The effect of universal testing and treatment on HIV stigma in 21 communities in Zambia and South Africa

Anne L Stangl, Triantafyllos Pliakas, Tila Mainga, Mara Steinhaus, Constance Mubekapi-Musadaidzwa, Lario Viljoen, Rory Dunbar, Ab Schaap, Sian Floyd, Nomtha Mandla, Virginia Bond, Graeme Hoddinott, Sarah Fidler, Richard Hayes, Helen Ayles, Peter Bock, Deborah Donnell, James R Hargreaves, HPTN 071 (PopART) study team, Anne L Stangl, Triantafyllos Pliakas, Tila Mainga, Mara Steinhaus, Constance Mubekapi-Musadaidzwa, Lario Viljoen, Rory Dunbar, Ab Schaap, Sian Floyd, Nomtha Mandla, Virginia Bond, Graeme Hoddinott, Sarah Fidler, Richard Hayes, Helen Ayles, Peter Bock, Deborah Donnell, James R Hargreaves, HPTN 071 (PopART) study team

Abstract

Objectives: To assess the impact of a combination HIV prevention intervention including universal testing and treatment (UTT) on HIV stigma among people living with HIV, and among community members and health workers not living with HIV.

Design: This HIV stigma study was nested in the HPTN 071 (PopART) trial, a three-arm cluster randomised trial conducted between 2013 and 2018 in 21 urban/peri-urban communities (12 in Zambia and nine in South Africa).

Methods: Using an adjusted two-stage cluster-level analysis, controlling for baseline imbalances, we compared multiple domains of stigma between the trial arms at 36 months. Different domains of stigma were measured among three cohorts recruited across all study communities: 4178 randomly sampled adults aged 18-44 who were living with HIV, and 3487 randomly sampled adults and 1224 health workers who did not self-report living with HIV.

Results: Prevalence of any stigma reported by people living with HIV at 36 months was 20.2% in arm A, 26.1% in arm B, and 19.1% in arm C (adjusted prevalence ratio, A vs. C 1.01 95% CI 0.49-2.08, B vs. C 1.34 95% CI 0.65-2.75). There were no significant differences between arms in any other measures of stigma across all three cohorts. All measures of stigma reduced over time (0.2--4.1% reduction between rounds) with most reductions statistically significant.

Conclusion: We found little evidence that UTT either increased or decreased HIV stigma measured among people living with HIV, or among community members or health workers not living with HIV. Stigma reduced over time, but slowly. CLINICALTRIALS.

Gov number: NCT01900977.

Conflict of interest statement

There are no conflicts of interest.

Figures

Fig. 1
Fig. 1
Adjusted prevalence ratios and 95% confidence intervals comparing arms of the trial at endline for all stigma outcomes.
Fig. 2
Fig. 2
Trends in (a) any stigma reported by PC-HIV+SR over time by study arm and Tripleta and in (b) stigma outcomes and job stress over time by study population.

References

    1. UNAIDS. Confronting discrimination: overcoming HIV-related stigma and discrimination in healthcare settings and beyond. Geneva: UNAIDS; 2017.
    1. Link BG, Phelan JC. Conceptualizing stigma. Annu Rev Sociol 2001; 27:363–385.
    1. Stangl AL, Earnshaw VA, Logie CH, Van Brakel W, Simbayi LC, Barré I, Dovidio JF. The health stigma and discrimination framework: a global, crosscutting framework to inform research, intervention development, and policy on health-related stigmas. BMC Med 2019; 17:31.
    1. Goffman E. Stigma: notes on the management of spoiled identity. New York: Simon & Schuster; 1963.
    1. Parker R, Aggleton P. HIV and AIDS-related stigma and discrimination: a conceptual framework and implications for action. Soc Sci Med 2003; 57:13–24.
    1. Nyblade L, Stangl A, Weiss E, Ashburn K. Combating HIV stigma in healthcare settings: what works?. J Int AIDS Soc 2009; 12:15.
    1. Nyblade L, Stockton MA, Giger K, Bond V, Ekstrand ML, Lean RM, et al. . Stigma in health facilities: why it matters and how we can change it. BMC Med 2019; 17:25.
    1. Mahajan A, Sayles J, Patel V, Remien R, Sawires S, Ortiz D, et al. . Stigma in the HIV/AIDS epidemic: a review of the literature and recommendations for the way forward. AIDS 2008; 2: Suppl 2: S67–S79.
    1. Reynolds LJ, Camlin CS, Ware NC, Seeley J. Exploring critical questions for the implementation of ‘universal test and treat’ approaches to HIV prevention and care. AIDS Care - Psychol Sociomed Asp AIDS/HIV 2016; 28:1–6.
    1. Musheke M, Ntalasha H, Gari S, McKenzie O, Bond V, Martin-Hilber A, Merten S. A systematic review of qualitative findings on factors enabling and deterring uptake of HIV testing in Sub-Saharan Africa. BMC Public Health 2013; 13:220.
    1. Golub SA, Gamarel KE. The impact of anticipated HIV stigma on delays in HIV testing behaviors: findings from a community-based sample of men who have sex with men and transgender women in New York City. AIDS Patient Care STDS 2013; 27:621–627.
    1. Sabapathy K, Mubekapi-Musadaidzwa C, Mulubwa C, Schaap A, Hoddinott G, Stangl A, et al. . Predictors of timely linkage-to-ART within universal test and treat in the HPTN 071 (PopART) trial in Zambia and South Africa: Findings from a nested case-control study: Findings. J Int AIDS Soc 2017; 20:e25037.
    1. Bond V, Nomsenge S, Mwamba M, Ziba D, Birch A, Mubekapi-Musadaidzwa C, et al. . Being seen’ at the clinic: Zambian and South African health worker reflections on the relationship between health facility spatial organisation and items and HIV stigma in 21 health facilities, the HPTN 071 (PopART) study. Health Place 2019; 55:87–99.
    1. Katz IT, Ryu AE, Onuegbu AG, Psaros C, Weiser SD, Bangsberg DR, et al. . Impact of HIV-related stigma on treatment adherence: systematic review and meta-synthesis. J Int AIDS Soc 2013; 16: Suppl 2: 18640.
    1. Gesesew HA, Gebremedhin AT, Demissie TD, Kerie MW, Sudhakar M, Mwanri L. Significant association between perceived HIV related stigma and late presentation for HIV/AIDS care in low and middle-income countries: a systematic review and metaanalysis. PLoS One 2017; 12:e0173928.
    1. Hayes R, Ayles H, Beyers N, Sabapathy K, Floyd S, Shanaube K, Tsai AC. HPTN 071 (PopART): Rationale and design of a cluster-randomised trial of the population impact of an HIV combination prevention intervention including universal testing and treatment – a study protocol for a cluster randomised trial. Trials 2014; 15:57.
    1. Stangl AL, Lloyd JK, Brady LM, Holland CE, Baral S. A systematic review of interventions to reduce HIV-related stigma and discrimination from 2002 to 2013: how far have we come?. J Int AIDS Soc 2013; 16: Suppl 2: 18734.
    1. Rao D, Elshafei A, Nguyen M, Hatzenbuehler ML, Frey S, Go VF. A systematic review of multilevel stigma interventions: state of the science and future directions. BMC Med 2019; 17:41.
    1. Roura M, Urassa M, Busza J, Mbata D, Wringe A, Zaba B. Scaling up stigma? The effects of antiretroviral roll-out on stigma and HIV testing. Early evidence from rural Tanzania. Sex Transm Infect 2009; 85:308–312.
    1. Orne-Gliemann J, Larmarange J, Boyer S, Iwuji C, McGrath N, Bärnighausen T, et al. . Addressing social issues in a universal HIV test and treat intervention trial (ANRS 12249 TasP) in South Africa: methods for appraisal. BMC Public Health 2015; 15:1344.
    1. Kim MH, Mazenga AC, Simon K, Yu X, Ahmed S, Nyasulu P, et al. . Burnout and self-reported suboptimal patient care amongst healthcare workers providing HIV care in Malawi. PLoS One 2018; 13:e0192983.
    1. Hayes RJ, Donnell D, Floyd S, Mandla N, Bwalya J, Sabapathy K, et al. . HPTN 071 (PopART) Study Team. Effect of Universal Testing and Treatment on HIV Incidence — HPTN 071 (PopART). N Engl J Med 2019; 381:207–218.
    1. Hargreaves JR, Stangl A, Bond V, Hoddinott G, Krishnaratne S, Mathema H, et al. . HPTN 071 (PopART) study team. HIV-related stigma and universal testing and treatment for HIV prevention and care: design of an implementation science evaluation nested in the HPTN 071 (PopART) cluster-randomized trial in Zambia and South Africa. Health Policy Plan 2016; 31:1342–1354.
    1. Shanaube K, Schaap A, Floyd S, Phiri M, Griffith S, Chaila J, et al. . HPTN 071 (PopART) Study Team. What works - reaching universal HIV testing: Lessons from HPTN 071 (PopART) trial in Zambia. AIDS 2017; 31:1555–1564.
    1. Hargreaves JR, Krishnaratne S, Mathema H, Lilleston PS, Sievwright K, Mandla N, et al. . HPTN 071 (PopART) Study Team. Individual and community-level risk factors for HIV stigma in 21 Zambian and South African communities: analysis of data from the HPTN071 (PopART) study. AIDS 2018; 32:783–793.
    1. Maslach C, Jackson SE, Leiter M. The Maslach Burnout Inventory: manual. Palo Alto, CA: Consulting Psychologists Press; 1996.
    1. Stangl A, Lilleston P, Mathema H, Pliakas T, Krishnaratne S, Sievwright K, et al. . HPTN 071 (PopART) Study Team. Development of parallel measures to assess HIV stigma and discrimination among people living with HIV, community members and health workers in the HPTN 071 (PopART) trial in Zambia and South Africa. J Int AIDS Soc 2019; 22:e25421.
    1. Hayes RJ, Moulton LH. Cluster randomised trials, second edition. Boca Raton, FL: Chapman and Hall/CRC; 2017.
    1. Lee RS, Kochman A, Sikkema KJ. Internalized stigma among people living with HIV-AIDS. AIDS Behav 2002; 6:309–319.
    1. UNAIDS. Evidence for elimination HIV-related stigma and discrimination. Geneva: UNAIDS; 2020.
    1. Chan BT, Tsai AC, Siedner MJ. HIV treatment scale-up and HIV-related stigma in sub-Saharan Africa: a longitudinal cross-country analysis. Am J Public Health 2015; 105:1581–1587.
    1. UNAIDS. Understanding fast-track: accelerating action to end the AIDS epidemic by 2030. Geneva: UNAIDS; 2015.

Source: PubMed

Sponsors et collaborateurs

Les conditions médicales

Interventions en matière de drogue

3
S'abonner