Goffman (1963) defines stigma as a “mark” that links a person to undesirable characteristics (label) (Goffman 1963). HIV/AIDS related stigma has been a negative factor in the crusade to diminish the prevalence and effect of the HIV/AIDS pandemic. From the inception of AIDS, people have advocated extensive measures including quarantine of HIV infected people in order to protect the populace from the infection. Discrimination has often been rampant. Ostracism, isolation, and rejection have been common place in the lives of people identified to have AIDS (Carr and Gramling 2004). HIV/AIDS related stigma can range from a simple gossip to outright discrimination, resulting in job loss, house evictions, rejection, isolation and even killing of an HIV infected person. It can stem from legislative, and employment policies, hospital policies, cultural beliefs, or individual behaviors, thoughts, and attitudes (Standing 1992, Zwi 1993, Aggleton 1996). HIV/AIDS related stigma and discrimination have been linked to misconceptions about the disease, fear of the disease due to its manifestations and fatality, and to the association of HIV/AIDS with stigmatized/marginalized individuals in the community (Herek and Glunt 1988, Alonzo and Reynolds 1995, Boer and Emons 2004).

Since the beginning of the epidemic, much progress has been made in preventing new HIV infections and in delaying progression of the disease. However, very little has been done to halt the effect of stigma (Piot 2006). In 1988, a panel convened by the Institute of Medicine concluded that “the fear of discrimination is a major constraint to the wide acceptance of many potentially effective public health measures” (Herek and Glunt 1988). Now, twenty-five years after the start of the epidemic, the stigma of AIDS is still a hindrance in the fight against the disease. The stigma of AIDS, unswervingly hampers the effective AIDS response, deters people from knowing their HIV status, prevents high risk individuals from receiving needed services, prevents condom use, and creates non-compliance with breastfeeding recommendations for HIV positive mothers (WHO/UNAIDS 2004). Halting the epidemic will involve changing the perceptions of individuals in the community towards HIV and PLWHA.

In Ghana and many countries of sub-Saharan Africa, HIV transmission occurs primarily through heterosexual intercourse. In these countries, HIV/AIDS is widely viewed as a consequence of sexual immorality or immoral behaviors, thus, infected individuals are considered responsible for acquiring the disease. In some cases, the infection is perceived as a punishment given by God to perpetuators of sins like prostitution, promiscuity, drug use, or homosexuality (Kaldjian, et al. 1998, Ayranci 2005). Ghanaians are very religious and moral people and have a value system to which they adhere (Awusabo-Asare et al. 2004). They believe an individual should abstain from sex until marriage and that those who acquire HIV/AIDS through commercial sex work or promiscuity bring disgrace to their families. In Ghana, HIV/AIDS is believed to have emerged from individuals who engaged or solicited commercial sex workers (prostitutes) from Cote d’Ivoire (Yeboah-Afari 1988, Decosas 1995). HIV/AIDS is also blamed on foreigners, gay men and the Devil (Prince, 2004). Thus, people who have HIV/AIDS are blamed for the disease. The stigma related to sexual immorality due to cultural values against prostitution, promiscuity and homosexuality coupled with the fear of HIV/AIDS (due to misconception and fatality of AIDS) may be the source of HIV/AIDS stigma in Ghana (Ankomah 1998, Mill 2003, Prince, 2004). For example, commercial sex workers have been stigmatized and frequently harassed and humiliated by law enforcement agents (WiLDAF 2006).

Although there are homosexuals in Ghana (Known MSM Sites, 2008), the only form of sexual transmission of HIV that working documents of Ghana on HIV/AIDS recognize is heterosexual transmission (Republic of Ghana, 2000; Ghana AIDS Commission, 2000, National AIDS/STI Control Programme, 2001). International documents report nothing on HIV transmission by homosexual or bisexual groups in Ghana (UNAIDS, UNICEF, WHO 2002 Update; UNAIDS 2006). The Criminal Code of 1960 (Act 29) of Ghana, makes “sexual intercourse with a person in an unnatural manner” a crime (Attipoe, 2008). Although the act does not define what “Sexual intercourse in an unnatural manner” means, persons suspected of homosexuality are swiftly punished and incarcerated by law officials (Prince, 2004). Homosexuals (men who have sex with men; MSM) are also harassed, called evil, evicted from their homes and even beaten by members of the community (Prince, 2004). Drug use does not seem to play a major role among MSM in the Ghana Metropolis. Only 2% of MSM reported using methamphetamines or inhaling nitrates (Influencing Factors, 2008). Although a paper on HIV prevention among injecting drug users in developing and transitional countries list Ghana as one of these countries, no data was reported for Ghana and the source of the information was given as unpublished data from WHO, UNAIDS (Ball et al, 1998).

In Ghana, family members are considered ultimately responsible for the behavior of each household member and the family is blamed or praised for the behavior of its members (Hintz 1987). An individual is linked to a long chain of living and deceased members in his or her family and in his or her town or village (Hintz 1987). Thus, family members of a person who dies of or lives with HIV/AIDS are also stigmatized. Family members may encourage relatives with HIV/AIDS to remain silent about their HIV status to prevent gossip, social rejection and HIV related stigma. In some cases, family members isolate relatives with HIV to minimize social contact and/or prevent infection. Identifying the perception of family members towards HIV and family members with HIV/AIDS will be important in designing stigma averting interventions and educational programs for family members.

At the community level, the fear of stigma can lead to the refusal of voluntary counseling and testing (VCT) for HIV, increased gender-based violence, and marginalization of high risk individuals (Heyward, et al. 1993). Community members may not seek VCT because of the fear of discovering that they are HIV positive and fear of the resulting stigma and discrimination that may accompany their HIV/AIDS positive status. Thus, HIV/AIDS related stigma and discrimination may have a profound impact on the disclosure (revelation) of HIV status and the subsequent care, support, or treatment that HIV positive persons receive (Moneyham, et al. 1996, Muyinda, et al. 1997, Weiss and Ramakrishna 2001, Mill 2003, Carr and Gramling 2004, Reynolds, et al. 2004). In Ghana, HIV positive persons hide their HIV-seropositive status to reduce HIV/AIDS related stigma and discrimination and to retain the care and support of family members. Ironically, this secrecy hinders uptake of treatment and of support services that can be provided by family members (Mill 2003). People who feel stigmatized or discriminated against are more likely to have poor health outcomes, socio-psychological problems, and suicidal thoughts (Sowell, et al. 1996, Reynolds, et al. 2004, Bottonari, et al. 2005, Katz and Nevid 2005, Sledjeski, et al. 2005). Tackling HIV stigma will involve tackling perceptions and values towards sexuality and HIV/AIDS.

People with lower education also exhibited some other forms of stigma. They were also more likely to favor mandatory screening and identification of HIV status, revelation of HIV status, and social distancing of people with HIV/AIDS. Non-Christians, predominately Muslims, were more likely to be in favor of mandatory screening, identification and revelation of HIV status. Policies that favor mandatory screening and testing for HIV/AIDS with the intent of identifying those positive can create avenues for further stigmatization and discrimination of PLWHA. In many cases, PLWHA perceive and/or experience further discrimination when their HIV serostatus is revealed. Yet, 59% of respondents agreed that PLWHA should tell others about their HIV seropositivity. Males were also more likely to be in favor of disclosure of HIV positive status than females. It was important to note that majority (85.6%) of respondents had not been tested for HIV/AIDS or knew their HIV serostatus, yet they supported the identification of persons with HIV with the intent to know and be safe from the virus. Many of these respondents admitted that the fear of HIV-related stigma and discrimination and fear of knowing their HIV status were the main reasons why they had not sought HIV voluntary counseling and testing.

The study also found that 29% of respondents agreed that people with HIV should be isolated in certain villages or towns. Social distancing of people with HIV/AIDS was more likely to be exhibited by people with lower educational status and those older than 30 years. Employed individuals were more likely to have social contact or interaction with people living with HIV/AIDS. It may be that employed people encountered HIV positive people on the job or during their travel to and from work. Studies have shown that men with access to resources, including those who are employed, may be more likely to have a greater number of female sexual partners and be at greater risk of HIV infection (Wilkins et al. 1991; Gregson et al. 2001). The coupling of high awareness of HIV/AIDS with low knowledge of HIV pathology, symptoms, care and support may be a huge contributing factor to the presence of HIV/AIDS stigma in the study population.

During the recruitment phase of the study, we experienced setbacks in recruiting family members of PLWHA. There was a general reluctance by PLWHA to recruit family members or to discuss their HIV/AIDS status with them. This reluctance stemmed from fear of the resulting stigma, discrimination, and loss of support from family and friends if HIV positive status is revealed. Data on family members were obtained primarily from community members who indicated that they had a family member who was living with or who had died from HIV/AIDS. Our study is limited by the small sample size that we recruited. A larger sample may have improved the reliability of two of the stigma constructs namely “Screening and Identification of HIV status” with Cronbach alpha of 0.44 and “Social Contact/Interaction” with Cronbach alpha of 0.68. Cronbach alpha measures how well a set of items (or variables) measures a single unidimensional latent construct, and is an important measure of the reliability or consistency of survey questions or psychometric instruments. In natural science, a Cronbach alpha of 0.70 is considered acceptable (Nunnally 1978), but in the social sciences, Cronbach alphas of less than 0.60 have been noted (Hatcher 1994). The Cronbach alpha of 0.68 for “Social Contact/Interaction” can be considered acceptable because with rounding off this would be 0.70, but the Cronbach alpha of 0.44 for “Screening and Identification of HIV Status” is marginal or low. The variables measuring the Screening and Identification construct all had factor loadings ranging form 0.45 to 0.63 which can be considered acceptable. However, since the Cronbach alpha is marginal we place less emphasis on this part of the results and suggest that future studies should be conducted to re-examine the questions that were asked.

The restriction of our data collection to Kumasi limits generalization of our results to this region of Ghana. Despite the limitations, this study identified constructs of HIV/AIDS stigma and characteristics of individuals more likely to demonstrate stigma. These findings add to the scientific body of literature focused on identifying the experience and effects of HIV/AIDS stigma on PLWHA, community members, caregivers and family members. Further research is needed to identify the effect of stigma reduction interventions in the workplace and community. Particular emphasis should be placed on careful identification of educational messages that will bring about change in cultural and religious attitudes and result in reduction of HIV/AIDS stigmatization in the work place and community. Our findings provide insightful information that can guide policy makers and researchers in the design and implementation of such interventions.