HIV-Related Discrimination among Grade Six Students in Nine Southern African Countries

"HIV-related stigmatisation and discrimination by young children towards their peers have important consequences at the individual level and for our response to the epidemic, yet research on this area is limited."

This study examines stigma and discrimination of HIV-positive children by grade six students (n = 39,664) across nine countries in Southern Africa: Botswana, Lesotho, Malawi, Mozambique, Namibia, South Africa, Swaziland, Zambia, and Zimbabwe. Stigma, as reported here, can result in: bullying, victimisation, and poorer mental health outcomes among HIV-affected and infected children; disclosure-of-status decisions and school attendance; and possible delays in treatment and care for children living with HIV due to caregivers' hesitation to disclose a child's status. Intervention designs that reduce stigma at an early age, minimise negative impacts on child health, and reduce discrimination that distances and excludes children may, as researchers indicate, improve health outcomes for children living with HIV. [Footnotes are removed throughout.]

 For the study, "[d]escriptive statistics are used to compare discrimination by country, gender, geographic location and socioeconomic status. Multivariate logistic regression is employed to assess potential determinants of discrimination." Sources of the data are school surveys from participating countries of the Southern and Eastern African Consortium for Monitoring Educational Quality (SACMEQ), a consortium of education ministries, policymakers and researchers, in conjunction with the United Nations Educational, Scientific and Cultural Organization (UNESCO)'s International Institute for Educational Planning (IIEP). The survey "SACMEQ III included a number of attitudinal questions relating to HIV and an HIV-AIDS Knowledge Test (HAKT)....Two different measures of HIV-related discrimination towards children living with HIV were used. The first from the question: “A close friend of yours has told you that he or she is infected with HIV. How would you behave towards him or her?” with the options being '1) I would be more friendly than before; 2) I would behave the same as before, 3) I would avoid or shun him/her, 4) I am not sure how I would behave'. The second from the question: 'Should a pupil who is infected with HIV be allowed to continue to attend school?' with the available options being 'No', 'Yes' and 'I am not sure.'"

The median age range was 12-14 years old with an equal gender distribution; geographic location (urban/rural) varied - "with the proportion from rural areas being 37% in Mozambique and 70% and greater in Malawi, Swaziland and Zimbabwe....More than one in four students in all countries reported the loss of at least one parent. In terms of HIV information and knowledge, students reported receiving information about HIV from a variety of sources (averages between 10 sources in Lesotho and 13.5 sources in Botswana and Swaziland). The most common cited sources of information were classes at school, radio, clinic, magazines/newspapers and books....On average, respondents answered 71% of the HIV knowledge questions correctly....Respondents scored lowest on the question “Having sex only with people who look healthy is one way to prevent getting HIV”, with around half or more answering true to this statement in Lesotho, Mozambique, Namibia, South Africa and Zambia....The vast majority (72%) reported that HIV could be transmitted via some form of casual contact...."

Table 2 in the document displays levels of discrimination on reporting whether the respondent would "avoid or shun" an HIV-positive close friend, showing variation by country, e.g., 1 in 10 grade six students in Botswana, Malawi, South Africa, and Swaziland would, while 2 in 10 would do the same in Lesotho, Mozambique, Zambia, and Zimbabwe.

A higher percentage of children believed that HIV-positive students should not be allowed to continue to attend school, e.g., Zambia (33%), Lesotho (37%), and Zimbabwe (42%), compared to Malawi (13%) and Swaziland (12%). Larger differences in discrimination on school attendance were found by geographic location (rural vs. urban - up to 12-15% for rural children) and socioeconomic status (economically richest vs. poorest - up to 12-13% more among the economically poor) than by gender (boys showing just slightly more discrimination).

Looking closely at data on shunning a friend - measured by various demographics -"[m]ixed results were also found for the effect of orphan status, mother's education and having met a person living with HIV...", as well as age of child. Factors associated with lower rates of reporting discrimination via shunning varied by country and included: attending more affluent schools; living in a rural area (in Zambia); exposure to a greater number of sources of HIV information (and in South Africa, greater levels of general HIV knowledge); and reading ability and beliefs about whether there is HIV transmission via casual contact.

Looking closely at school attendance by HIV-positive children - measured by various demographics, gender was a factor only in South Africa where girls were less likely to report that a student should not attend. In Namibia, South Africa, and Swaziland, older students were less likely to report that a student should not attend. In Malawi (OR = 3.1), Mozambique (OR = 1.7) and Swaziland (OR = 2.4), students in rural areas were significantly more likely to report than students in urban areas that students should not attend. "[I]n Namibia, South Africa and Zambia, there was a negative association between mother's education and levels of discrimination. Generally, there was a negative association between discrimination and reading ability, exposure to HIV information and general HIV knowledge." The greater the misconception that HIV can be transmitted via casual contact, the greater the odds of students reporting discrimination on school attendance by an HIV-positive child.

The researchers conclude that: "Our findings reiterate that stigmatisation and discrimination are complex social processes, which are clearly influenced by local context, and therefore vary widely by country, school location and socioeconomic status...[E]vidence does not point towards the need for gender specific interventions. Overall, our study also found relatively small differences in HIV-related discrimination by age, which suggests that interventions aimed at grade 6 students also do not need to be tailored to different age groups....Findings show that beliefs that HIV can be transmitted via casual contact could be a strong factor that influences discriminatory outcomes across the region. Our results indicate that reductions in HIV-related discrimination among children may be achieved through interventions to correct these misconceptions around casual contact....Overall, our study points toward the need for early interventions (grade six or before) to reduce stigma and discrimination among children, especially in schools in rural and poorer areas. In particular, interventions should aim to correct misconceptions that HIV can be transmitted via casual contact with people living with HIV."