‘Management of a spoiled identity’: systematic review of interventions to address self-stigma among people living with and affected by HIV

Abstract

BackgroundSelf-stigma, also known as internalised stigma, is a global public health threat because it keeps people from accessing HIV and other health services. By hampering HIV testing, treatment and prevention, self-stigma can compromise the sustainability of health interventions and have serious epidemiological consequences. This review synthesised existing evidence of interventions aiming to reduce self-stigma experienced by people living with HIV and key populations affected by HIV in low-income and middle-income countries.MethodsStudies were identified through bibliographic databases, grey literature sites, study registries, back referencing and contacts with researchers, and synthesised following Cochrane guidelines.ResultsOf 5880 potentially relevant titles, 20 studies were included in the review. Represented in these studies were 9536 people (65% women) from Ethiopia, India, Kenya, Lesotho, Malawi, Nepal, South Africa, Swaziland, Tanzania, Thailand, Uganda and Vietnam. Seventeen of the studies recruited people living with HIV (of which five focused specifically on pregnant women). The remaining three studies focused on young men who have sex with men, female sex workers and men who inject drugs. Studies were clustered into four categories based on the socioecological level of risk or resilience that they targeted: (1) individual level only, (2) individual and relational levels, (3) individual and structural levels and (4) structural level only. Thirteen studies targeting structural risks (with or without individual components) consistently produced significant reductions in self-stigma. The remaining seven studies that did not include a component to address structural risks produced mixed effects.ConclusionStructural interventions such as scale-up of antiretroviral treatment, prevention of medication stockouts, social empowerment and economic strengthening may help substantially reduce self-stigma among individuals. More research is urgently needed to understand how to reduce self-stigma among young people and key populations, as well as how to tackle intersectional self-stigma.

Project YES! Youth Engaging for Success: A randomized controlled trial assessing the impact of a clinic-based peer mentoring program on viral suppression, adherence and internalized stigma among HIV-positive youth (15-24 years) in Ndola, Zambia

“…was the significant decrease in internalized stigma experienced by intervention arm participants across all study sites. AYA are in a developmental stage when they are "developing and consolidating their sense of self" [45], and the impact of internalized stigma among this age group is not well studied [46]. In a systematic review of stigmareduction interventions in low-and middle-income countries, the authors found only one study that focused on youth [46,47].…”

“…AYA are in a developmental stage when they are "developing and consolidating their sense of self" [45], and the impact of internalized stigma among this age group is not well studied [46]. In a systematic review of stigmareduction interventions in low-and middle-income countries, the authors found only one study that focused on youth [46,47]. This study used motivational interviewing to change sexual risk behaviors and alcohol use among Thai youth and did not find evidence of an impact on internalized stigma.…”

Expansion of HIV testing in Eswatini: stakeholder perspectives on reaching the first 90

“…Stigma interventions have been reviewed extensively but have focused on enacted stigma (Siegfried & Beanland, 2017;Stangl et al, 2013) rather than self-stigma. Self-stigma or internalised stigma, although defined by Goffman decades ago (1963), remains strikingly understudied (Pantelic et al, 2019). In our research, self-stigma was a rising concern regarding HIV testing uptake and treatment, and was described as an even stronger barrier to HIV testing and treatment than enacted stigma.…”

Multiple forms of discrimination and internalized stigma compromise retention in HIV care among adolescents: findings from a South African cohort

“…Our findings further suggest that early intervention in the form of psychological support might help improve retention in care amongst young people who have experienced various forms of discrimination. Little is known about what might work to address internalized stigma among young people living with HIV but the broader, adult‐focused evidence base points to cognitive behavioural therapy, economic strengthening and community mobilization as promising approaches [46]. These should be adapted and tested for use among adolescents living with HIV.…”