HIV Community-Level Stigmatizing Attitudes in Tanzania: Perspectives from Antenatal Care

Abstract

Introduction: Stigma significantly impacts retention in HIV care and quality of life among people living with HIV. This study explored community-level HIV stigma from the perspective of patients and healthcare workers in antenatal care (ANC) in Moshi, Tanzania. Methods: We conducted in-depth interviews with 32 women (20 living with HIV), key-informant interviews with 7 ANC clinic employees, and two focus group discussions with 13 community health workers. Results: Themes emerged related to drivers and manifestations of stigma, resilience to stigmatizing attitudes, and opportunities to address stigma in ANC. Drivers of stigma included a fear of infection through social contact and associations of HIV with physical weakness (e.g., death, sickness) and immoral behaviour (e.g., sexual promiscuity). Manifestations included gossip, physical and social isolation, and changes in intimate relationships. At the same time, participants identified people who were resilient to stigmatizing attitudes, most notably individuals who worked in healthcare, family members with relevant life experiences, and some supportive male partners. Conclusion/Recommendations: Supportive family members, partners, and healthcare workers can serve as role models for stigma-resilient behaviour through communication platforms and peer programs in ANC. Manifestations of HIV stigma show clear links to constructs of sexuality, gender, and masculinity, which may be particularly impactful during pregnancy care. The persistence of stigma emphasizes the need for innovation in addressing stigmatizing attitudes in the community. Campaigns and policies should go beyond dispelling myths about HIV transmission and immorality to innovate peer-led and couples-based stigma reduction programming in the ANC space

The Development and Psychometric Evaluation of the HIV Stigmatizing Attitudes Scale (HSAS) in Tanzania

“…We developed the HIV Stigma Attitudes Scale (HSAS) for Tanzania in three phases: (1) addition of new items to the original Visser scale to address missing content areas based on our team’s formative qualitative research [ 15 , 27 ], and a USAID HIV Stigma in Tanzania field report [ 28 ]; (2) translation into Swahili and reordering of items for ease of answering; and (3) pilot testing of the scale with 88 individuals, a sample of men and women attending appointments for antenatal care (ANC) at one of the clinics where the study took place. The qualitative research involved in-depth interviews with 32 pregnant and postpartum women (20 living with HIV) and interviews and two focus group discussions with ANC clinic employees and community health workers.…”

“…The qualitative research involved in-depth interviews with 32 pregnant and postpartum women (20 living with HIV) and interviews and two focus group discussions with ANC clinic employees and community health workers. These interviews and focus group discussions sought insights into the drivers of HIV stigma in the community, and the manifestations of HIV stigmatizing attitudes [ 15 , 27 ]. The data were thematically analyzed by a team of U.S. and Tanzanian researchers, with a goal of identifying expressions of stigmatizing attitudes.…”

“…Therefore, items designed to measure HIV stigma must be translated, modified, and validated for specific cultural contexts [ 11 – 14 ]. Qualitative research conducted in East Africa has shown that HIV stigmatizing attitudes are primarily driven by a fear of infection through casual social contact, associations of HIV with physical weakness that therefore affects economic productivity, and the association of HIV with sexual promiscuity by the general population [ 15 ]. Stigmatizing attitudes manifest in behaviors such as gossip, physical and social isolation, and termination of intimate partner relationships [ 15 ].…”

“…Qualitative research conducted in East Africa has shown that HIV stigmatizing attitudes are primarily driven by a fear of infection through casual social contact, associations of HIV with physical weakness that therefore affects economic productivity, and the association of HIV with sexual promiscuity by the general population [ 15 ]. Stigmatizing attitudes manifest in behaviors such as gossip, physical and social isolation, and termination of intimate partner relationships [ 15 ]. These manifestations of stigmatizing attitudes are especially detrimental because they strip away the networks of social support that people need to facilitate HIV testing, linkage to HIV care, and long-term retention in care to support viral suppression [ 1 , 16 ].…”

“…While this scale was validated and culturally adapted by Visser et al in South Africa, no such instrument exists for the region of East Africa, where stigma is a high barrier to care engagement [ 4 , 9 , 11 , 25 ]. In Tanzania, stigmatizing attitudes manifest not only as beliefs and dispositions, but also translate into behavior, as literature has documented that social distancing and isolation are still common manifestations of HIV stigma [ 4 , 9 , 11 , 15 , 25 ]. A reliable and validated HIV Stigma Attitudes Scale in the Tanzania context and Swahili language can be used in the broader East African context to facilitate studies of HIV stigmatizing attitudes among the general population.…”