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The Impact of HIV Stigma and Discrimination on HIV Testing, Antiretroviral Treatment, and Viral Suppression in Africa: A Pooled Analysis of Population-Based Surveys
25 Pages Posted: 23 Apr 2025
More...Abstract
Background: UNAIDS’ Ending AIDS targets include ensuring that <10% of people experience HIV stigma and discrimination. We estimated the effect of HIV stigma and discrimination on the HIV care cascade in eastern, southern, central, and western Africa –regions with the highest HIV burden worldwide.
Methods: Using population-based surveys, we assessed three community-level HIV stigma exposures (continuous): discriminatory attitudes, perceived stigma, and shame of association with people living with HIV (PLHIV). Among PLHIV, we examined individual-level, past-year anticipated or experienced stigma in healthcare settings (binary). Using Poisson regression, we estimated adjusted prevalence ratios (aPR) for the effect of each stigma measure on past-year HIV testing, antiretroviral therapy use (ART), and viral suppression. We used segmented regression with a median breakpoint to model non-linear effects of community-level stigma.
Findings: We identified 124 surveys in 38 countries (2000-2023). Stigma towards PLHIV was high: 51% of participants held discriminatory attitudes, 74% perceived HIV stigma, and 43% reported shame of association. Among PLHIV, 21% had anticipated and 4% experienced stigma. At the community-level, where the prevalence of discriminatory attitudes was above the median, people were less likely to have tested for HIV (aPR=0.88 per 10% increase, 95%CI:0.87-0.88), and PLHIV had lower ART use (aPR=0.96, 95%CI:0.94-0.97) and viral suppression (aPR=0.96, 95%CI:0.95-0.98). Similarly, communities with higher (≥median) shame of association levels had lower testing (aPR=0.97 per 10% increase, 95%CI:0.96-0.98) and viral suppression (aPR=0.98, 95%CI:0.96-1.00). PLHIV who anticipated and/or experienced stigma were 7% (95%CI:4-10%) and 10% (95%CI:6-14%) less likely to be on ART and virally suppressed, respectively, possibly reaching 14% (95%CI:7-21%) and 16% (95%CI:9-23%) when adjusted for selection bias.
Interpretation: HIV stigma and discrimination have measurable, widespread, negative effects on the full cascade of care: HIV testing, treatment, and viral suppression. These effects are most pronounced in communities with the highest levels of stigma.
Keywords: HIV stigma and discrimination, structural determinants of health, HIV testing, HIV treatment cascade, Africa
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