HIV This Week

Roura M, Urassa M, Busza J, Mbata D, Wringe A, Zaba B. Scaling up stigma? The effects of antiretroviral roll-out on stigma and HIV testing. Early evidence from rural Tanzania. Sex Transm Infect. 2008. [Epub ahead of print]

This study aimed to investigate the interplay between antiretroviral therapy scale-up, different types of stigma, and voluntary counselling and testing uptake two years after the introduction of free antiretroviral therapy in a rural ward of Tanzania. Qualitative study using in-depth interviews and group activities with a purposive sample of 91 community leaders, 77 antiretroviral therapy clients and 16 health providers. Data were analysed for recurrent themes using NVIVO-7 software. The complex interplay between antiretroviral therapy, stigma, and voluntary counselling and testing in this setting is characterised by two powerful but opposing dynamics. The availability of effective treatment has transformed HIV into a manageable condition which is contributing to a reduction of self-stigma and is stimulating uptake of voluntary counselling and testing. However, this is counter-balanced by the persistence of blaming attitudes and emergence of new sources of stigma associated with antiretroviral therapy provision. The general perception among community leaders was that as antiretroviral therapy users regained health they increasingly engaged in sexual relations and «spread the disease». Fears were exacerbated because they were perceived to be very mobile and difficult to identify physically. Some leaders suggested giving antiretroviral therapy recipients drugs «for impotence», marking them «with a sign», and putting them «in isolation camps». In this context, traditional beliefs about disease aetiology provided a less stigmatised explanation for HIV symptoms contributing to a situation of collective denial. Where anticipated stigma prevails, provision of antiretroviral drugs alone is unlikely to have sufficient impact on voluntary counselling and testing uptake. Achieving widespread public health benefits of antiretroviral therapy roll-out requires community-level interventions to ensure local acceptability of antiretroviral drugs.

Editors’ note: Stigma may be internalized (self-stigma), anticipated (stigma people expect from others), secondary (affecting those related to the infected person) or enacted stigma (discrimination). Stigma related to inability of ill people living with HIV to conduct productive activities and care for themselves (‘drain of resources’) may be reduced by the health enhancing effects of antiretroviral treatment as people regain weight and energy. However, without social analysis, community engagement, and careful planning, scaling up antiretroviral treatment can lead to new sources of treatment-associated stigma that ostracizes people on treatment and dissuades others from learning their HIV serostatus.