Introduction
Stigma is a common human reaction to disease. Throughout history many diseases have carried considerable stigma, including leprosy, tuberculosis, cancer, mental illness, and many sexually transmitted diseases. HIV/AIDS is only the latest disease to be stigmatized.¹

Understanding the concept of stigmatization
Goffman² defines stigma, in general, as an undesirable or discrediting attribute that an individual possesses, thus reducing that individual’s status in the eyes of society. Stigma can result from a particular characteristic, such as a physical deformity, or it can stem from negative attitudes toward the behaviour of a group, such as homosexuals or commercial sex workers. Herek and Mitnick³ brings us closer to our topic of discussion when they define AIDS-related stigma as prejudice, discounting, discrediting and discrimination directed at people perceived to have AIDS or being infected with HIV and at the individuals, groups and communities with which they are associated.

Why do people manifest stigma towards people living with HIV or AIDS (PLHA)?
Sources of stigma include fear of illness, fear of contagion, and fear of death. Fear of illness and fear of contagion is a common reaction among health workers, co-workers, and caregivers, as well as the general population. Stigma is one means of coping with the fear that contact with a member of an affected group (e.g. by caring for or sharing utensils with a PLHA) will result in contracting the disease⁴.

HIV-stigma is often layered on top of many other stigmas associated with such specific groups as homosexuals and commercial sex workers and such behaviours as drug abuse by using needles and casual sex. These behaviours are perceived as controllable and are therefore assigned more blame, receive less sympathy, but instead, more anger and are less likely to receive assistance as opposed to people with AIDS who were infected through circumstances where there was no control, such as receiving a blood transfusion⁵.

Effects of stigma
Consequences of stigma can be viewed along a continuum from mild reactions (e.g., silence and denial), to ostracism and ultimately violence.

The way in which individuals discover and disclose their HIV status to others, as well as how they cope with their HIV status, is influenced by cultural and community beliefs and values regarding causes of illness, learned patterns of response to illness, social and economic contexts, and social norms.

In particular, AIDS-related stigma is expressed around the world in a variety of ways:

• Ostracism, rejection and a voidance of PLHA;
• Discrimination against PLHA;
• Compulsory HIV testing without prior consent or protection of confidentiality;
• Violence against persons who are perceived to have AIDS or to be infected with HIV; and
• Quarantine of persons with HIV.

However, whatever the form of stigmatization, it inflicts suffering on people and interferes with attempts to fight the AIDS epidemic. In this regard research has found that not knowing one’s HIV status is far preferable to being tested. The fear is that the lack of confidentiality, which is highly likely in many settings, forces disclosure and that individuals can then face prejudice, discrimination, the loss of a job, strains on or the break-up of relationships, social ostracism, or violence⁶. By displaying this kind of behaviour the transmitting of the virus can continue.

A more recent study (May 2004) completed by Dr. Ben Olley⁷, concluded that HIV/AIDS is usually associated with high rates of psychiatric and emotional problems. This research has found that these problems contribute to people not sticking to their drug regiments. It can even speed up the progression of the disease and hasten the death of a patient.

Women and stigma
The impact of HIV/AIDS on women is particularly acute. Especially in Africa, women are often economically, culturally and socially disadvantaged and will lack equal access to treatment, financial support and education. It has even been found that in a number of societies women are mistakenly perceived as the main transmitters of sexually transmitted diseases⁸. HIV positive women are treated very different from men in many developing countries: men are likely to be ‘excused’ for their behaviour that resulted in their infection, whereas women are not.

Women in the developing world face more stigmatization and suffer more negative effects than men. In the study of Olley, previously mentioned, 149 (44 male and 105 female) newly diagnosed HIV/AIDS patients in Tygerberg hospital, South Africa, were assessed. The most frequent diagnosis was depression (34,9%) followed by dysthymic disorder⁹ (21,5%). Women were more likely to suffer from post-traumatic stress disorder, while male patients were significantly more likely to abuse alcohol and have morenprotected sex.

Employment
Unfortunately the risk of transmission has been used by numerous employers to terminate or refuse employment. It has also been found that if PLHA are open about their status at work, they may well experience stigmatization and discrimination by fellow employees¹⁰. In developing countries some instances of compulsory pre-employment testing took place; some of these industries have used the information to deny employment to people with HIV or AIDS.

Health care
In general, literature suggests that ironically PLHA are stigmatised and discriminated against by health care systems. The stigmatization ranged from withheld of treatment, non-attendance of hospital staff to patients, HIV testing without consent, lack of confidentiality and denial of hospital facilities and medicines.

A significant survey was conducted in 2002 among 1 000 physicians, nurses and midwives in four Nigerian states¹¹. Some of their disturbing findings were:

• One in 10 doctors and nurses have admitted having refused to care for an HIV-positive patient or had denied HIV-positive patients admission to a hospital;
• Almost 40% thought that a person’s appearance betrayed his or her HIV-positive status;
• 20% felt that PLHA had behaved immorally and deserved their fate; and
• Stigma persisted among doctors and nurses because of fear of exposure to HIV as a result of lack of protective equipment.

What can be done to lessen stigma?
It has become just as important to combat the stigma as it is to develop medical cures to prevent or control the spread of HIV. Changing attitudes are not that easy. Eliminating stigma completely remains at this stage only a dream, but an overview of the main research does suggest that something can be done through a variety of interventions, such as focussed information dissemination, counselling, coping skills acquisition and direct contact with someone that is living with HIV or AIDS¹².

Some of the interventions are:

• People living with HIV/AIDS need to be educated on their basic human rights;
• These rights will enable them to enforce it through the legal process;
• In order to mitigate the effects of discrimination and stigma, institutions should implement their HIV/AIDS policies based on sound information and taking into account the rights of everybody; and
• HIV negative people need to be educated too, in order to create an environment free of fear of HIV biased social attitudes and no stereotypes towards HIV.

Conclusion
The ever-presence of stigma and its persistence even in areas where HIV prevalence is high makes it an extraordinarily important yet difficult attitude to eradicate. One would expect stigma to decrease with increased visibility of HIV, but this is not the case, especially in much of sub-Saharan Africa. Given the fact that AIDS stigma caused enormous barriers to public health programs–from the denial and silence, to problems associated with disclosure, health seeking behaviour, and to the communal violence, it would be fitting for the public health community to begin to use more creativity in designing AIDS stigma interventions and to implement them on a significant scale.

This topic has been addressed in response to requests from our subscribers and the AfroAIDSinfo project team would like to invite anyone with workable suggestions that would lessen the effects of HIV-stigma to respond to this article.

Sources