AIDS and Behavior

, Volume 17, Issue 8, pp 2725–2731 | Cite as

How Does Antiretroviral Treatment Attenuate the Stigma of HIV? Evidence from a Cohort Study in Rural Uganda

  • Alexander C. Tsai
  • David R. Bangsberg
  • Mwebesa Bwana
  • Jessica E. Haberer
  • Edward A. Frongillo
  • Conrad Muzoora
  • Elias Kumbakumba
  • Peter W. Hunt
  • Jeffrey N. Martin
  • Sheri D. Weiser
Original Paper

Abstract

Program implementers and qualitative researchers have described how increasing availability of HIV antiretroviral therapy (ART) is associated with improvements in psychosocial health and internalized stigma. To determine whether, and through what channels, ART reduces internalized stigma, we analyzed data from 262 HIV-infected, treatment-naïve persons in rural Uganda followed from ART initiation over a median of 3.4 years. We fitted Poisson regression models with cluster-correlated robust estimates of variance, specifying internalized stigma as the dependent variable, adjusting for time on treatment as well as socio-demographic, clinical, and psychosocial variables. Over time on treatment, internalized stigma declined steadily, with the largest decline observed during the first 2 years of treatment. This trend remained statistically significant after multivariable adjustment (χ2 = 28.3; P = 0.03), and appeared to be driven by ART-induced improvements in HIV symptom burden, physical and psychological wellbeing, and depression symptom severity.

Keywords

Social stigma Depression Antiretroviral therapy Highly active HIV Uganda 

References

  1. 1.
    Weiser SD, Gupta R, Tsai AC, Frongillo EA, Grede N, Kumbakumba E, et al. Changes in food insecurity, nutritional status, and physical health status after antiretroviral therapy initiation in rural Uganda. J Acquir Immune Defic Syndr. 2012;61(2):179–86.PubMedCrossRefGoogle Scholar
  2. 2.
    Palar K, Wagner G, Ghosh-Dastidar B, Mugyenyi P. Role of antiretroviral therapy in improving food security among patients initiating HIV treatment and care in Uganda. AIDS. 2012;26(18):2375–81.PubMedCrossRefGoogle Scholar
  3. 3.
    Wagner GJ, Ghosh-Dastidar B, Garnett J, Kityo C, Mugyenyi P. Impact of HIV antiretroviral therapy on depression and mental health among clients with HIV in Uganda. Psychosom Med. 2012;74(9):883–90.PubMedCrossRefGoogle Scholar
  4. 4.
    Rabkin JG, Ferrando SJ, Lin SH, Sewell M, McElhiney M. Psychological effects of HAART: a 2-year study. Psychosom Med. 2000;62(3):413–22.PubMedGoogle Scholar
  5. 5.
    Brent RJ. The effects of HIV medications on the quality of life of older adults in New York city. Health Econ. 2012;21(8):967–76.PubMedCrossRefGoogle Scholar
  6. 6.
    Low-Beer S, Chan K, Yip B, Wood E, Montaner JS, O’Shaughnessy MV, et al. Depressive symptoms decline among persons on HIV protease inhibitors. J Acquir Immune Defic Syndr. 2000;23(4):295–301.PubMedGoogle Scholar
  7. 7.
    Thirumurthy H, Zivin JG, Goldstein M. The economic impact of AIDS treatment: labor supply in western Kenya. J Hum Resour. 2008;43(3):511–52.PubMedCrossRefGoogle Scholar
  8. 8.
    Wolfe WR, Weiser SD, Leiter K, Steward WT, Percy-de Korte F, Phaladze N, et al. The impact of universal access to antiretroviral therapy on HIV stigma in Botswana. Am J Public Health. 2008;98(10):1865–71.PubMedCrossRefGoogle Scholar
  9. 9.
    Baranov V, Bennett D, Kohler H-P. The indirect impact of antiretroviral therapy. Population Studies Center Working Paper Series, PSC 12-08. Philadelphia: University of Pennsylvania, 2012.Google Scholar
  10. 10.
    Khandelwal S, Avode G, Baingana F, Conde B, Cruz M, Deva P, et al. Mental and neurological health research priorities setting in developing countries. Soc Psychiatry Psychiatr Epidemiol. 2010;45(4):487–95.PubMedCrossRefGoogle Scholar
  11. 11.
    Adewuya AO, Afolabi MO, Ola BA, Ogundele OA, Ajibare AO, Oladipo BF, et al. Post-traumatic stress disorder (PTSD) after stigma related events in HIV infected individuals in Nigeria. Soc Psychiatry Psychiatr Epidemiol. 2009;44(9):761–6.PubMedCrossRefGoogle Scholar
  12. 12.
    Jones EE, Farina A, Hastorf AH, Markus H, Miller DT, Scott RA. Social stigma: the psychology of marked relationships. New York: W.H. Freeman and Company; 1984.Google Scholar
  13. 13.
    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(9):1823–31.PubMedCrossRefGoogle Scholar
  14. 14.
    Tsai AC, Bangsberg DR, Frongillo EA, Hunt PW, Muzoora C, Martin JN, et al. Food insecurity, depression and the modifying role of social support among people living with HIV/AIDS in rural Uganda. Soc Sci Med. 2012;74(12):2012–9.PubMedCrossRefGoogle Scholar
  15. 15.
    Norman A, Chopra M, Kadiyala S. Factors related to HIV disclosure in 2 South African communities. Am J Public Health. 2007;97(10):1775–81.PubMedCrossRefGoogle Scholar
  16. 16.
    Boyer S, Clerc I, Bonono C-R, Marcellin F, Bile P-C, Ventelou B. Non-adherence to antiretroviral treatment and unplanned treatment interruption among people living with HIV/AIDS in Cameroon: individual and healthcare supply-related factors. Soc Sci Med. 2011;72(8):1383–92.PubMedCrossRefGoogle Scholar
  17. 17.
    Farmer P, Leandre F, Mukherjee JS, Claude M, Nevil P, Smith-Fawzi MC, et al. Community-based approaches to HIV treatment in resource-poor settings. Lancet. 2001;358(9279):404–9.PubMedCrossRefGoogle Scholar
  18. 18.
    Farmer P, Leandre F, Mukherjee J, Gupta R, Tarter L, Kim JY. Community-based treatment of advanced HIV disease: introducing DOT-HAART (directly observed therapy with highly active antiretroviral therapy). Bull World Health Organ. 2001;79(12):1145–51.PubMedGoogle Scholar
  19. 19.
    Castro A, Farmer P. Understanding and addressing AIDS-related stigma: from anthropological theory to clinical practice in Haiti. Am J Public Health. 2005;95(1):53–9.PubMedCrossRefGoogle Scholar
  20. 20.
    Gilbert L, Walker L. ‘My biggest fear was that people would reject me once they knew my status…’: stigma as experienced by patients in an HIV/AIDS clinic in Johannesburg, South Africa. Health Soc Care Community. 2010;18(2):139–46.PubMedCrossRefGoogle Scholar
  21. 21.
    Zuch M, Lurie M. ‘A virus and nothing else’: the effect of ART on HIV-related stigma in rural South Africa. AIDS Behav. 2012;16(3):564–70.PubMedCrossRefGoogle Scholar
  22. 22.
    Gilbert L, Walker L. “They (ARVs) are my life, without them I’m nothing”–experiences of patients attending a HIV/AIDS clinic in Johannesburg, South Africa. Health Place. 2009;15(4):1123–9.PubMedCrossRefGoogle Scholar
  23. 23.
    Campbell C, Skovdal M, Madanhire C, Mugurungi O, Gregson S, Nyamukapa C. “We, the AIDS people…“: how antiretroviral therapy enables Zimbabweans living with HIV/AIDS to cope with stigma. Am J Public Health. 2011;101(6):1004–10.PubMedCrossRefGoogle Scholar
  24. 24.
    Kaai S, Bullock S, Sarna A, Chersich M, Luchters S, Geibel S, et al. Perceived stigma among patients receiving antiretroviral treatment: a prospective randomised trial comparing an m-DOT strategy with standard-of-care in Kenya. SAHARA J. 2010;7(2):62–70.PubMedCrossRefGoogle Scholar
  25. 25.
    Makoae LN, Portillo CJ, Uys LR, Dlamini PS, Greeff M, Chirwa M, et al. The impact of taking or not taking ARVs on HIV stigma as reported by persons living with HIV infection in five African countries. AIDS Care. 2009;21(11):1357–62.PubMedCrossRefGoogle Scholar
  26. 26.
    Munoz M, Finnegan K, Zeladita J, Caldas A, Sanchez E, Callacna M, et al. Community-based DOT-HAART accompaniment in an urban resource-poor setting. AIDS Behav. 2010;14(3):721–30.PubMedCrossRefGoogle Scholar
  27. 27.
    Pearson CR, Micek MA, Pfeiffer J, Montoya P, Matediane E, Jonasse T, et al. One year after ART initiation: psychosocial factors associated with stigma among HIV-positive Mozambicans. AIDS Behav. 2009;13(6):1189–96.PubMedCrossRefGoogle Scholar
  28. 28.
    Kinyanda E, Woodburn P, Tugumisirize J, Kagugube J, Ndyanabangi S, Patel V. Poverty, life events and the risk for depression in Uganda. Soc Psychiatry Psychiatr Epidemiol. 2011;46(1):35–44.PubMedCrossRefGoogle Scholar
  29. 29.
    Ovuga E, Boardman J, Wasserman D. The prevalence of depression in two districts of Uganda. Soc Psychiatry Psychiatr Epidemiol. 2005;40(6):439–45.PubMedCrossRefGoogle Scholar
  30. 30.
    Wilk CM, Bolton P. Local perceptions of the mental health effects of the Uganda acquired immunodeficiency syndrome epidemic. J Nerv Ment Dis. 2002;190(6):394–7.PubMedCrossRefGoogle Scholar
  31. 31.
    Geng EH, Bwana MB, Kabakyenga J, Muyindike W, Emenyonu NI, Musinguzi N, et al. Diminishing availability of publicly funded slots for antiretroviral initiation among HIV-infected ART-eligible patients in Uganda. PLoS One. 2010;5(11):e14098.PubMedCrossRefGoogle Scholar
  32. 32.
    Siedner MJ, Lankowski A, Haberer JE, Kembabazi A, Emenyonu N, Tsai AC, et al. Rethinking the “pre” in pre-therapy counseling: no benefit of additional visits prior to therapy on adherence or viremia in Ugandans initiating ARVs. PLoS One. 2012;7(6):e39894.PubMedCrossRefGoogle Scholar
  33. 33.
    Kalichman SC, Simbayi LC, Cloete A, Mthembu PP, Mkhonta RN, Ginindza T. Measuring AIDS stigmas in people living with HIV/AIDS: the Internalized AIDS-Related Stigma Scale. AIDS Care. 2009;21(1):87–93.PubMedCrossRefGoogle Scholar
  34. 34.
    Tsai AC, Weiser SD, Steward WT, Mukiibi NF, Kawuma A, Kembabazi A, et al. Evidence for the reliability and validity of the Internalized AIDS-Related Stigma Scale in rural Uganda. AIDS Behav. 2013;17(1):427–33.PubMedCrossRefGoogle Scholar
  35. 35.
    Tsai AC, Bangsberg DR, Kegeles SM, Katz IT, Haberer JE, Muzoora C, et al. Internalized stigma, social distance, and disclosure of HIV seropositivity in rural Uganda. Ann Behav Med. 2013 (in press).Google Scholar
  36. 36.
    Kling JR, Liebman JB, Katz LF. Experimental analysis of neighborhood effects. Econometrica. 2007;75(1):83–119.CrossRefGoogle Scholar
  37. 37.
    Wu AW, Rubin HR, Mathews WC, Ware JE Jr, Brysk LT, Hardy WD, et al. A health status questionnaire using 30 items from the medical outcomes study. Preliminary validation in persons with early HIV infection. Med Care. 1991;29(8):786–98.PubMedCrossRefGoogle Scholar
  38. 38.
    Derogatis LR, Lipman RS, Rickels K, Uhlenhuth EH, Covi L. The Hopkins Symptom Checklist (HSCL): a self-report symptom inventory. Behav Sci. 1974;19(1):1–15.PubMedCrossRefGoogle Scholar
  39. 39.
    Bolton P. Cross-cultural validity and reliability testing of a standard psychiatric assessment instrument without a gold standard. J Nerv Ment Dis. 2001;189(4):238–42.PubMedCrossRefGoogle Scholar
  40. 40.
    Kalichman SC, Rompa D, Cage M. Distinguishing between overlapping somatic symptoms of depression and HIV disease in people living with HIV-AIDS. J Nerv Ment Dis. 2000;188(10):662–70.PubMedCrossRefGoogle Scholar
  41. 41.
    Filmer D, Pritchett LH. Estimating wealth effects without expenditure data—or tears: an application to educational enrollments in states of India. Demography. 2001;38(1):115–32.PubMedGoogle Scholar
  42. 42.
    Young SD, Hlavka Z, Modiba P, Gray G, Van Rooyen H, Richter L, et al. HIV-related stigma, social norms, and HIV testing in Soweto and Vulindlela, South Africa: National Institutes of Mental Health Project Accept (HPTN 043). J Acquir Immune Defic Syndr. 2010;55(5):620–4.PubMedCrossRefGoogle Scholar
  43. 43.
    Weiser SD, Heisler M, Leiter K, Percy-de Korte F, Tlou S, DeMonner S, et al. Routine HIV testing in Botswana: a population-based study on attitudes, practices, and human rights concerns. PLoS Med. 2006;3(7):e261.PubMedCrossRefGoogle Scholar
  44. 44.
    Musheke M, Ntalasha H, Gari S, McKenzie O, Bond V, Martin-Hilber A, et al. A systematic review of qualitative findings on factors enabling and deterring uptake of HIV testing in sub-Saharan Africa. BMC Pub Health. 2013;13:220.CrossRefGoogle Scholar
  45. 45.
    Musheke M, Bond V, Merten S. Deterrents to HIV-patient initiation of antiretroviral therapy in urban Lusaka, Zambia: a qualitative study. AIDS Patient Care STDs. 2013;27(4):231–41.PubMedCrossRefGoogle Scholar
  46. 46.
    Turan JM, Bukusi EA, Onono M, Holzemer WL, Miller S, Cohen CR. HIV/AIDS stigma and refusal of HIV testing among pregnant women in rural Kenya: results from the MAMAS Study. AIDS Behav. 2011;15(6):1111–20.PubMedCrossRefGoogle Scholar
  47. 47.
    Pollini RA, Blanco E, Crump C, Zuniga ML. A community-based study of barriers to HIV care initiation. AIDS Patient Care STDS. 2011;25(10):601–9.PubMedCrossRefGoogle Scholar
  48. 48.
    Kigozi IM, Dobkin LM, Martin JN, Geng EH, Muyindike W, Emenyonu NI, et al. Late-disease stage at presentation to an HIV clinic in the era of free antiretroviral therapy in Sub-Saharan Africa. J Acquir Immune Defic Syndr. 2009;52(2):280–9.PubMedCrossRefGoogle Scholar
  49. 49.
    Muhamadi L, Nsabagasani X, Tumwesigye MN, Wabwire-Mangen F, Ekstrom AM, Peterson S, et al. Inadequate pre-antiretroviral care, stock-out of antiretroviral drugs and stigma: policy challenges/bottlenecks to the new WHO recommendations for earlier initiation of antiretroviral therapy (CD < 350 cells/microL) in eastern Uganda. Health Policy. 2010;97(2–3):187–94.PubMedCrossRefGoogle Scholar
  50. 50.
    Sayles JN, Wong MD, Kinsler JJ, Martins D, Cunningham WE. The association of stigma with self-reported access to medical care and antiretroviral therapy adherence in persons living with HIV/AIDS. J Gen Intern Med. 2009;24(10):1101–8.PubMedCrossRefGoogle Scholar
  51. 51.
    Judd CM, Kenny DA. Process analysis: estimating mediation in treatment evaluations. Eval Rev. 1981;5(5):602–19.CrossRefGoogle Scholar
  52. 52.
    James LR, Brett JM. Mediators, moderators, and tests for mediation. J Appl Psychol. 1984;69(2):307–21.CrossRefGoogle Scholar
  53. 53.
    Valeri L, VanderWeele TJ. Mediation analysis allowing for exposure-mediator interactions and causal interpretation: theoretical assumptions and implementation with SAS and SPSS macros. Psychol Methods. 2013. doi:10.1037/a0031034.
  54. 54.
    Sengupta S, Banks B, Jonas D, Miles MS, Smith GC. HIV interventions to reduce HIV/AIDS stigma: a systematic review. AIDS Behav. 2011;15(6):1075–87.PubMedCrossRefGoogle Scholar
  55. 55.
    Yamano T, Jayne TS. Measuring the impact of working-age adult mortality on small-scale farm households in Kenya. World Dev. 2004;32(1):91–119.CrossRefGoogle Scholar
  56. 56.
    Wagner G, Ryan G, Huynh A, Kityo C, Mugyenyi P. A qualitative analysis of the economic impact of HIV and antiretroviral therapy on individuals and households in Uganda. AIDS Patient Care STDS. 2009;23(9):793–8.PubMedCrossRefGoogle Scholar
  57. 57.
    Samuels FA, Rutenberg N. “Health regains but livelihoods lag”: findings from a study with people on ART in Zambia and Kenya. AIDS Care. 2011;23(6):748–54.PubMedCrossRefGoogle Scholar
  58. 58.
    Heijnders M, Van Der Meij S. The fight against stigma: an overview of stigma-reduction strategies and interventions. Psychol Health Med. 2006;11(3):353–63.PubMedCrossRefGoogle Scholar
  59. 59.
    Goudge J, Ngoma B, Manderson L, Schneider H. Stigma, identity and resistance among people living with HIV in South Africa. SAHARA J. 2009;6(3):94–104.PubMedCrossRefGoogle Scholar
  60. 60.
    Reidpath DD, Chan KY, Gifford SM, Allotey P. ‘He hath the French pox’: stigma, social value and social exclusion. Sociol Health Illn. 2005;27(4):468–89.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Alexander C. Tsai
    • 1
    • 2
    • 3
  • David R. Bangsberg
    • 2
    • 3
    • 4
  • Mwebesa Bwana
    • 4
  • Jessica E. Haberer
    • 2
    • 3
  • Edward A. Frongillo
    • 5
  • Conrad Muzoora
    • 4
  • Elias Kumbakumba
    • 4
  • Peter W. Hunt
    • 6
  • Jeffrey N. Martin
    • 7
  • Sheri D. Weiser
    • 6
    • 8
  1. 1.Chester M. Pierce, MD Division of Global Psychiatry, Department of PsychiatryMassachusetts General Hospital (MGH), Center for Global HealthBostonUSA
  2. 2.MGH Center for Global HealthBostonUSA
  3. 3.Harvard Medical SchoolBostonUSA
  4. 4.Mbarara University of Science and TechnologyMbararaUganda
  5. 5.Department of Health Promotion, Education, and BehaviorArnold School of Public Health, University of South CarolinaColumbiaUSA
  6. 6.Division of HIV/AIDSSan Francisco General Hospital, University of California at San Francisco (UCSF)San FranciscoUSA
  7. 7.Department of Epidemiology and BiostatisticsUCSFSan FranciscoUSA
  8. 8.Center for AIDS Prevention Studies, UCSFSan FranciscoUSA

Personalised recommendations