 29 years with HIV/AIDS reported more intense stigma than men, especially
women who reside in rural area.
16–19
Stangl et al
20
devised a comprehensive theoretical framework to interrupt or alleviate the detrimental effects of health-
related stigmatization. Within this framework, they delineated the stigmatization process into domains, encompassing drivers
and facilitators, stigma markings, and stigma manifestations. These stigmatizations extend beyond affecting the impacted
populations to inuencing organizations, institutions, and society. The initial domain focuses on factors driving or facilitating
health-related stigma, ranging from the fear of infection through casual contact with communicable diseases to social
judgment and blame.
20,21
Stigma markings, shaped by drivers and facilitators, involve applying a stigma to individuals or
groups based on a particular health condition or perceived differences, including demographic and economic characteristics.
21
After the application of stigma, it gives rise to various experiences, including discrimination in areas such as housing, forced
eviction upon knowledge of health conditions, verbal abuse, and gossip, among other manifestations.
Stigma experiences encompass both internal, known as “self-stigma”, and external stigma. Self-stigma is when
a stigmatized group member adopts negative societal beliefs associated with their status. External stigma involves stigmatiza-
tion from external groups regarding a person’s health condition.
22
Perceived stigma involves perceptions of how stigmatized
groups are treated in a situation, while anticipated stigma includes expectations of bias if their health condition is
disclosed.
23,24
Additionally, there is secondary or “associative” stigma, referring to the stigma experienced by family, friends,
or health care providers associated with members of stigmatized groups.
20,25
HIV-related stigmatization is linked to
misinformation about disease transmission, fear, and moral judgments among those living with the virus, and studies indicate
that there is discrimination in health care facilities or communities, including denial of care, breaches of condentiality, and
humiliating attitudes, or gossiping.
14,26
External stigma from the community leads to internalized stigma, resulting in self-
exclusion from social events and anticipating exposure that may lead to adverse health and psychosocial outcomes.
14
Evidence from Nigeria
27
and other parts of Africa, such as Ghana
28
and Ethiopia,
15
reveals a level of HIV-related
stigmatization and discrimination. Efforts to reduce stigma related to HIV/AIDS will not only help countries to achieve
key strategies of the Sustainable Development Goals (SDGs), but also protect and promote the human rights of PLHIV.
29
This study examined the experience of stigma and discrimination among PLHIV in Akwa Ibom State, Nigeria, and their
effects on access to health care services.
Methods and Materials
Study Design
The study was a community-based study. It employed a cross-sectional survey procedure, using a multi-stage random and
purposive sampling technique with random selection of eligible respondents from 12 local government areas (LGAs) in
Akwa Ibom State. The study used primary data and made use of a quantitative method to gather data.
Study Area
The study was conducted in 12 LGAs which were randomly selected from 31 LGAs where the Integrated Child Health and
Social Services Award (ICHSSA 1) project has been implemented in Akwa Ibom State, for the data collection exercise. Akwa
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Ibom State occupies a landmass of 8412 km
2
and is bounded to the north by Abia State, to the east by Rivers State, to the west
by Cross River State, and to the south by the Atlantic Ocean. It has the longest coastline in Nigeria. Akwa Ibom State consists
of 31 LGAs, which are further divided into three senatorial districts, namely, Akwa Ibom North-East, Akwa Ibom North-West,
and Akwa Ibom South. The major ethnic groups are Ibibio, Annang, and Oron. The state is one of the largest producers of
crude oil in Nigeria and is of major economic importance in the country. ICHSSA 1 is a USAID-funded project designed to
mitigate the impact of HIV/AIDS on vulnerable children and their households in Akwa Ibom State. The ICHSSA 1 project
includes more than 4000 PLHIV beneciaries who have been served in the state. The state is located in the South-South region
of Nigeria, with a projected population of 5,482,177, according to the 2017 NBS Demographic Population Bulletin. The state
has an HIV prevalence of 5.6%, which is the highest among the 36 states of Nigeria, and this state accounts for about 41% of
vertically transmitted HIV infections in children in the country.
3,30,31
The study population included all the randomly selected
beneciary households in the selected LGAs.
Sample Size Calculation
where Z is the value for a selected α level (type 1 error) of 0.05 = 1.96; e is the acceptable margin of error = 5%; p is the
estimate of variance = 0.5 (in the absence of any data regarding stigma in PLHIV in Akwa Ibom); therefore, assuming
p = 0.5 (maximum variability), q=1−p=1−0.5=0.5.
Therefore, the sample size comes out to be:1:962�0:5 10:5ð Þ
0:0052
However, with the response rate of 90%, the overall sample size used for the study was 425.
Training and Supervision
Adequate numbers of enumerators in Akwa Ibom State, including community case managers and volunteers from among
the PLHIV population, were trained by the Center for Clinical Care and Clinical Research, Nigeria (CCCRN), team
leader. The training dwelt on study methodology, indicator measurements for the Stigma Index, and quantitative data
collection procedures. Consequently, at the end of the training and on the basis of satisfactory performance, qualied
interviewers in the team were formed to staff each of the randomly selected LGAs in the state. Two additional teams
were kept on reserve/standby. During the interview, teams in each LGA worked closely with the supervisors, while the
team leader supervised the exercise. However, adequate arrangement was made for constant communication among the
team leader, supervisor, and eld members while in the eld, especially through WhatsApp, calls, and SMS.
Study Measurement Tool and Data Collection
The study adopted a multi-stage random sampling technique in which four respondents who were HIV positive were
randomly selected from all 10 wards in each of the 12 LGAs where the study was implemented. Data were collected by
a team comprising the team leader, two supervisors, and 10 trained interviewers who were trained in the content of the
research instrument, both in English and in the local language (Ibibio).
The study instrument is a well-structured quantitative questionnaire, which was administered by trained interviewers.
All interviews were conducted in a private room, where no one could overhear the discussion. The Stigma Index
questionnaire explored the demographics; experiences with stigmatization, discrimination, and advocacy; and experi-
ences with testing, disclosure, and access to services. Other areas were experiences with stigma/discrimination from other
people, access to health, educational services, and their experiences with enternal and internal stigmatization.
The outcome variable for this study was dened as health-related stigmatization, which was measured by asking the
question “Have you been denied health care services, including dental care services, because of your HIV status in the
past 12 months?”. Respondents who responded “Yes” were classied as having experienced health-related stigmatization,
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while respondents who responded “No” were classied as not having experienced health-related stigmatization because
of their HIV status.
Data Processing and Analysis
The data were extracted using KoboCollect software, cleaned, and analyzed using Stata software (version 14). Univariate
and bivariate analyses were applied. First, we described the characteristics of the study population (frequency counts and
percentages of socio-demographic variables, experience of stigmatization and discrimination among PLHIV, and a pie
chart showing the percentage distribution of health-related stigma). Secondly, logistic regression was used to test the
association between the outcome (health-related stigma) and independent variables (socio-demographic variables,
including age, sex, marital status, level of education, employment status, place of residence, and orphan living with
you), and nally, a logistic regression analysis was conducted, showing the experience of internal stigmatization on
health-related stigma.
Ethical Considerations
The data were collected after obtaining ethical approval from the ethics committee, University of Uyo, Teaching
Hospital, Akwa Ibom State. Each study participant was informed in detail about the research objectives, methods, and
techniques, and written and signed informed consent was obtained from the participants who were 18 years and above,
while for participants under the age of 18 consent was provided by their parent/legal guardian on their behalf. This study
was conducted in accordance with the Declaration of Helsinki, and the data collection procedure was anonymous to
maintain the privacy and condentiality of any information.
Results
A total of 425 PLHIV were included in the analysis. The majority of the respondents were female, and were the head of
their households. Also, about one-third of the respondents were between the ages of 30 and 39 years and were rural
residents. Most of the respondents were married and about three-quarters of the respondents were employed. In this
study, about 41% of the respondents had received secondary education and more than one-quarter of the households had
an orphan living with them (Table 1).
Percentage of Health-Related Stigma Among PLHIV in Akwa Ibom State
More than half of the PLHIV in Akwa Ibom State had been denied health care services, including dental care, in the past
12 months because of their HIV status. The overall percentage of health-related stigma among PLHIV was 50.4%
(Figure 1).
Table 1 Frequency and Percentage Distribution of the Demographic Characteristics of PLHIV
Households in Akwa Ibom State
Demographic Characteristics Frequency (n=425) Percentage (%)
Age (years)
<18 33 7.8
19–29 112 26.4
30–39 142 33.4
40–49 85 20.0
50+ 53 12.5
(Continued)
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Experience of External and Internal Stigmatization/Discrimination Among PLHIV
During the past 12 months, 21% of the respondents had felt excluded from social activities and gatherings, 11% had
experienced exclusion from religious activities, while more than half of the respondents had experienced exclusion from
their family and friends because of their HIV status in the past 12 months. Also, 58% of PLHIV were unable to secure
accommodation or had been forced to change their accommodation, while 56% had lost their jobs or source of income
because of their HIV status.
About 70% of the respondents were afraid of being gossiped about, 17% were afraid of being verbally abused, and
13% were scared of being physically harassed or assaulted because of their HIV-positive status. As regards self-
stigmatization, 29% of the respondents were ashamed of being HIV positive and 16% exhibited self-guilt, while
a larger percentage of the respondents (38%) had low self-esteem because of their HIV status. About 5% had thought
Table 1 (Continued).
Demographic Characteristics Frequency (n=425) Percentage (%)
Sex
Male 159 37.4
Female 266 62.6
Level of education
No education 64 15.1
Primary education 120 28.2
Secondary education 176 41.4
Tertiary education 65 15.3
Employment status
Unemployed 108 25.4
Employed 317 74.6
Place of residence
Rural 278 34.6
Urban 147 65.4
Marital status
Single 198 46.6
Married 129 30.4
Separated/divorced 48 11.3
Widowed 50 11.8
Household headship
Female 242 56.9
Male 183 43.1
Do you have any HIV orphans living with you?
Yes 88 20.7
No 337 79.3
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about taking their own lives (suicidal) because of their HIV status. In the past 12 months, 36% of the respondents had
isolated themselves from friends and family, 5% had avoided hospital, 7% had chosen not to attend a social gathering,
5% had decided to stop working/not to apply for jobs or even seek any opportunities, while 12% had decided to stop
having sex or a sexual partner because of their HIV status. Also, about 20% of the respondents had decided to stop
childbearing for fear of transmitting the disease to their unborn children or sexual partner (Table 2). More than 50% of
the respondents had been forced to declare their status in order to attend an educational institution or get a scholarship,
and about 43% had been forced to declare their status before they could access health care services. Moreover, in the past
12 months, 54% of the respondents had confronted, challenged, and educated someone who was stigmatizing or
discriminating against them, and one-quarter of the respondents had supported someone else with regard to stigma and
discrimination. The results also show that about half of the respondents believed that they had experienced stigmatization
because they were HIV positive, 12% of the respondents felt that they experienced stigmatization because people were
afraid of getting infected with HIV, and 14% had experienced stigmatization because people do not understand what HIV
is. Also, about half of the respondents expressed that the root cause of stigmatization is fear of being infected with HIV
(Table 3).
Figure 1 Percentage of PLHIV who have been denied health services, including dental care, because of their HIV status in the past 12 months in Akwa Ibom State.
Note: 50.4% (blue) reported having experienced health-related stigma, while 49.6% (orange) reported that they had not experienced health-related stigma.
Table 2 Experience of External Stigmatization and Discrimination Among People Living with HIV
External Stigma Frequency
(n=425)
Percentage
(%)
Have you ever felt excluded from social gatherings/activities in the past 12 months?
Yes 91 21.4
No 334 78.6
Have you ever experienced exclusion from religious activities?
No 377 88.7
Yes 48 11.3
Have you ever experienced exclusion within your family/relatives?
Yes 245 57.7
No 180 42.3
(Continued)
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Table 2 (Continued).
External Stigma Frequency
(n=425)
Percentage
(%)
Because of your HIV status, in the past 12 months have you been forced to change your
accommodation or unable to secure accommodation?
Yes 247 58.1
No 178 41.9
In the past 12 months, have you lost a job or a source of your income because of HIV?
Yes 239 56.2
No 186 43.8
In the past 12 months, have you been fearful of any of the following things happening to you?
Being gossiped about 297 69.7
Being physically harassed/assaulted 55 13.1
Being verbally insulted 73 17.2
Table 3 Experience of Internal Stigmatization and Discrimination Among People Living with HIV
Frequency
(n=425)
Percentage
(%)
Have you ever experienced the following feelings because of your HIV status? (internal
stigma)
Ashamed 121 28.5
Self-blaming 69 16.2
Low self-esteem 161 37.9
Suicidal 22 5.2
No feeling 52 12.2
Have you done the following because of your HIV status in the past 12 months?
Avoided hospital 21 4.9
Isolated self from family and friends 154 36.2
Chosen not to attend social gathering 31 7.3
Decided not to apply for a job/stop working 14 3.3
Decided not to get married 44 10.3
Decided not to have (more) children 78 18.4
Decided not to have sex 50 11.8
Withdrew from/did not take on opportunities 10 2.4
None 23 5.4
(Continued)
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Experience of Testing, Disclosure, and Treatment Among PLHIV
The results showed that the majority of the respondents had been tested because a family member(s) was ill or had died
from HIV, while 28% had been tested because of suspected HIV-related symptoms. About 12% had been tested because
of pregnancy and 6% because a family member(s) was HIV positive. With regard to disclosing their status, more than
90% of the respondents had been pressurized into disclosing their status. About 43% of the respondents knew
organizations or groups that they can go to for help if they experience stigmatization or discrimination. They also
expressed that advocating for the right of all PLHIV (35%) and raising the awareness and knowledge of the public about
HIV (31%) should be the important tasks for these organizations to address stigma and discrimination (Table 4).
Table 3 (Continued).
Frequency
(n=425)
Percentage
(%)
For which of these have you been forced to declare your status in the past 12 months?
Applying for a job or set pension plan 21 4.9
Attending an educational institution or getting a scholarship 215 50.6
Getting health care 184 43.3
Getting medical insurance 2 0.5
Obtain a visa or applying for permanent residency 3 0.7
In the past 12 months, have you done any of the following because you are HIV positive?
Confronted, challenged, or educated someone who was stigmatizing and/or discriminating 229 53.9
Participated in an organization or a group that works to address stigma and discrimination 72 16.9
Supported others living with HIV in relation to stigma and/or discrimination 110 25.9
Tried to get a community leader to take action about issues of stigma and discriminating 13 3.1
Spoken to the media about issues of stigma and discrimination against people living with HIV 1 0.2
Why do you think you have experienced HIV-related stigma/discrimination?
Because of my HIV 214 50.4
People are afraid of getting infected 52 12.2
People are ashamed of associating with me 15 3.5
People do not understand what HIV is 59 13.9
People do not like my behavior/lifestyle 7 1.7
Religious belief/moral judgment 29 6.8
No stigma/discrimination 49 11.5
In your own opinion, what do you think are the root causes of HIV stigmatization?
Fear of being infected 210 49.4
Lack of awareness 104 24.5
Illiteracy 73 17.2
Cultural belief 13 3.1
Do not know 25 5.9
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Association of Socio-Demographic Parameters of Study Participants and
Health-Related Stigma (Logistic Regression Analysis) (n=425)
Table 5 shows the association of socio-demographic characteristics of the study subjects with health-related stigma using
logistic regression analysis. All independent variables were entered in the logistic regression model. The results are
presented as odds ratio (OR), 95% condence interval (CI), and p-values. The results of the study showed that young
age, place of residence, marital status, and education were signicantly associated with health-related stigma. It was found
that respondents who were urban residents were 29% less likely to experience health-related stigmatization compared with
rural residents (OR=0.71, 95% CI: 0.279–1.147). With regard to age, signicantly, respondents who were between the ages
of 19 and 29 years were 18% more likely to experience health-related stigmatization (OR=1.18, 95% CI: 2.119–0.233)
compared with respondents aged less than 18 years, while respondents between the ages of 30 and 49 years were less likely
to experience health-related stigmatization. The odds of being denied access to health care services because of their HIV
status increased signicantly, by 36%, among respondents aged 50 years and above (OR=1.36, 95% CI: 2.508–0.204).
The results further showed that male respondents were 52% less likely to experience health-related stigmatization
compared with female respondents (OR=0.48, 95% CI: 0.527–0.518). With regard to educational status, the odds of
being denied access to health care services because of their HIV status increased signicantly with no formal education
compared with those with higher educational level, as respondents with no formal education were 29% more likely to
have experienced health-related stigmatization compared with respondents with education (OR=1.29, 95% CI: 0.443–
Table 4 Experience of Testing, Disclosure, and Treatment Among People Living with HIV
Frequency
(n=425)
Percentage
(%)
Why were you tested for HIV?
Employment 4 0.9
Family member is positive 27 6.4
Illness/death of family member 217 51.1
Pregnancy 52 12.2
Referred due to suspected HIV-related symptoms 117 27.5
To prepare for marriage 8 1.9
What kind of experience do you have about disclosing your status?
I felt pressure from other people NOT living with HIV to disclose my status 413 97.2
Health care professional told other people about my HIV status without my consent 12 2.8
Do you know any organization or group you can go to for help if you experience stigma or
discrimination?
Yes 186 43.8
No 239 56.2
What do you think is the most important task that organizations should carry out to address
stigma/discrimination?
Advocating for the rights of all PLHIV 149 35.1
Providing emotional, physical, and referral support 81 19.1
Educating people living with HIV about living with HIV 62 14.6
Raising the awareness and knowledge of the public about HIV 133 31.2
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1.028). Similarly, respondents who were employed were 90% less likely to experience health-related stigma when
compared with respondents who were unemployed (OR=0.10, 95% CI: 0.686–0.466). Moreover, the odds of experien-
cing health-related stigma increased signicantly, by 20%, among respondents who were single compared with married
respondents (OR=1.20, 95% CI: 0.540–0.957). Finally, respondents with orphaned children living with them were 13%
Table 5 Association of Socio-Demographic Parameters of Study Subjects with
Health-Related Stigma (Logistic Regression Analysis) (n=425)
Variable OR 95% CI p-Value
Age (years)
<18 ref – –
19–29 1.1764 2.119–0.233 0.014*
30–39 0.7615 1.752–0.229 0.132
40–49 1.0572 2.124–0.010 0.052
50+ 1.3564 2.508–0.204 0.021*
Sex
Female ref – –
Male 0.4780 0.527–0.518 0.986
Place of residence
Rural ref – –
Urban 0.7135 0.279–1.1478 0.00*
Educational status
Tertiary ref – –
No education 1.2925 0.443–1.028 0.006*
Primary 0.3840 0.264–0.957 0.246
Secondary 0.0764 0.446–1.282 0.805
Employment status
Unemployed ref – –
Employed 0.1098 0.686–0.466 0.709
Marital status
Married ref – –
Divorced 0.6460 0.053–1.345 0.070
Single 1.2074 0.540–0.957 0.004*
Widowed 0.4176 0.446–1.281 0.344
Orphan living with you
No ref – –
Yes 1.1346 0.194–0.843 0.220
Note: *p-Value less than 0.05, which indicates a signicant relationship between the two variables
analyzed in binary logistic regression.
Abbreviations: OR, odds ratio; CI, condence interval.
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more likely to experience health-related stigma when compared with respondents with no orphaned children residing
with them (OR=1.13, 95% CI: 0.194–0.843).
Logistic Regression Analysis Showing the Experience of Internal Stigmatization on
Health-Related Stigma (n=425)
Table 6 shows the association between internal stigmatization on health-related stigma using logistic regression analysis.
The results revealed that respondents who were afraid of being physically assaulted or harassed because of their status
were 11% more likely to experience health-related stigmatization (OR=1.111, 95% CI: 1.836–0.185) when compared
with respondents who were afraid of being gossiped about because of their HIV status. Those respondents who were
afraid of being verbally insulted were 3% less likely to experience health-related stigmatization (OR=0.977, 95% CI:
1.517–0.438) compared with respondents who were afraid of being gossiped about owing to their HIV status (Table 6).
Furthermore, the odds of experiencing health-related stigmatization increased signicantly among respondents who
experienced internal stigmatization, such as blaming self (OR=1.405, 95% CI: 2.178–0.633), and respondents with low
self-esteem (OR=1.267 (95% CI: 1.944–0.589) compared with respondents who did not experience any internal
stigmatization; similarly, respondents who were ashamed (OR=1.620, 95% CI: 1.319–0.079) and suicidal (OR=1.077,
95% CI: 1.035–1.191) had higher odds of experiencing health-related stigmatization. Also, respondents who thought they
were being stigmatized because they looked sick with AIDS (OR=1.527, 95% CI: 2.131–0.923), or thought that people
were afraid of being infected by them (OR=1.329, 95% CI: 2.001–0.657), had signicantly higher odds of experiencing
health-related stigmatization compared with respondents who did not feel stigmatized, and respondents who thought that
people were ashamed of associating with them because of their status had higher odds of experiencing health-related
stigmatization (OR=1.098, 95% CI: 2.190–0.006).
Table 6 Logistic Regression Analysis Showing the Effects of Internal Stigmatization on Health-Related
Stigma (n=425)
Variable OR 95% CI p-Value
Do you fear the following might happen to you?
Being gossiped about ref – –
Being physically assaulted 1.111 1.836–0.185 0.016*
Being physically harassed and/or threatened 1.038 1.127–0.450 0.401
Being verbally insulted 0.977 1.517–0.438 0.000*
Internal stigma
No negative feelings ref – –
Ashamed 1.620 1.319–0.079 0.082
Blaming self 1.405 2.178–0.633 0.000*
Low self-esteem 1.267 1.944–0.589 0.000*
Do you know any organization or group you can go to for help if you experience stigma or
discrimination?
No ref – –
Yes 0.894 0.590–1.356 0.600
Note: *p-Value less than 0.05, which indicates a signicant relationship between the two variables analyzed in binary logistic regression.
Abbreviations: OR, odds ratio; CI, condence interval.
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Discussion
The ndings in the study suggest that there is a high level of stigmatization towards PLHIV in accessing health services in
Akwa Ibom State. This is consistent with previous studies.
4,15,26,32,33
Also in line with previous studies, the level of
stigmatization appears to be quite high in this study, with about 50% of PLHIV having been denied access to health care
services, including dental care, in the past 12 months, because of their HIV status. This high level of health-related
stigmatization may have substantial adverse effects on the day-to-day lives of HIV-infected people. It could result in
psychological and emotional stress, inconsistent health care-seeking behavior, and non-disclosure of HIV status.
15
Besides,
it may also lead to non-adherence to antiretroviral therapy, retention in care, and eventually causing people not to attain viral
suppression. By 2030, Nigeria is set to achieve the 95–95–95 goal set by the Joint United Nations Programme on HIV/AIDS
(UNAID): 95% of all PLHIV will know their HIV status, 95% of all people with diagnosed HIV infection will receive
sustained antiretroviral therapy, and 95% of all people receiving antiretroviral therapy will have viral suppression.
Subsequently, high levels of stigmatization and discrimination among PLHIV create the circumstances for spreading HIV
and undermine the ability of individuals and communities to protect them, which is one difculty in achieving the three 95s.
In this study, place of residence, age, educational status, and marital status were signicantly associated with health-
related stigmatization and discrimination against HIV-infected people. In line with previous studies, respondents who
reside in urban areas are less likely to experience health-related stigmatization compared with rural residents.
15,26,27
This
is because urban residents have access to various mass media, which are a powerful way of sending public health and
health promotion messages to the population, and particularly for sending messages relating to stigmatization and
discrimination to the community.
15
Furthermore, people with no education were more likely to experience health-related stigmatization, which is
supported by past studies.
26,34,35
Uneducated PLHIV who are not knowledgeable about HIV and modes of transmission
of the virus are more likely to experience HIV-related stigma. Young and single individuals were more likely to
experience health-related stigma owing to their HIV status, in line with previous studies
4,15
which stated that young
and single individuals may experience stigmatization; this can be attributed to the fact that most unmarried people are
viewed as being promiscuous, and engaging in high-risk behaviors including indiscriminate drug use. Single/unmarried
individuals are vulnerable to higher levels of stigmatization because of a lack of social support resulting from isolation,
discrimination, prejudice, and lack of psychosocial support from their family members and the society once their status is
revealed. The study showed that male individuals were less likely to experience health-related stigmatization compared
with female individuals; this is in contrast with previous studies in India,
4,36
which reported that males experienced
stigmatization more than females, but is consistent with other studies in India.
37,38
Individuals who experience self-stigmatization, such as self-guilt or low self-esteem, or individuals who are ashamed
of their status or even suicidal, were more likely to experience health-related stigmatization when compared with
individuals with no self-stigmatization. This nding is in line with a previous study.
26
Individuals who were afraid of
being gossiped about or who were afraid of being physically harassed or assaulted because of their HIV status had
a higher odds of experiencing health-related stigmatization; this is consistent with a study conducted in Peru, where
a respondent declared that “they would rather die than go back to the hospital again for care”, because of being gossiped
about by health care professionals.
39
The study indicated that respondents who knew organizations or groups who could
help during stigmatization were less likely to experience health-related stigmatization. This is consistent with a study
conducted in Kenya, which discovered that PLHIV who participated in organization or group activities experienced
signicantly less stigmatization than individuals who did not. Elimination of discrimination and stigma from the day-to-
day life of PLHIV will help in reducing the barriers to counseling and treatment, and improve the quality of care.
40
Strengths and Limitations of the Study
The study had a high completion rate and provided an understanding of stigma characteristics among PLHIV, thereby bringing
into focus the areas still in need of further study and improvements in practice. The high response rate was achieved because
questionnaire interviews were conducted among the project beneciaries. However, this study is not without its limitations.
One of the limitations was the use of closed-ended (yes/no) questions; a more accurate representation of questions would be
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the use of a stigma scale. Moreover, the study was conducted in only 12 LGAs, and a greater knowledge of stigma
characteristics may have been obtained if the study had been conducted in more LGAs in the state.
Conclusion
In this study, more than half of the PLHIV in Akwa Ibom State experienced health-related stigmatization, as many of the
respondents were denied access to healthcare services, including dental care, because of their HIV status. The study
indicated that young people, single individuals, uneducated people and rural residents were more likely to experience
health-related stigmatization. Also, PLHIV who suffer from internal stigma are more likely to experience HIV health-
related stigmatization. This nding serves as a key indicator in generating and implementing policies against health-
related stigmatization among PLHIV and other HIV-related stigma in Akwa Ibom State, where HIV is predominant. The
older population should be considered when drafting such policies.
Acknowledgment
This paper is made possible by the Center for Clinical Care and Clinical Research Nigeria (CCCRN) with support from the
United States Agency for International Development (USAID) under cooperative agreement funding for the ICHSSA 1 project.
The contents are the responsibility of the authors and do not necessarily represent the views of USAID or the United States
Government.
Funding
This study is funded, as part of the approved scope of work for CCCRN ICHSSA 1 Project on orphan and vulnerable
households in Akwa Ibom State, through the US Agency for International Development (USAID), Cooperative
Agreement (72062020CA00006).
Disclosure
The authors report no conicts of interest in this work.
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