Prevalence And Associated Factors Of Enacted, Internalized And Anticipated Stigma Among People Living With HIV In South Africa: Results Of The First National Survey

Figures & data

Table 1 Sample Characteristics And Overall HIV-Related Stigma

Variable		Overall HIV-Related Stigma
	Sample	Low (0)	Medium (1–4)	High (5–30)
	N (%)	%	%	%
All	10,432	33.7	32.0	34.4
Age
15–29	2646 (25.3)	28.8	29.7	41.5
30–39	4017 (38.4)	36.7	30.5	32.8
40–49	2683 (25.6)	36.0	33.8	30.2
50 or more	1127 (10.8)	28.2	38.2	33.6
Gender/orientation
Male	3340 (31.9)	39.4	28.7	31.9
Female	6557 (62.6)	31.5	33.5	35.0
LGBT	576 (5.5)	24.9	33.2	41.9
HIV test decision
Voluntary	8344 (82.2)	34.2	33.2	32.6
Pressure	1141 (11.2)	29.9	28.7	41.5
Coerced	664 (6.5)	33.8	24.1	42.1
Years live with HIV
5 or more	5164 (49.6)	34.4	32.8	32.8
2–4	4038 (38.8)	34.1	31.0	34.9
0–1	1207 (11.6)	29.3	31.4	39.3
On ART
No	1248 (12.0)	35.1	28.7	36.1
Yes	9150 (88.0)	33.4	32.4	34.1
Sexually active
No	1748 (18.2)	22.0	31.9	46.1
Yes	7877 (81.8)	36.6	32.0	31.4
Relationship status
Married or cohabiting	3015 (28.9)	35.1	35.4	29.5
In relationship	4132 (39.6)	37.2	30.3	32.4
Single	2178 (20.9)	30.8	30.2	39.0
Divorced/widowed	1111 (10.6)	21.7	31.6	46.7
Education
Primary or none	2357 (22.8)	29.6	34.2	36.3
Secondary	6836 (66.1)	35.0	31.9	33.1
Post-secondary	1151 (11.1)	33.0	28.5	38.6
Household wealth status
Low	5036 (50.3)	31.4	33.0	35.6
Medium	3886 (38.8)	35.3	29.2	35.5
High	1097 (10.9)	36.8	35.7	27.5
Residence
Rural area	3199 (31.2)	33.9	35.8	40.4
A small town or village	4962 (48.4)	31.8	31.2	37.0
A large town or city	2087 (20.4)	38.0	29.2	32.8
Physical disability
No	9639 (94.2)	34.4	32.0	33.5
Yes	598 (5.8)	19.8	32.7	47.5
Self-rated health status
Good/very good/excellent	9791 (93.9)	34.0	32.4	33.2
Fair or poor	641 (6.1)	22.5	25.5	52.0
Knowledge of PLHIV rights
Low (0)	4626 (45.0)	38.1	29.1	32.7
Medium (1–2)	2828 (27.5)	23.6	36.1	40.3
High (3–4)	2817 (27.4)	36.9	31.7	31.4
Member of HIV support group
No	2860 (28.2)	29.6	34.1	36.3
Yes	7279 (71.8)	35.4	31.0	33.6

Table 2 Experiences Of HIV-Related Stigma In The Past 12 Months At Least Once (N=10,432)

Variable	All	Male	Female	LGBT
	N (%)	%	%	%
Enacted stigma	2823 (29.0)	24.9	30.5	35.0
Social gatherings	713 (6.8)	6.2	7.0	8.6
Family activities	578 (5.6)	5.0	5.8	6.8
Religious activities	241 (2.3)	1.9	2.3	5.6
Workplace activities	191 (1.9)	2.1	1.7	1.9
School/university activities	95 (0.9)	0.9	0.9	1.2
Being gossiped about	2130 (20.6)	17.2	22.0	24.4
Experienced discrimination	1579 (15.1)	13.5	16.1	18.5
Verbally insulted and harassment	1096 (10.6)	7.7	11.7	15.5
Physically harassed	555 (5.4)	4.1	5.7	8.9
Physically assaulted	474 (4.6)	2.8	5.3	6.8
Internalized stigma	4433 (43.0)	42.3	43.6	41.4
Blaming oneself	3186 (30.5)	32.7	29.7	27.9
Ashamed	2991 (28.7)	27.9	29.3	25.8
Guilty	2922 (28.0)	28.5	27.8	27.7
Blaming others	1991 (19.1)	15.9	20.8	18.9
Having low self-esteem	2311 (22.2)	20.8	22.6	24.6
Should be punished	1157 (11.1)	11.4	11.0	11.0
Suicidal	1164 (11.2)	11.0	11.1	13.8
Avoidance due to internalized stigma	4114 (41.9)	35.4	44.8	47.3
Decided not to have (more) children	3370 (32.4)	24.7	36.0	36.7
Decided not to get married	1543 (14.9)	11.4	16.6	15.3
Decided not to have sex	1409 (13.5)	9.6	15.7	12.4
Chosen not to attend social gatherings	1222 (11.7)	11.9	11.4	14.2
Isolated oneself from family or friends	1039 (10.0)	9.8	9.8	12.6
Avoided going to a local clinic/doctor when needed to	498 (4.8)	5.4	4.3	6.6
Decided not to apply for a job or promotion	476 (4.6)	5.4	4.2	4.2
Made the decision to stop working	428 (4.2)	4.5	4.1	3.9
Withdrew from/did not take opportunity for education	430 (4.2)	4.2	4.2	4.6
Avoided going to hospital when needed to	357 (3.4)	3.9	3.0	5.8
Anticipated stigma	4014 (41.9)	37.3	39.1	49.8
Being gossiped about	2979 (28.6)	27.1	28.7	35.0
Someone would not want to be sexually intimate with self	2181 (21.1)	21.8	20.2	27.4
Being verbally insulted/harassed/threatened	1814 (17.4)	14.9	17.8	27.7
Being physically insulted/harassed/threatened	1305 (12.5)	9.9	13.0	22.5
Being physically assaulted	1220 (11.7)	9.4	11.9	22.7

Table 3 Description Of HIV-Related Stigma Sub-Scales (N=10,473)

Variable	Enacted Stigma	Internalized Stigma	Avoidance Due To Internalized Stigma	Anticipated Stigma
	%	%	%	%
All	29.0	43.0	41.9	39.1
Age
15–29	32.3	53.1	38.5	47.6
30–39	28.9	41.8	38.0	37.5
40–49	28.0	36.2	44.7	34.8
50 or more	23.7	40.0	57.4	35.2
Gender/orientation
Male	24.9	42.3	35.4	37.3
Female	30.5	43.6	44.8	39.1
LGBT	35.0	41.4	47.3	49.8
HIV test decision
Voluntary	28.1	41.6	41.3	37.1
Pressure	33.3	50.3	45.6	47.2
Coerced	32.4	47.8	43.7	47.9
Years live with HIV
5 or more	29.7	39.5	44.8	36.6
2–4	28.6	43.9	39.5	40.9
0–1	27.1	54.8	36.9	43.9
On ART
No	26.7	47.2	35.9	39.6
Yes	29.3	42.4	42.7	39.1
Sexually active
No	31.1	50.3	63.4	46.1
Yes	28.4	40.9	36.8	37.1
Relationship status
Married or cohabiting	28.9	40.5	40.2	35.7
In relationship	28.3	43.0	33.1	38.0
Single	29.0	44.2	49.3	42.5
Divorced/widowed	31.8	48.1	64.9	46.5
Education
Primary or none	28.2	43.6	50.2	40.2
Secondary	29.7	42.1	39.9	38.2
Post-secondary	26.7	47.9	37.3	42.9
Household wealth status
Low	30.6	43.2	44.8	38.9
Medium	29.3	43.5	41.3	41.0
High	22.5	41.8	32.1	34.2
Residence
Rural area	25.3	45.4	40.5	36.7
A small town or village	31.0	43.3	41.6	42.1
A large town or city	29.8	38.1	42.5	35.6
Physical disability
No	28.3	42.4	41.0	38.5
Yes	40.3	52.5	59.1	49.0
Self-rated health status
Good/very good/excellent	28.2	42.1	40.9	38.2
Fair or poor	41.7	58.0	57.9	52.9
Knowledge of rights
Low (0)	26.6	41.5	39.7	35.7
Medium (1–2)	33.7	50.8	48.7	47.4
High (3–4)	27.8	38.1	38.6	36.2
Member of support group
No	26.9	47.9	48.1	41.7
Yes	30.9	41.1	39.5	37.9

Table 4 Multinomial Regression Results With Overall Medium And High HIV-Related Stigma (With No HIV-Related Stigma As Reference Category)

	Overall HIV-Related Stigma		Overall HIV-Related Stigma
	Medium (1–4)	High (5–30)	Medium (1–4)	High (5–30)
	UOR (95% CI)	UOR (95% CI)	AOR (95% CI)	AOR (95% CI)
Age
15–29	1 (Reference)	1 (Reference)	1 (Reference)	1 (Reference)
30–39	0.81 (0.70, 0.92)*	0.62 (0.55, 0.71)**	0.78 (0.66, 0.93)*	0.64 (0.55, 0.76)**
40–49	0.91 (0.79, 1.05)	0.58 (0.51, 0.67)**	0.83 (0.68, 1.01)	0.55 (0.45, 0.67)**
50 or more	1.31 (1.08, 1.59)*	0.83 (0.88, 1.00)	1.09 (0.83, 1.43)	0.52 (0.39, 0.68)**
Gender/orientation
Male	1 (Reference)	1 (Reference)	1 (Reference)	1 (Reference)
Female	1.47 (1.31, 1.64)**	1.37 (1.23, 1.53)**	1.52 (1.34, 1.74)**	1.32 (1.16, 1.50)**
LGBT	1.84 (1.43, 2.36)**	2.08 (1.64, 2.64)**	2.28 (1.71, 3.06)**	2.12 (1.58, 2.83)**
HIV test decision
Voluntary	1 (Reference)	1 (Reference)	1 (Reference)	1 (Reference)
Pressure	0.87 (0.83, 1.17)	1.45 (1.24, 1.71)**	0.91 (0.75, 1.11)	1.27 (1.06, 1.53)
Coerced	0.73 (0.58, 0.91)**	1.31 (1.07, 1.59)*	0.70 (0.54, 0.90)*	1.14 (0.90, 1.44)
Years live with HIV
5 or more	1 (Reference)	1 (Reference)	1 (Reference)	1 (Reference)
2–4	0.95 (0.86, 1.07)	1.07 (0.96, 1.19)	0.96 (0.84, 1.10)	0.96 (0.84, 1.10)
0–1	1.13 (0.95, 1.34)	1.41 (1.19, 1.66)**	1.20 (0.96, 1.49)	1.21 (0.98, 1.51)
On ART
No	1 (Reference)	1 (Reference)	1 (Reference)	1 (Reference)
Yes	1.18 (1.01, 1.39)	0.99 (0.85, 1.15)	1.11 (0.92, 1.34)	0.97 (0.81, 1.16)
Sexually active
No	1 (Reference)	1 (Reference)	1 (Reference)	1 (Reference)
Yes	0.60 (0.52, 0.70)**	0.41 (0.36, 0.48)**	0.71 (0.58, 0.88)**	0.53 (0.44, 0.65)**
Relationship status
Married or cohabiting	1 (Reference)	1 (Reference)	1 (Reference)	1 (Reference)
In relationship	0.81 (0.72, 0.91)**	1.04 (0.92, 1.18)	0.78 (0.67, 0.90)**	0.87 (0.75, 1.02)
Single	0.98 (0.84, 1.13)	1.51 (1.30, 1.75)**	0.76 (0.62, 0.92)*	1.06 (0.87, 1.23)
Divorced/widowed	1.45 (1.19, 1.77)**	2.57 (2.12, 3.12)**	0.99 (0.77, 1.27)	1.88 (1.47, 2.39)**
Education
Primary or none	1 (Reference)	1 (Reference)	1 (Reference)	1 (Reference)
Secondary	0.79 (0.69, 0.90)**	0.77 (0.68, 0.88)**	1.06 (0.89, 1.25)	0.97 (0.82, 1.15)
Post-secondary	0.75 (0.62, 0.91)*	0.95 (0.79, 1.15)	1.03 (0.80, 1.32)	1.27 (1.00, 1.61)
Household wealth status
Low	1 (Reference)	1 (Reference)	1 (Reference)	1 (Reference)
Medium	0.79 (0.70, 0.88)**	0.89 (0.80, 0.99)	0.79 (0.70, 0.91)**	0.91 (0.80, 1.04)
High	0.92 (0.78, 1.09)	0.66 (0.55, 0.78)**	0.93 (0.76, 1.14)	0.72 (0.58, 0.89)*
Residence
Rural area	1 (Reference)	1 (Reference)	1 (Reference)	1 (Reference)
A small town or village	0.93 (0.82, 1.05)	1.30 (1.15, 1.46)**	0.91 (0.79, 1.05)	1.28 (1.11, 1.48)**
A large town or city	0.73 (0.63, 0.84)**	0.96 (0.83, 1.11)	0.74 (0.63, 0.88)**	0.95 (0.80, 1.12)
Physical disability
No	1 (Reference)	1 (Reference)	1 (Reference)	1 (Reference)
Yes	1.78 (1.37, 2.31)**	2.46 (1.93, 3.15)**	1.67 (1.23, 2.27)**	2.15 (1.60, 2.88)**
Self-rated health status
Good	1 (Reference)	1 (Reference)	1 (Reference)	1 (Reference)
Fair or poor	1.21 (0.94, 1.54)	2.40 (1.93, 2.98)**	1.24 (0.92, 1.65)	2.28 (1.75, 2.96)**
Knowledge of PLHIV rights
Low (0)	1 (Reference)	1 (Reference)	1 (Reference)	1 (Reference)
Medium (1–2)	2.00 (1.76, 2.28)**	1.99 (1.75, 2.26)**	2.20 (1.90, 2.56)**	2.21 (1.90, 2.57)**
High (3–4)	1.12 (0.99, 1.27)	0.99 (0.88, 1.12)	1.32 (1.14, 1.54)**	1.21 (1.03, 1.40)
Member of HIV support group
No	1 (Reference)	1 (Reference)	1 (Reference)	1 (Reference)
Yes	0.76 (0.67, 0.85)**	0.77 (0.69, 0.87)**	0.68 (0.59, 0.78)**	0.77 (0.67, 0.89)**

Notes: **P<0.001; *P<0.01.

Abbreviations: AOR, adjusted odds ratio; UOR, unadjusted odds ratio.

Table 5 Associations With HIV-Related Stigma Sub-Scales

Variable	Enacted Stigma	Internalized Stigma	Avoidance Due ToInternalized Stigma	Anticipated Stigma
	AOR (95% CI)	AOR (95% CI)	AOR (95% CI)	AOR (95% CI)
Age
15–29	1 (Reference)	1 (Reference)	1 (Reference)	1 (Reference)
30–39	0.81 (0.70, 0.92)*	0.68 (0.60, 0.77)**	0.92 (0.81, 1.05)	0.69 (0.61, 0.78)**
40–49	0.72 (0.61, 0.85)**	0.52 (0.45, 0.60)**	1.09 (0.93, 1.27)	0.57 (0.49, 0.66)**
50 or more	0.54 (0.43, 0.68)**	0.47 (0.38, 0.57)**	1.28 (1.03, 1.59)	0.44 (0.36, 0.55)**
Gender/orientation
Male	1 (Reference)	1 (Reference)	1 (Reference)	1 (Reference)
Female	1.26 (1.13, 1.41)**	1.02 (0.92, 1.13)	1.44 (1.29, 1.61)**	1.09 (0.99, 1.21)
LGBT	1.62 (1.29. 2.04)**	0.82 (0.66, 1.02)	1.85 (1.48, 2.31)**	1.69 (1.36, 2.09)**
HIV test decision
Voluntary	1 (Reference)	1 (Reference)	1 (Reference)	1 (Reference)
Pressure	1.20 (1.03, 1.40)	1.35 (1.17, 1.56)**	1.11 (0.96, 1.29)	1.41 (1.22, 1.63)**
Coerced	1.05 (0.85, 1.29)	1.16 (0.95, 1.40)	1.12 (0.92, 1.37)	1.44 (1.19, 1.74)**
Years live with HIV
5 or more	1 (Reference)	1 (Reference)	1 (Reference)	1 (Reference)
2–4	0.90 (0.80, 1.01)	1.04 (0.93, 1.15)	0.92 (0.82, 1.03)	1.05 (0.94, 1.17)
0–1	0.83 (0.69, 0.99)	1.48 (1.26, 1.74)**	0.82 (0.69, 0.97)	1.12 (0.95, 1.33)
On ART
No	1 (Reference)	1 (Reference)	1 (Reference)	1 (Reference)
Yes	1.11 (0.95, 1.30)	0.83 (0.72, 0.96)*	1.16 (0.99, 1.35)	1.01 (0.88, 1.17)
Sexually active
No	1 (Reference)	1 (Reference)	1 (Reference)	1 (Reference)
Yes	0.98 (0.83, 1.15)	0.67 (0.58, 0.78)**	0.51 (0.44, 0.59)**	0.74 (0.64, 0.86)**
Relationship status
Married or cohabiting	1 (Reference)	1 (Reference)	1 (Reference)	1 (Reference)
In relationship	0.85 (0.74, 0.97)	0.88 (0.78, 0.99)	0.84 (0.74, 0.94)*	0.95 (0.84, 1.08)
Single	0.92 (0.78, 1.09)	0.85 (0.73, 0.99)	1.30 (1.11, 1.52)**	1.05 (0.90, 1.23)
Divorced/widowed	1.24 (1.01, 1.51)	1.17 (0.97, 1.40)	1.79 (1.48, 2.16)**	1.45 (1.20, 1.74)**
Education
Primary or none	1 (Reference)	1 (Reference)	1 (Reference)	1 (Reference)
Secondary	1.21 (1.04, 1.39)*	0.95 (0.84, 1.09)	0.96 (0.84, 1.10)	0.91 (0.80, 1.04)
Post-secondary	1.17 (0.95, 1.44)	1.19 (0.90, 1.43)	0.92 (0.76, 1.12)	1.07 (0.89, 1.30)
Household wealth status
Low	1 (Reference)	1 (Reference)	1 (Reference)	1 (Reference)
Medium	0.93 (0.93, 1.04)	1.00 (0.90, 1.10)	0.94 (0.84, 1.04)	1.10 (0.99, 1.22)
High	0.69 (0.57, 0.83)**	0.95 (0.81, 1.12)	0.68 (0.57, 0.81)**	0.86 (0.72, 1.01)
Residence
Rural area	1 (Reference)	1 (Reference)	1 (Reference)	1 (Reference)
A small town or village	1.31 (1.16, 1.48)**	0.86 (0.77, 0.96)*	1.12 (1.00, 1.26)	1.15 (1.03, 1.28)
A large town or city	1.17 (1.01, 1.35)	0.66 (0.58, 0.75)**	1.21 (1.06, 1.39)*	0.88 (0.77, 1.01)
Physical disability
No	1 (Reference)	1 (Reference)	1 (Reference)	1 (Reference)
Yes	1.77 (1.44, 2.18)**	1.53 (1.25, 1.88)**	1.49 (1.20, 1.85)**	1.47 (1.20, 1.80)**
Self-rated health status
Good	1 (Reference)	1 (Reference)	1 (Reference)	1 (Reference)
Fair or poor	1.84 (1.51, 2.25)**	1.85 (1.51, 2.25)**	1.61 (1.31, 1.98)**	1.79 (1.47, 2.17)**
Knowledge of PLHIV rights
Low (0)	1 (Reference)	1 (Reference)	1 (Reference)	1 (Reference)
Medium (1–2)	1.39 (1.23, 1.57)**	1.55 (1.39, 1.74)**	1.71 (1.52, 1.93)**	1.69 (1.51, 1.89)**
High (3–4)	1.06 (0.93, 1.21)	1.03 (0.91, 1.15)	1.18 (1.04, 1.33)*	1.12, 0.99, 1.26)
Member of HIV support group
No	1 (Reference)	1 (Reference)	1 (Reference)	1 (Reference)
Yes	1.17 (1.04, 1.32)*	0.80 (0.72, 0.89)**	0.64 (0.57, 0.72)**	0.86 (0.77, 0.96)*

Notes: **P<0.001; *P<0.01.

Abbreviation: AOR, adjusted odds ratio.