Negative labeling and social exclusion of people living with human immunodeficiency virus/acquired immune deficiency syndrome in the antiretroviral therapy era: insight from attitudes and behavioral intentions of female heads of households in Zambézia Province, Mozambique

Abstract

In the age of antiretroviral therapy (ART), unraveling specific aspects of stigma that impede uptake and adherence to human immunodeficiency virus (HIV) services and the complex intersections among them might enhance the efficacy of stigma-reduction interventions targeted at the general public. Few studies have described community stigma in high HIV prevalence regions of Mozambique where program scale-up has been concentrated, but fear of stigma persists as a barrier to HIV service uptake. Principal components analysis of attitudinal data from 3749 female heads of households surveyed in Zambézia Province was used to examine patterns of agreement with stigmatizing attitudes and behavior toward people living with HIV. Inferences were based on comparison of factor loadings and commonality estimates. Construct validity was established through correlations with levels of knowledge about HIV transmission and consistency with the labeling theory of stigma. Two unique domains of community stigma were observed: negative labeling and devaluation (NLD, α = 0.74) and social exclusion (SoE, α = 0.73). NLD is primarily an attitudinal construct, while SoE captures behavioral intent. About one-third of the respondents scored in the upper tertile of the NLD stigma scale (scale: 0–100 stigma points) and the equivalent was 41.3% in the SoE stigma scale. Consistent with literature, NLD and SoE stigma scores were inversely correlated with HIV transmission route knowledge. In item level analysis, fear of being labeled a prostitute/immoral and of negative family affect defined the nature of stigma in this sample. Thus, despite ART scale-up and community education about HIV/acquired immune deficiency syndrome (AIDS), NLD and SoE characterized the community stigma of HIV in this setting. Follow-up studies could compare the impact of these stigma domains on HIV services uptake, in order to inform domain-focused stigma-reduction interventions.

Keywords:

• community stigma
• HIV/AIDS knowledge
• household survey
• rural Mozambique

Acknowledgments

We are grateful for the contributions of the Ogumaniha-SCIP consortium members to the baseline survey and for permission to analyze the survey data. The Ogumaniha-SCIP baseline survey was supported by the United States Agency for International Development (USAID) – Mozambique (Award No. 656-A-00-09-00141-00) through a sub-grant from World Vision, Inc. Funders are not responsible for study design, data collection and analysis, decision to publish, or preparation of this manuscript. The contents of this manuscript are the responsibility of the authors and do not necessarily reflect the views of USAID, the US Government, or World Vision, Inc. Funding support for the secondary data analysis is from Vanderbilt University through the endowment of the Amos Christie Chair in Global Health. Ethical approval for secondary data analysis was provided by the Vanderbilt University Institutional Review Board (IRB#121003). We are also grateful to Raquel Villegas, Vanderbilt University Medical Center, for reviewing the manuscript.