Symbolic and anticipated HIV stigma are associated with mental health and education in South Africa

Figures & data

Table 1. Participant characteristics.

Variable	Respondents to Simple Stigma Scale N (%)
	N = 7,724
Sex
Male	3,932 (50.9%)
Female	3,792 (49.1%)
Age (years)
18–25	2,254 (29.2%)
26–35	3,344 (43.3%)
36–45	1,305 (16.9%)
> 45	821 (10.6%)
Marital status
Married	525 (6.8%)
Never Married (Single)	7,129 (92.3%)
Widowed/Divorced	70 (0.9%)
Education
Higher Degree (University)	308 (4.0%)
Some High School or Matric (completed High School)	6,202 (80.3%)
Primary School	126 (1.6%)
None (primary school not completed)	1,087 (14.1%)
Missing values	1 (<0.1%)
Employment status
Not employed	4,670 (60.5%)
Employed	3,054 (39.5%)
Income
< 2,000 ZAR/month (<$143 USD/month)	5,819 (75.3%)
≥ 2,000 ZAR/month (≥ $143 USD/month)	1,833 (23.7%)
Missing values	72 (0.9%)
Number of children
0	2,302 (29.8%)
≥ 1	5,382 (69.7%)
Missing values	40 (0.5%)
Church attendance
Yes	5,698 (73.8%)
No	1,536 (19.9%)
Missing values	490 (6.3%)
Visit to a traditional healer w/in last six months
Yes	479 (6.2%)
No	7,239 (93.7%)
Missing values	6 (0.1%)
Partner tested for HIV
Yes, HIV (+)	1,348 (17.4%)
Yes, HIV (-)	2,364 (30.6%)
No or unknown status	3,967 (51.4%)
Missing values	45 (0.6%)
Depressive symptoms (by PHQ-9)
None	6,547 (84.8%)
Mild-Severe	1,098 (14.2%)
Missing Values	79 (1.0%)
HIV status
HIV Negative	4,690 (60.7%)
HIV Positive	3,034 (39.3%)

ZAR = South African Rand; PHQ-9 =  The Patient Health Questionnaire

Table 2. Unadjusted and adjusted odds ratios of reported symbolic stigma by sociodemographic characteristics

	n/N (%)	Unadjusted (N = 7,724)		Adjusted (N = 7,524)
Sociodemographic characteristics		OR (CI)	P – value	aOR (CI)	P – value
Sex
Female	680/3,792 (17.9%)	1.15 (1.02–1.30)	0.020	1.11 (0.95–1.29)	0.175
Male	627/3,932 (16.0%)	1.0	–	1.0	–
Education (N = 7,723)
Higher Degree (University)	152/308 (49.4%)	7.64 (5.70–10.22)	<0.001	6.99 (4.87–10.03)	<0.001
Some High School or Matric	979/6,202 (15.8%)	1.47 (1.20–1.79)	<0.001	1.34 (1.05–1.70)	<0.001
Primary School	53/126 (42.1%)	5.69 (3.87–8.49)	<0.001	3.17 (1.89–5.33)	<0.001
None	123/1,087 (11.3%)	1.0	–	1.0	–
Employment Status
Employed	640/3,054 (21.0%)	1.59 (1.41–1.79)	<0.001	1.47 (1.22–1.77)	<0.001
Not employed	667/4,670 (14.3%)	1.0	–	1.0	–
Income (N = 7,652)
≥ 2000 ZAR/month	419/1,833 (22.9%)	1.67 (1.47–1.90)	<0.001	1.16 (0.94–1.43)	0.171
< 2000 ZAR/month	876/5,819 (15.0%)	1.0	–	1.0	–
Visit to a Traditional healer (N = 7,718)
No	1,242/7,239 (17.2%)	1.37 (1.04–1.80)	0.024	2.13 (1.52–2.98)	<0.001
Yes	63/479 (13.2%)	1.0	–	1.0	–
Partner tested for HIV? (N = 7,679)
No	743/3,967 (18.7%)	1.11 (0.94–1.30)	0.213	1.12 (0.92–1.37)	0.262
Yes, HIV (-)	328/2,364 (13.9%)	0.77 (0.64–0.93)	0.006	0.91 (0.73–1.15)	0.446
Yes, HIV (+)	232/1,348 (17.2%)	1.0	–	1.0	–
Depressive symptoms (N = 7,645)
Mild – severe	710/1,098 (64.7%)	19.30 (16.60–22.44)	<0.001	19.46 (16.58–22.85)	<0.001
None	567/6,547 (8.7%)	1.0	–	1.0	–
HIV status
HIV positive	599/3,034 (19.7%)	1.38 (1.23–1.56)	<0.001	1.02 (0.87–1.19)	0.810
HIV negative	708/4,690 (15.1%)	1.0	–	1.0	–

^a OR = odds ratio; aOR = adjusted odds ratio; CI = 95% confidence intervals. Age, marital status, children, and church attendance were not significant in the unadjusted model and were not included in the adjusted model.

Table 3. Unadjusted and adjusted odds ratios of reported anticipated stigma by sociodemographic characteristics.

	n/N (%)	Unadjusted (N = 7,724)		Adjusted (N = 7,093)
Sociodemographic characteristics		OR (CI)	P – value	aOR (CI)	P – value
Sex
Female	1,224/3,792 (32.3%)	1.16 (1.05–1.28)	0.003	1.22 (1.08–1.38)	0.001
Male	1,146/3,932 (29.2%)	1.0	–	1.0	–
Age (years)
18–25	748/2,254 (33.2%)	1.57 (1.31–1.89)	<0.001	1.49 (1.16–1.91)	0.002
26–35	1,031/3,344 (30.8%)	1.41 (1.18–1.68)	<0.001	1.42 (1.13–1.80)	0.003
36–45	394/1,305 (30.2%)	1.37 (1.12–1.67)	0.002	1.33 (1.03–1.72)	0.027
> 45	197/821 (24.0%)	1.0	–	1.0	–
Marital status
Single	2,253/7,129 (31.6%)	2.01 (1.61–2.52)	<0.001	1.87 (1.40–2.51)	<0.001
Divorced/Widowed	19/70 (27.1%)	1.62 (0.92–2.87)	0.096	1.11 (0.51–2.42)	0.783
Married	98/525 (18.7%)	1.0	–	1.0	–
Education (N = 7,816)
Higher Degree (University)	193/308 (62.7%)	7.54 (5.71– 9.94)	<0.001	7.10 (5.10–9.87)	<0.001
Some High School or Matric	1,914/6,202 (30.9%)	2.00 (1.70–2.36)	<0.001	2.01 (1.65–2.45)	<0.001
Primary School	65/126 (51.6%)	4.78 (3.26–7.01)	<0.001	3.93 (2.37–6.53)	<0.001
None	198/1,087 (18.2%)	1.0	–	1.0	–
Employment
Employed	1,021/3,054 (33.4%)	1.24 (1.12–1.36)	<0.001	1.24 (1.10–1.40)	0.001
Not employed	1,349/4,670 (28.9%)	1.0	–	1.0	–
Income (N = 7,744)
≥2000ZAR/month	720/1,833 (39.3%)	1.69 (1.51–1.88)	<0.001	_b
<2000 ZAR/month	1,613/5,819 (27.7%)	1.0	–
Children (N = 7,740)
No	757/2,302 (32.9%)	1.15 (1.04–1.28)	0.009	1.05 (0.92–1.20)	0.464
Yes	1,608/5,382 (29.9%)	1.0	–	1.0	–
Church Attendance (N = 7,290)
No	519/1,536 (33.8%)	1.40 (1.24–1.58)	<0.001	1.40 (1.22–1.60)	<0.001
Yes	1,522/5,698 (26.7%)	1.0	–	1.0	–
Partner tested for HIV? (N = 7,771)
No	1,313/3,967 (33.1%)	1.51 (1.31–1.74)	<0.001	1.79 (1.50–2.12)	<0.001
Yes, HIV (-)	706/2,364 (29.9%)	1.30 (1.11–1.51)	0.001	1.65 (1.37–2.00)	<0.001
Yes, HIV (+)	333/1,348 (24.7%)	1.0	–	1.0	–
Depressive symptoms (N = 7,736)
Mild – severe	807/1,098 (73.5%)	9.16 (7.91–10.59)	<0.001	9.52 (8.02–11.29)	<0.001
None	1,522/6,547 (23.2%)	1.0	–	1.0	–
HIV status
HIV positive	988/3,034 (32.6%)	1.16 (1.05–1.28)	0.004	1.07 (0.94–1.21)	0.330
HIV negative	1,383/4,690 (29.5%)	1.0	–	1.0	–

^aOR = odds ratio; aOR = adjusted odds ratio CI = 95% confidence intervals. Visiting a traditional healer within the past six months was not significant in the unadjusted model and was not included in the adjusted model.

^b Income excluded in final model due to poor model fit.

Table 4. Frequency of participants reporting symbolic and anticipated stigma by year.

Year	Symbolic Stigma Reported	Anticipation of Stigma Reported
	n/N (%)	n/N (%)
2013	189/448 (42.2%)	300/448 (67.0%)
2014	692/1,426 (48.5%)	673/1,426 (52.8%)
2015	375/1,134 (33.1%)	421/1,134 (37.1%)
2016	35/1,884 (1.9%)	143/1,884 (7.6%)
2017	11/1,427 (0.8%)	250/1,427 (17.5%)
2018	5/1,245 (0.4%)	431/1,245 (34.6%)
2019	0/161 (0.0%)	72/160 (45.0%)