Advertisement

AIDS and Behavior

, Volume 24, Issue 1, pp 81–94 | Cite as

Using a Multi-level Framework to Test Empirical Relationships Among HIV/AIDS-Related Stigma, Health Service Barriers, and HIV Outcomes in KwaZulu-Natal, South Africa

  • Leslie D. WilliamsEmail author
  • J. Lawrence Aber
  • The SIZE Research Group
Original Paper
  • 178 Downloads

Abstract

HIV/AIDS-related (HAR) stigma is an ongoing problem in Sub-Saharan Africa that is thought to impede HIV preventive and treatment interventions. This paper uses a systematic sample of households (Level 1) nested within near-neighbor clusters (Level 2) and communities (Level 3) to examine multilevel relationships of HAR stigma to health service barriers (HSBs) and HIV outcomes in KwaZulu-Natal, South Africa, thereby addressing methodological and conceptual gaps in the literature from this context. Findings suggest differential patterns of prediction at Level 1 when examining two different dimensions of stigma: more highly stigmatizing attitudes predicted more household health service barriers; and perceptions of greater levels of community normative HAR stigma predicted higher household HIV ratios. Level 2 findings were similarly dimension-differentiated. Cross-level analyses found that near-neighbor cluster-level (setting level) consensus about (standard deviation) and level of (mean) community normative HAR stigma significantly predicted household-level HSBs and HIV ratio, controlling for household-level community normative HAR stigma. These differential patterns of prediction suggest that HAR stigma is a multi-level construct with multiple dimensions that relate to important outcomes differently within and across multiple ecological levels. This has important implications for future research, and for developing interventions that address setting-level variation in stigma.

Keywords

HIV-related stigma Health service barriers HIV prevalence Ecological measurement Multilevel analysis South Africa Setting-level measurement 

Notes

Acknowledgements

This research was funded by a graduate training grant from the National Institute of Mental Health (F31MH097666; PI Dr. Leslie D. Williams). Its parent project, SIZE, was funded by a 2008 grant from the National Institute of Child Health and Human Development (R01HD055137; PI Dr. J. Lawrence Aber) titled “Well-being of South African Children: Household, Community, and Policy Influences,” as well as by financial contributions from the Rockefeller Foundation and from the Center for World Health at the UCLA David Geffen School of Medicine. The authors acknowledge the support and guidance of their collaborators at UNICEF and the South African Department of Social Development. They extend their appreciation to all involved local municipal counselors, traditional leaders, school principals, and community-based organizations working in the area. Finally, and most importantly, they would like to thank the Human Sciences Research Council research staff (including data collectors and community outreach staff), the communities in which the study was conducted, and the children and families who participated in the study.

Funding

This study was funded by the National Institute of Mental Health (F31MH097666; PI Dr. Leslie D. Williams); and by the National Institute of Child Health and Human Development (R01HD055137; PI Dr. J. Lawrence Aber).

Compliance with Ethical Standards

Conflict of interest

All authors declared that they have no conflict of interest.

Research Involving Human Participants

Institutional review boards at both New York University in New York, NY; and Human Sciences Research Council in Durban, South Africa approved all study procedures.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.

Informed Consent

Informed consent was obtained for all study participants. For child participants, informed consent was obtained from their primary caregivers. After this caregiver consent was obtained, children were informed about the study using child-appropriate language, and asked whether they wanted to give assent to participate. All consent and assent forms were reviewed and approved by institutional review boards at both New York University in New York, NY and Human Sciences Research Council in Durban, South Africa.

Supplementary material

10461_2019_2439_MOESM1_ESM.docx (176 kb)
Supplementary material 1 (DOCX 175 kb)

References

  1. 1.
    UNAIDS. AIDS Epidemic Update: December 2009. Geneva, Switzerland: Joint United Nations Programme on HIV/AIDS and World Health Organization; 2009.Google Scholar
  2. 2.
    UNAIDS. (2006). 2006 Report on the Global AIDS Epidemic. Joint United Nations Programme on HIV/AIDS.Google Scholar
  3. 3.
    Rankin WW, Brennan S, Schell E, Laviwa J, Rankin SH. The stigma of being HIV-positive in Africa. Public Library of Science Medicine. 2005;2(8):0702–4.Google Scholar
  4. 4.
    Simbayi LC, Kalichman S, Strebel A, Cloete A, Henda N, Mqeketo A. Internalized stigma, discrimination, and depression among men and women living with HIV/AIDS in Cape Town, South Africa. Soc Sci Med. 2007;64:1823–31.PubMedPubMedCentralGoogle Scholar
  5. 5.
    Kohi TW, Makoae L, Chirwa M, Holzemer WL, Phetlhu DR, Uys L, Naidoo J, et al. HIV and AIDS stigma violates human rights in five African countries. Nursing Ethics. 2006;13(4):404–15.PubMedGoogle Scholar
  6. 6.
    Chan BT, Tsai AC. HIV stigma trends in the general population during antiretroviral treatment expansion: analysis of 31 countries in sub-Saharan Africa, 2003–2013. J Acquir Immune Defic Syndr (1999). 2016;72(5):558–64.Google Scholar
  7. 7.
    Kalichman SC, Simbayi L. Traditional beliefs about the cause of AIDS and AIDS-related stigma in South Africa. AIDS Care. 2004;16(5):572–80.PubMedGoogle Scholar
  8. 8.
    Kalichman SC, Simbayi LC. HIV testing attitudes, AIDS stigma, and voluntary counseling and testing in a black township in Cape Town, South Africa. Sex Trans Inf. 2003;79:442–7.Google Scholar
  9. 9.
    Nachega JB, Stein DM, Lehman DA, Hlatshwayo D, Mothopeng R, Chaisson RE, Karstaedt AS. Adherence to antiretroviral therapy in HIV-infected adults in Soweto, South Africa. AIDS Res Hum Retroviruses. 2004;20(10):1053–6.PubMedGoogle Scholar
  10. 10.
    Weiser S, Wolfe W, Bangsberg D, Thior I, Gilbert P, et al. Barriers to antiretroviral adherence for patients living with HIV infection and AIDS in Botswana. J Acquir Immune Defic Syndr. 2003;34(3):281–8.PubMedGoogle Scholar
  11. 11.
    Greeff M, Phetlhu R, Makoae LN, Dlamini PS, Holzemer WL, et al. Disclosure of HIV status: experiences and perceptions of persons living with HIV/AIDS and nurses involved in their care in Africa. Qual Health Res. 2008;18(3):311–24.PubMedGoogle Scholar
  12. 12.
    Campbell C, Foulis CA, Maimane S, Sibiya Z. “I have an evil child at my house”: stigma and HIV/AIDS management in a South African community. Am J Public Health. 2005;95(5):808–15.PubMedPubMedCentralGoogle Scholar
  13. 13.
    Treves-Kagan S, Steward WT, Ntswane L, et al. Why increasing availability of ART is not enough: a rapid, community-based study on how HIV-related stigma impacts engagement to care in rural South Africa. BMC Public Health. 2016;16(1):87.PubMedPubMedCentralGoogle Scholar
  14. 14.
    Khan R, Yassi A, Engelbrecht MC, Nophale L, van Rensburg AJ, Spiegel J. Barriers to HIV counselling and testing uptake by health workers in three public hospitals in Free State Province, South Africa. AIDS Care. 2015;27(2):198–205.PubMedGoogle Scholar
  15. 15.
    Okoror TA, BeLue R, Zungu N, Adam AM, Airhihenbuwa CO. HIV positive women’s perceptions of stigma in health care settings in Western Cape, South Africa. Health Care Women Int. 2014;35(1):27–49.PubMedGoogle Scholar
  16. 16.
    Duffy L. Suffering, shame, and silence: the stigma of HIV/AIDS. J Assoc Nurses AIDS Care. 2005;16(1):13–20.PubMedGoogle Scholar
  17. 17.
    Ahmed S, Lutalo T, Wawer M, Serwadda D, Sewankambo NK, Nalugoda F, Makumbi F, Wabwire-Mangen F, Kiwanuka N, Kigozi G, Kiddugavu M, Gray R. HIV incidence and sexually transmitted disease prevalence associated with condom use: a population study in Rakai, Uganda. AIDS. 2001;15:2171–9.PubMedGoogle Scholar
  18. 18.
    Creese A, Floyd K, Alban A, Guinness L. Cost-effectiveness of HIV/AIDS interventions in Africa: a systematic review of the evidence. Lancet. 2002;359:1635–42.PubMedGoogle Scholar
  19. 19.
    Ngugi EN, Simonsen JN, Bosire M, Ronald AR, Plummer FA, Cameron DW, Waiyaki P, Ndinya-Achola JO. Prevention of transmission of human immunodeficiency virus in Africa: effectiveness of condom promotion and health education among prostitutes. Lancet. 1988;332:887–90.Google Scholar
  20. 20.
    Suksomboon N, Poolsup N, Ket-aim S. Systematic review of the efficacy of antiretroviral therapies for reducing the risk of mother-to-child transmission of HIV infection. J Clin Pharm Ther. 2007;32:293–311.PubMedGoogle Scholar
  21. 21.
    Weiss HA, Quigley MA, Hayes RJ. Male circumcision and risk of HIV infection in sub-Saharan Africa: a systematic review and meta-analysis. AIDS. 2000;14:2361–70.PubMedGoogle Scholar
  22. 22.
    Lima VD, Harrigan R, Bangsberg DR, Hogg RS, Gross R, Yip B, Montaner JSG. The combined effect of modern highly antiretroviral therapy regimens and adherence on mortality over time. J Acquir Immune Defic Syndr. 2009;50(5):529–36.PubMedPubMedCentralGoogle Scholar
  23. 23.
    Murphy EL, Collier AC, Kalish LA, Assmann SF, Para MF, Flanigan TP, Kumar PN, Mintz L, Wallach FR, Nemo GJ. Highly active antiretroviral therapy decreases mortality and morbidity in patients with advanced HIV disease. Ann Intern Med. 2001;135(1):17–26.PubMedGoogle Scholar
  24. 24.
    Abaynew Y, Deribew A, Deribe K. Factors associated with late presentation to HIV/AIDS care in South Wollo ZoneEthiopia: a case-control study. AIDS Res Ther. 2011;8(1):8.PubMedPubMedCentralGoogle Scholar
  25. 25.
    Nyamathi A, Ekstrand M, Zolt-Gilburne J, et al. Correlates of stigma among rural Indian women living with HIV/AIDS. AIDS Behav. 2013;17(1):329–39.PubMedPubMedCentralGoogle Scholar
  26. 26.
    Nozaki I, Dube C, Kakimoto K, Yamada N, Simpungwe JB. Social factors affecting ART adherence in rural settings in Zambia. Aids Care. 2011;23(7):831–8.PubMedPubMedCentralGoogle Scholar
  27. 27.
    Rueda S, Mitra S, Chen S, et al. Examining the associations between HIV-related stigma and health outcomes in people living with HIV/AIDS: a series of meta-analyses. BMJ open. 2016;6(7):e011453.PubMedPubMedCentralGoogle Scholar
  28. 28.
    Nelson LE, Wilton L, Agyarko-Poku T, et al. The association of HIV stigma and HIV/STD knowledge with sexual risk behaviors among adolescent and adult men who have sex with men in Ghana, West Africa. Res Nursing Health. 2015;38(3):194–206.Google Scholar
  29. 29.
    Kelly J, Ryan AM, Altman BE, Stelzner SP. Understanding and changing social systems: an ecological view. In: Rappaport J, Seidman E, editors. Handbook of Community Psychology. Julian Kluwer Academic/Plenum Publishers, New York; 2000.Google Scholar
  30. 30.
    Williams LD. Understanding the relationships among HIV/AIDS-related stigma, health service utilization, and HIV prevalence and incidence in Sub-Saharan Africa: a multi-level theoretical perspective. Am J Commun Psychol. 2014;53:146–58.Google Scholar
  31. 31.
    Li L, Lee S, Thammawijaya P, Jiraphongsa C, Rotheram-Borus MJ. Stigma, social support, and depression among people living with HIV in Thailand. AIDS Care. 2009;21(8):1007–13.PubMedPubMedCentralGoogle Scholar
  32. 32.
    Treves-Kagan S, El Ayadi AM, Pettifor A, et al. Gender, HIV testing and stigma: the association of HIV testing behaviors and community-level and individual-level stigma in rural South Africa differ for men and women. AIDS Behav. 2017;21(9):2579–88.PubMedPubMedCentralGoogle Scholar
  33. 33.
    Chan D. Functional relations among constructs in the same content domain at different levels of analysis: a typology of composition models. J Appl Psychol. 1998;83(2):234–46.Google Scholar
  34. 34.
    Lindell MK, Brandt CJ. Climate quality and climate consensus as mediators of the relationship between organizational antecedents and outcomes. J Appl Psychol. 2000;85(3):331–48.PubMedGoogle Scholar
  35. 35.
    Bronfenbrenner U, Morris PA. The bioecological model of human development. In: Handbook of Child Psychology. 6th ed. Volume 1, Wiley, Hoboken; 2006. pp. 793–828Google Scholar
  36. 36.
    Von Korff M, Koepsell T, Curry S, Diehl P. Multilevel analysis in epidemiologic research on health behaviors and outcomes. Am J Epidemiol. 1992;135(10):1077–82.Google Scholar
  37. 37.
    Shisana, O., Simbayi, L., & Human Sciences Research Council. Nelson Mandela/HSRC Study of HIV/AIDS: South African National HIV Prevalence, Behavioural Risks and Mass Media. Cape Town, South Africa: Human Sciences Research Council Publishers; 2002.Google Scholar
  38. 38.
    Bond V, Chase E, Aggleton P. Stigma, HIV/AIDS and prevention of mother-to-child transmission in Zambia. Eval Prog Plan. 2002;25:347–56.Google Scholar
  39. 39.
    Shisana O, Rehle T, Simbayi LC, Zuma K, Jooste S, Zungu N, Labadarios D, Onoya D. South African national HIV prevalence, incidence and behaviour survey, 2012. Cape Town, South Africa: HSRC Press; 2014.Google Scholar
  40. 40.
    McBurney P. On transferring statistical techniques across cultures: the Kish grid. Curr Anthropol. 1988;29(2):323–5.Google Scholar
  41. 41.
    Genburg BL, Hlavka Z, Konda KA, Maman S, Chariyalertsak S, Chingono A, Mbwambo J, Modiba P, Van Rooyen H, Celentano DD. A comparison of HIV/AIDS-related stigma in four countries: negative attitudes and perceived acts of discrimination towards people living with HIV/AIDS. Soc Sci Med. 2009;68:2279–87.Google Scholar
  42. 42.
    Westbrook L, Bauman L. Perceived stigma of HIV/AIDS: public view. Bronx: Albert Einstein College of Medicine; 1996.Google Scholar
  43. 43.
    Academy for Educational Development (AED) (2002). Speak for the Child Data Collection Protocols. USAID and the Academy for Educational Development.Google Scholar
  44. 44.
    Garson GD. Introductory Guide to HLM with HLM 7 Software. Hierarchical linear modeling: guide and applications. North Carolina State University, Raleigh; 2013.Google Scholar
  45. 45.
    Shinn M. Mixing and matching: levels of conceptualization, measurement, and statistical analysis in community research. In: Tolan P, Keys C, Chertok F, Jason LA, editors. Researching community psychology: issues of theory and methods, 1990. 111-126.Google Scholar
  46. 46.
    Latkin CA, Vlahov D. Socially desirable response tendency as a correlate of accuracy of self-reported HIV serostatus for HIV seropositive injection drug users. Addiction. 2002;93(8):1191–7.Google Scholar
  47. 47.
    Hamra M, Ross MW, Orrs M, D’Agostino A. Relationship between expressed HIV/AIDS-related stigma and HIV-beliefs/knowledge and behavior in families of HIV infected children in Kenya. Trop Med Int Health. 2006;11(4):513–27.PubMedGoogle Scholar
  48. 48.
    Skinner D, Mfecane S. Stigma, discrimination and the implications for people living with HIV/AIDS in South Africa. J des Aspects Soc du VIH/SIDA. 2004;1(3):157–64.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Steinhardt School of Culture, Education, and Human DevelopmentNew York UniversityNew YorkUSA
  2. 2.National Development and Research InstitutesNew YorkUSA
  3. 3.Human Sciences Research CouncilSweetwatersSouth Africa

Personalised recommendations