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


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.


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



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.


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)


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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

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