Stigma in the Balance: Ensuring the Roll-Out of ART Decreases Stigma

This 4-page policy briefing paper, published by Evidence for Action, explores the impact of anti-retroviral treatment (ART) on stigma and outlines recommendations for ensuring that the roll-out of ART helps to reduce stigma. The report draws on findings from qualitative research carried out against the backdrop of a longitudinal cohort study in a semi-rural area of North-Tanzania.

According to the brief, HIV-related stigma is still a major problem in Tanzania, preventing people from accessing HIV services (including testing and treatment) and from protecting themselves and others from infection. The roll-out of ART has led to increasing normalisation of HIV and reducing some types of stigma, but has also led to increases in other types of stigma. The authors argue that to ensure that ART benefits rural communities in Tanzania, action is needed to promote the normalisation of HIV and prevent a scale-up of stigma.

According to the brief, because ART patients are recovering and able to look after themselves and resume work, burden-related stigma has decreased. Self-stigma has also decreased as people living with HIV realise they are not the only ones with HIV through interaction with health professionals and other people living with HIV at the clinic.

However, as stated in the report, some types of stigma are not decreasing. Blame-related stigma still persists, as does fear-related stigma, because people are concerned that the physical recovery of people with HIV after receiving ART will lead to increased sexual activity and transmission. Another source of stigma is "moral outrage" - people who are seen as blameworthy are given economic and nutritional aid through support programmes in a context where many community members live in extreme poverty.

The brief contains recommendations for decreasing stigma during ART roll-out:

Increasing visibility and "normalisation" -

The first recommendation is to increase visibility of people living with HIV to help increased "normalisation" of HIV and reduce self-stigma. This includes: running periodic sensitisation campaigns that emphasise that HIV can affect anyone, and that testing and treatment are available; encouraging media to run features of people living with HIV who are willing to disclose their status; encouraging people living with HIV to act as voluntary counselling and testing (VCT) and ART advocates; and promoting VCT uptake among local leaders.

Training -

According to this report, training is also important to reduce some of the misconceptions that exacerbate stigma. Training should take place on several levels: national-level workshops should be held for anti-stigma trainers appointed by regions/districts; anti-stigma modules should be included in training for local HIV committees; and workshops addressing stigma should be given to anti-stigma focal points appointed by local HIV committees.

Reducing fear-related stigma -

Fear-related stigma can be decreased by: supporting associations of people living with HIV to develop and share a "chart of rights and responsibilities"; promoting realistic positive prevention strategies; and considering alternatives to criminalising HIV.

Involving all key stakeholders -

Involvement is key to reducing stigma. Suggestions include: health service providers should participate in local multi-sectoral HIV committees and share with committees how HIV is detected and treated; faith leaders, people living with HIV, and traditional healers should be part of local HIV committees and involved in anti-stigma activities; and home-based care providers should be involved as family educators about HIV.