Our findings cast doubts on the assumption that ARV provision will lead to a reduction in stigma and a substantial increase in VCT uptake. Instead, two seemingly opposing dynamics emerge. On the one hand, the availability of effective treatment has transformed HIV into a chronic, invisible and manageable condition which is contributing to a reduction in self-stigma and growing openness among ART clients. Such “normalisation” of the disease can encourage VCT uptake. On the other hand, the persistence of blaming attitudes in the community and the emergence of new sources of stigma directly associated with ARV provision fuel stubbornly high levels of anticipated stigma, which contribute to disease denial and discourage VCT uptake (). These counterbalancing trends are likely to explain the relatively slow increase in the rate of VCT uptake, and context-specific manifestation of each type of stigma will need to be considered in order to develop appropriate interventions.
Effect of antiretroviral (ARV) provision on HIV stigma and Voluntary Counselling and Testing (VCT) uptake: early evidence from rural Tanzania. ART, antiretroviral therapy; PLHA, persons living with HIV/AIDS.
- There is insufficient evidence for the common assumption that antiretroviral therapy (ART) provision automatically leads to reduction in stigma and increased HIV test uptake.
- In our study setting, the complex interplay between ART, HIV stigma and Voluntary Counselling and Testing (VCT) is characterised by two powerful dynamics in different directions.
- The positive impact of HIV normalisation on VCT uptake is counterbalanced by persistent blaming attitudes and the emergence of new sources of stigma.
- Achieving widespread public health benefits of ART roll-out requires community-level interventions to ensure local acceptability of antiretroviral drugs.
Where PLHA are blamed for their condition, identified as a modern, sexually transmitted disease, and belief in supernatural forces as the origin of a wide array of diseases prevails, there might be further incentives to avoid testing and the risk of receiving a clear HIV diagnosis. As some cases of witchcraft are not subject to social sanction, cultural beliefs about disease aetiology provide a mechanism to blame others and turn the “guilty” into “victims,” thus allowing widespread avoidance of confronting the epidemic.
Targeted interventions may be required to prevent a scale-up of new types of stigma, tackle the deeply rooted association of HIV with “immoral behaviour,” and ensure the local acceptability of ART. Community leaders, opinion makers and representatives of community-based organisations should be made aware of the adverse effects of stigma, and home-based care providers should continue to act as “role models.” Positive prevention messages addressed to ART clients covering all available options should be delivered at health facilities and community settings, and the effects of prioritising PLHA when delivering food support within impoverished communities considered. Opinion leaders able to influence norms and values should closely collaborate with PLHA in community sensitisation activities promoting VCT uptake and emphasising that HIV can affect anyone.
The proposed interventions are backed by previous initiatives demonstrating that education interventions addressed to ART clients can contribute to safer sexual behaviours23
and that existing community assets can be mobilised to tackle stigma and promote HV testing.24–27
However, uncertainties remain about the overall impact of ART provision and VCT on sexual behaviour15 28 29
as well as the long-term effect of ART provision on stigma and VCT uptake.
Our findings are constrained by some methodological limitations including reliance on self-reported data and use of snowball sampling. PLHA might have under-reported negative experiences, and community leaders could have directed us to persons holding similar opinions. However, the sampling of key informants was conducted through group exercises, and we triangulated information by using different data-collection tools and categories of participants.
The challenges we have identified have been documented in other areas of Tanzania30
and are likely to be similar to those faced in rural SSA settings where ART provision is being scaled up through National AIDS Control Programmes.