The association between HIV stigma and HIV incidence in the context of universal testing and treatment: analysis of data from the HPTN 071 (PopART) trial in Zambia and South Africa

Abstract

Introduction To investigate the association between individual and community‐level measures of HIV stigma and HIV incidence within the 21 communities participating in the HPTN (071) PopART trial in Zambia and South Africa. Methods Secondary analysis of data from a population‐based cohort followed‐up over 36 months between 2013 and 2018. The outcome was rate of incident HIV infection among individuals who were HIV negative at cohort entry. Individual‐level exposures, measured in a random sample of all participants, were: (1) perception of stigma in the community, (2) perception of stigma in health settings and (3) fear and judgement towards people living with HIV. Individual‐level analyses were conducted with adjusted, individual‐level Poisson regression. Community‐level HIV stigma exposures drew on data reported by people living with HIV, health workers and community members. We used linear regression to explore the association between HIV stigma and community‐level HIV incidence. Results Among 8172 individuals who were HIV negative and answered individual‐level stigma questions at enrolment to the cohort, there was no evidence of a statistically significant association between any domain of HIV stigma and risk of incident HIV infection. Among the full cohort of 26,110 individuals among whom HIV incidence was measured, there was no evidence that community‐level HIV incidence was associated with any domain of HIV stigma. Conclusions HIV stigma is often cited as a barrier to the effectiveness of HIV prevention programming. However, in the setting for the HPTN 071 “PopART trial,” measured stigma alone was not associated with the risk of HIV infection.

The local dynamics of sociostructural features and HIV stigma in the HPTN 071 (PopART) trial: An analysis of community-level data from Zambia and South Africa.

“…The methods for the quantitative surveys, including design, sampling, stigma measurement validity, and completion rates have been described in detail elsewhere—see Hargreaves et al (2016), Hargreaves et al (2022), Stangl et al (2020). For ease of reference, we summarize the key points here: (a) each of the quantitative surveys were open cohorts, with additional participants entering at each round, (b) community participants at each round were selected randomly, using simple random sampling techniques, while the health worker sample was comprised of a census of all health workers at the facility who agreed to participate in the 21 communities, and (c) participation rates were high.…”

“…Other key findings from the stigma ancillary study were as follows: a slow reduction and changes in HIV stigma over time (Stangl et al, 2020; Viljoen, Bond, et al, 2021); people living with HIV being made increasingly responsible for containing HIV (Viljoen, Bond, et al, 2021); high levels of HIV stigma (Hargreaves et al, 2018); persistent judgment of key populations and young women (Krishnaratne et al, 2020; Viljoen et al, 2017); continuing fear of being seen accessing HIV services in health facilities (Bond, Nomsenge, et al, 2019; Seeley et al, 2019), and evidence that although internalized stigma increased HIV viral load (Hargreaves et al, 2020), community-level HIV incidence was not alone associated with HIV stigma (Hargreaves et al, 2022). Critically, the quantitative analyses of HPTN 071 (PopART) stigma data consistently demonstrated variability in HIV stigma measures between the 21 communities and two countries (Hargreaves et al, 2018, 2020, 2022; Stangl et al, 2020). Variability, or the difference that made the difference, was a key area of enquiry for the broader social science design of the larger community-randomized trial HPTN 071 (PopART; Bond et al, 2016, 2021), which the stigma study was nested within.…”

Medical Male Circumcision and HIV Testing Practices among Men Aged 15 to 59 Years Old: Evidence from Zambia Demographics and Health Survey

“…Sociodemographic characteristics were chosen because of their dominance in literature and presence in the DHS dataset. WHO (2010) recognized a number of contributing factors to male circumcision and HIV testing, including age, religion, education, ethnicity, perceived social desirability, culture, socioeconomic status, and perceived social benefits, among other issues [9,34]. Therefore, sociodemographic characteristics assessed were province, resident type, age, marital status, education, religion, and wealth index in the current study.…”

“…In Zambia, as in many other sub-Saharan African countries, HIV remains a significant public health concern considering the national HIV adult prevalence rate of 12.3% [8], exacerbated by structural stigma [9]. Understanding the prevalence of HIV testing among males is crucial for effective public health planning, resource allocation, and intervention.…”

What will it take to get to the heart of stigma in the context of HIV?

“…Studies in this issue examine the impact of HIV-related stigma on the HIV prevention cascade. For instance, Hargreaves et al [22] explore the association between stigma and HIV incidence through a nestled study within the PopART trials in Zambia and South Africa. They found no evidence of an association between HIV stigma and HIV incidence in the trials, suggesting that efforts to reduce new HIV infections and improve HIV prevention and treatment programmes may fail if HIV stigma is considered in isolation and are not complemented by a more holistic approach.…”