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A Livelihood Intervention to Reduce the Stigma of HIV in Rural Kenya: Longitudinal Qualitative Study

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Abstract

The scale-up of effective treatment has partially reduced the stigma attached to HIV, but HIV still remains highly stigmatized throughout sub-Saharan Africa. Most studies of anti-HIV stigma interventions have employed psycho-educational strategies such as information provision, counseling, and testimonials, but these have had varying degrees of success. Theory suggests that livelihood interventions could potentially reduce stigma by weakening the instrumental and symbolic associations between HIV and premature morbidity, economic incapacity, and death, but this hypothesis has not been directly examined. We conducted a longitudinal qualitative study among 54 persons with HIV participating in a 12-month randomized controlled trial of a livelihood intervention in rural Kenya. Our study design permitted assessment of changes over time in the perspectives of treatment-arm participants (N = 45), as well as an understanding of the experiences of control arm participants (N = 9, interviewed only at follow-up). Initially, participants felt ashamed of their seropositivity and were socially isolated (internalized stigma). They also described how others in the community discriminated against them, labeled them as being “already dead,” and deemed them useless and unworthy of social investment (perceived and enacted stigma). At follow-up, participants in the treatment arm described less stigma and voiced positive changes in confidence and self-esteem. Concurrently, they observed that other community members perceived them as active, economically productive, and contributing citizens. None of these changes were noted by participants in the control arm, who described ongoing and continued stigma. In summary, our findings suggest a theory of stigma reduction: livelihood interventions may reduce internalized stigma among persons with HIV and also, by targeting core drivers of negative attitudes toward persons with HIV, positively change attitudes toward persons with HIV held by others. Further research is needed to formally test these hypotheses, assess the extent to which these changes endure over the long term, and determine whether this class of interventions can be implemented at scale.

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Acknowledgments

We acknowledge the Kenya Medical Research Institute-University of California at San Francisco (KEMRI-UCSF) Collaborative Group, Family AIDS Care and Education Services (FACES), the Director of KEMRI, the Director of KEMRI’s Centre for Microbiology Research, and Nyanza Provincial Ministries of Health, for their logistical support in conducting this research; Kyle Pusateri and Rachel Steinfeld, for project coordination and administrative support; and Gina Clark, Humphrey Diang’a, Kevin Kadade, Pamela Kimwele, Manali Nekkanti, and Prisca Owata, for their contributions to data collection and analysis.

Funding

This study was funded by U.S. National Institutes of Health (NIH) R34MH094215 and the United Nations World Food Programme The authors also acknowledge salary support through NIH K23MH096620. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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Authors and Affiliations

  1. Center for Global Health, Massachusetts General Hospital, 125 Nashua Street, Ste. 722, Boston, MA, 02114, USA

    Alexander C. Tsai

  2. Harvard Center for Population and Development Studies, Cambridge, MA, USA

    Alexander C. Tsai

  3. Mbarara University of Science and Technology, Mbarara, Uganda

    Alexander C. Tsai

  4. Division of HIV/AIDS, University of California at San Francisco at San Francisco General Hospital, San Francisco, CA, USA

    Abigail M. Hatcher, Lee Lemus Hufstedler & Sheri D. Weiser

  5. Wits Reproductive Health and HIV Institute, University of the Witwatersrand, Johannesburg, South Africa

    Abigail M. Hatcher

  6. Centre for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya

    Elizabeth A. Bukusi & Elly Weke

  7. Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA

    Elizabeth A. Bukusi

  8. Center of Expertise in Women’s Health and Empowerment, University of California Global Health Institute, San Francisco, CA, USA

    Shari L. Dworkin, Craig R. Cohen & Sheri D. Weiser

  9. Department of Social and Behavioral Sciences, School of Nursing, University of California at San Francisco, San Francisco, CA, USA

    Shari L. Dworkin

  10. United Nations Children’s Fund, Abuja, Nigeria

    Stephen Kodish

  11. Department of Obstetrics, Gynecology and Reproductive Sciences, University of California at San Francisco, San Francisco, CA, USA

    Craig R. Cohen

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  1. Alexander C. Tsai
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  9. Sheri D. Weiser
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Correspondence to Alexander C. Tsai.

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Tsai, A.C., Hatcher, A.M., Bukusi, E.A. et al. A Livelihood Intervention to Reduce the Stigma of HIV in Rural Kenya: Longitudinal Qualitative Study. AIDS Behav 21, 248–260 (2017). https://doi.org/10.1007/s10461-015-1285-6

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