Transcript The role of HIV stigma and discrimination on the health

The role of HIV stigma
and discrimination
on the health and HIVprotective behaviors of people living
with HIV in Rio de Janeiro, Brazil
Deanna Kerrigan, PhD, MPH
Department of Health, Behavior, and Society
Johns Hopkins Bloomberg School of Public Health
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Stigma, Discrimination,
HIV-Behaviors and Outcomes
• Stigma and Discrimination are recognized as
barriers to protective HIV-related behaviors and
health outcomes e.g. access to HIV counseling &
testing, HIV treatment, HIV medication adherence
and overall well-being and quality of life of PLHIV
• Recently greater attention has been paid to the
“layered” nature of stigma including the ways in
which multiple forms of social stigmas and
inequalities underlie and are associated with HIV
stigma, discrimination & human rights violations
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Stigma as a Socio-Structural Process
• Stigma and discrimination related to HIV is
understood here as a social process which
produces and reproduces social divisions,
hierarchies and unequal social structures:
– Sexual Orientation
– Gender
– Race/Ethnicity
– Class
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Intersections of HIV-related Stigma &
Underlying Social Stigmas and Inequalities
Parker R. and Aggleton P. (2002) HIV/AIDS- related stigma and discrimination: a
conceptual framework and an agenda for action. Population Council: Horizons Project.
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Specific Aims
– To examine the relationship between HIV stigma and
discrimination and protective health behaviors and
outcomes among a diverse sample of PLHIV attending
public clinics in Rio de Janeiro, Brazil
• Reported health, care adherence, HIV medication adherence,
consistent condom use, and reported STIs since diagnosis
– To assess how other forms of underlying social stigmas
intersect with HIV stigma and discrimination among a
diverse sample of PLHIV attending public clinics in Rio
de Janeiro, Brazil
• Gender, sexual orientation, income, race/ethnicity, sex work,
drug use, incarceration
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Brazilian Context
Brazil is leader in rights-based
HIV prevention, treatment & care:
 First lower to middle income country to
establish universal access to treatment
 Battle against stigma and discrimination
central to national response to HIV in Brazil
 Relatively limited research on HIV stigma and
discrimination among PLHIV in Brazil
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Study Setting, Population
& Sampling Strategy
• Government-run public health clinics providing
treatment and care to PLHIV in Rio de Janeiro
• Clinics (6/22) selected to ensure social and
geographic diversity within greater Rio area
• Sample of 900 PLHIV
– Specific targets to capture demographic
characteristics and diversity of clinics
– Gender, sexual orientation, and % on ARVs
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Methods
• Structured survey to assess psychosocial and
structural factors associated with HIV behaviors
and health outcomes among participating PLHIV
– Approximately 1 hour, private setting at clinic
• STI screening: Syphilis, Gonorrhea, Chlamydia
– FTA-ABS syphilis & PCR analysis for GC
• Medical Record Extraction: CD4 count, viral load,
opportunistic infections, hospitalizations
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Measures
Berger HIV Stigma Scale
Likert scale 1-4 (strongly agree to strongly disagree)
Minority of participants reported HIV stigma and discrimination
Aggregate Measures Mean & Range
Reliability
& Items
(Cronbach’s Alpha)
HIV Discrimination:
28.78 (9.0-32.0)
.7488
8 items (e.g. I lost my
job because of HIV)
HIV Stigma:
25.46 (8.0-32.0)
.7545
8 items (e.g. I feel
guilty because of HIV)
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Primary Outcome Variables
• Reported good physical health last 6 months:
66.9%
• No missed HIV appointments last 6 months:
62.2%
• Took all ARV medications last 4 days:
83.5%
• Consistent condom use last 6 months:
• Number of sexual partners:
0 (26%), 1 (48%), 2 or more (26%)
67.7%
• Reported STI since HIV diagnosis:
• Documented STI at time of survey:
19.7%
6.9%
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Data Analysis Approach
• Factor and reliability analysis for aggregate measures
• Univariate exploration of the distribution and normalcy
of all variables and aggregate measures
• Bivariate and multivariate logistic regression analyses
conducted for each of the study outcomes of interest
• Adjustments to standard errors of multivariate
regression coefficients for clinic intra-class correlation
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Characteristics of Sample
• Majority male (67%), 32% female, 1% trans
• Majority heterosexual (59%), 32% bisexual,
8% homosexual
• Majority non-white
• Median age (41.0)
• Low education (primary)/income ($375/mo)
• 10% prior sex work
• 15% prior drug use
• 75% of sample on ARVs
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Bivariate Analysis: HIV stigma and discrimination and
protective health behaviors and outcomes among PLHIV
Unadjusted
Odds Ratios
(95% CI)
Physical
health
Missed
treatment
& care
visits
ARV
adherence
Consistent
condom use
STI since
diagnosis
Higher HIV
Discrimination
.58
(.44-.77)
***
1.40
(1.06-1.84)
*
.63
(.41-.96)
*
.97
(.70-1.34)
1.7
(1.21-2.40)
**
Higher HIV
Stigma
.46
(.34-.61)
***
1.43
(1.09-1.89)
**
.60
(.39-.92)
*
.81
(.58-1.11)
1.33
(.96-1.87)
***=p<.001; **=p<.01; *=p<.05
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Multivariate Analysis: HIV stigma and discrimination and
protective health behaviors and outcomes among PLHIV
Adjusted Odds
Ratios (95% CI)
Physical
Health
Higher HIV
Discrimination
.71 (.52-.97)*
(p=.029)
Missed
Treatment &
care
appointments
1.24 (.92-1.65)
(p=.154)
.54(.40-.74)***
(p=.000)
1.26 (.94-1.69)
(p=.121)
Higher HIV
Stigma
ARV
adherence
STI since
diagnosis
.71 (.45-1.10)
(p=.127)
1.63 (1.142.32)*
(p=.008)
.70 (.45-1.09) 1.25 (.87-1.80)
(p=.122)
(p=.223)
***=p<.001; **=p<.01; *=p<.05; Controlling for socio-demographic and behavioral characteristics significant in bivariate analysis
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Factors Associated with
HIV Stigma and Discrimination
Factors
Female/Transgender
Higher HIV Stigma
Homo-bisexual
1.35 (1.02-1.78)
*
.71 (.54-.92) **
Age: 42 or older
.68 (.52-.89) **
Non-White
1.46 (1.08-1.96)
> Primary school
.58 (.45-.76)***
Pentecostal religion
1.53 (1.05-2.23)
*
1.12 (.86-1.46)
No regular partner
One or > child(ren)
1.28 (.96-1.70)
.83 (.63-1.09)
.65 (.49-.88)**
.70 (.53-.91)**
.72 (.54-.95)*
1.18 (.88-1.60)
.71 (.52-.96)*
Income: > 600 R
1.63 (1.25-2.12) 1.65 (1.14***
2.39)**
.60 (.45-.78) *** .74 (.55-.99)*
No prior sex work
.52 (.33-.83) **
No prior drug use
Not on ARVs
.69 (.47-1.01)
.95 (.71-1.28)
www.ias2011.org***=p<.001; **=p<.01; *=p<.05;
Higher HIV Discrimination
.56 (.35-.90)*
.91 (.70-1.19)
1.48 (1.012.15)*
1.31 (1.001.71)*
1.10 (.85-1.44)
.61 (.47.80)*** .62 (.46-.82)**
.60 (.38-.93)*
.62 (.43-.92)*
1.38 (1.031.86)*
.63 (.42-.95)*
1.56 (1.142.14)**
Discussion
• HIV stigma and discrimination are relatively low among
PLHIV attending public clinics in Rio de Janeiro, Brazil
• Significant associations documented in multivariate
analyses between HIV-related stigma and discrimination
and reported physical health as well as HIV-related
discrimination and reported STIs since diagnosis
• HIV stigma and discrimination are associated with
underlying social stigmas and inequalities e.g. poverty, sex
work, drug use and are greater among younger people
• Being on ARVs is protective against HIV discrimination
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Conclusions
 Findings from this study indicate the importance of addressing
multiple, overlapping social stigmas among PLHIV to improve
their health and well-being and reduce ongoing HIV transmission
 Brazil has led the way in combating HIV stigma and
discrimination, however, challenges still exist particularly among
marginalized population groups
 Socio-structural interventions focused addressing the multiple
dimensions of stigma and discrimination experienced by PLHIV
particularly those from marginalized groups are needed
 Evaluations of multi-level interventions to promote linkages to care,
protective HIV-related behaviors and reduce HIV/STI transmission
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Acknowledgements
Co-investigators: Francisco Bastos, MD,
Monica Malta, PhD,Neilane Bertoni, MPH,
Oswaldo Cruz Foundation, The Rio
Collaborative Group
Thanks to study participants, clinic personnel,
the study team and to the Ford Foundation
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