Top

Published in:

01-12-2013 | Original Article

Internalized Stigma, Social Distance, and Disclosure of HIV Seropositivity in Rural Uganda

Authors: Alexander C. Tsai, MD, PhD, David R. Bangsberg, MD, MPH, Susan M. Kegeles, PhD, Ingrid T. Katz, MD, MHS, Jessica E. Haberer, MD, MS, Conrad Muzoora, MBChB, MMed, Elias Kumbakumba, MBChB, MMed, Peter W. Hunt, MD, Jeffrey N. Martin, MD, MPH, Sheri D. Weiser, MD, MPH

Published in: Annals of Behavioral Medicine | Issue 3/2013

Abstract

Background

HIV is highly stigmatized, compromising both treatment and prevention in resource-limited settings.

Purpose

We sought to study the relationship between internalized HIV-related stigma and serostatus disclosure and to determine the extent to which this association varies with the degree of social distance.

Methods

We fit multivariable Poisson regression models, with cluster-correlated robust estimates of variance, to data from 259 persons with HIV enrolled in an ongoing cohort study in rural Uganda.

Results

Persons with more internalized stigma were less likely to disclose their seropositivity. The magnitude of association increased with social distance such that the largest association was observed for public disclosures and the smallest association was observed for disclosures to sexual partners.

Conclusions

Among persons with HIV in rural Uganda, internalized stigma was negatively associated with serostatus disclosure. The inhibiting effect of stigma was greatest for the most socially distant ties.

Duru OK, Collins RL, Ciccarone DH, et al. Correlates of sex without serostatus disclosure among a national probability sample of HIV patients. AIDS Behav. 2006;10:495-507.PubMedCrossRef

Klitzman R, Exner T, Correale J, et al. It’s not just what you say: Relationships of HIV dislosure and risk reduction among MSM in the post-HAART era. AIDS Care. 2007;19:749-756.PubMedCrossRef

Loubiere S, Peretti-Watel P, Boyer S, Blanche J, Abega SC, Spire B. HIV disclosure and unsafe sex among HIV-infected women in Cameroon: Results from the ANRS-EVAL study. Soc Sci Med. 2009;69:885-891.PubMedCrossRef

Simbayi LC, Kalichman SC, Strebel A, Cloete A, Henda N, Mqeketo A. Disclosure of HIV status to sex partners and sexual risk behaviours among HIV-positive men and women, Cape Town, South Africa. Sex Transm Infect. 2007;83:29-34.PubMedCrossRef

Eisele TP, Mathews C, Chopra M, et al. High levels of risk behavior among people living with HIV Initiating and waiting to start antiretroviral therapy in Cape Town South Africa. AIDS Behav. 2008;12:570-577.PubMedCrossRef

Kalichman SC, Ntseane D, Nthomang K, Segwabe M, Phorano O, Simbayi LC. Recent multiple sexual partners and HIV transmission risks among people living with HIV/AIDS in Botswana. Sex Transm Infect. 2007;83:371-375.PubMedCrossRef

Pinkerton SD, Galletly CL. Reducing HIV transmission risk by increasing serostatus disclosure: A mathematical modeling analysis. AIDS Behav. 2007;11:698-705.PubMedCrossRef

Kalichman SC, DiMarco M, Austin J, Luke W, DiFonzo K. Stress, social support, and HIV-status disclosure to family and friends among HIV-positive men and women. J Behav Med. 2003;26:315-332.PubMedCrossRef

Holt R, Court P, Vedhara K, Nott KH, Holmes J, Snow MH. The role of disclosure in coping with HIV infection. AIDS Care. 1998;10:49-60.PubMedCrossRef

10.

Paxton S. The paradox of public HIV disclosure. AIDS Care. 2002;14:559-567.PubMedCrossRef

11.

DiMatteo MR. Social support and patient adherence to medical treatment: A meta-analysis. Health Psychol. 2004;23:207-218.PubMedCrossRef

12.

Hansen NB, Vaughan EL, Cavanaugh CE, Connell CM, Sikkema KJ. Health-related quality of life in bereaved HIV-positive adults: Relationships between HIV symptoms, grief, social support, and Axis II indication. Health Psychol. 2009;28:249-257.PubMedCrossRef

13.

Simoni JM, Frick PA, Huang B. A longitudinal evaluation of a social support model of medication adherence among HIV-positive men and women on antiretroviral therapy. Health Psychol. 2006;25:74-81.PubMedCrossRef

14.

Catz SL, Kelly JA, Bogart LM, Benotsch EG, McAuliffe TL. Patterns, correlates, and barriers to medication adherence among persons prescribed new treatments for HIV disease. Health Psychol. 2000;19:124-133.PubMedCrossRef

15.

Gonzalez JS, Penedo FJ, Antoni MH, et al. Social support, positive states of mind, and HIV treatment adherence in men and women living with HIV/AIDS. Health Psychol. 2004;23:413-418.PubMedCrossRef

16.

Weaver KE, Llabre MM, Duran RE, et al. A stress and coping model of medication adherence and viral load in HIV-positive men and women on highly active antiretroviral therapy (HAART). Health Psychol. 2005;24:385-392.PubMedCrossRef

17.

Koenig LJ, Pals SL, Bush T, Pratt Palmore M, Stratford D, Ellerbrock TV. Randomized controlled trial of an intervention to prevent adherence failure among HIV-infected patients initiating antiretroviral therapy. Health Psychol. 2008;27:159-169.PubMedCrossRef

18.

Kalichman SC, Benotsch EG, Weinhardt L, Austin J, Luke W, Cherry C. Health-related Internet use, coping, social support, and health indicators in people living with HIV/AIDS: preliminary results from a community survey. Health Psychol. 2003;22:111-116.PubMedCrossRef

19.

Dercon S. Income risk, coping strategies, and safety nets. World Bank Res Observ. 2002;17:141-166.CrossRef

20.

Tsai AC, Bangsberg DR, Emenyonu N, Senkungu JK, Martin JN, Weiser SD. The social context of food insecurity among persons living with HIV/AIDS in rural Uganda. Soc Sci Med. 2011;73:1717-1724.PubMedCrossRef

21.

Ware NC, Idoko J, Kaaya S, et al. Explaining adherence success in sub-Saharan Africa: An ethnographic study. PLoS Med. 2009;6:e11.PubMedCrossRef

22.

Kalichman SC, Simbayi LC, Jooste S, et al. Development of a brief scale to measure AIDS-related stigma in South Africa. AIDS Behav. 2005;9:135-143.PubMedCrossRef

23.

Wolfe WR, Weiser SD, Bangsberg DR, et al. Effects of HIV-related stigma among an early sample of patients receiving antiretroviral therapy in Botswana. AIDS Care. 2006;18:931-933.PubMedCrossRef

24.

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.PubMedCrossRef

25.

Medley A, Garcia-Moreno C, McGill S, Maman S. Rates, barriers and outcomes of HIV serostatus disclosure among women in developing countries: Implications for prevention of mother-to-child transmission programmes. Bull World Health Organ. 2004;82:299-307.PubMed

26.

Lee MB, Wu Z, Rotheram-Borus MJ, Detels R, Guan J, Li L. HIV-related stigma among market workers in China. Health Psychol. 2005;24:435-438.PubMedCrossRef

27.

Swendeman D, Rotheram-Borus MJ, Comulada S, Weiss R, Ramos ME. Predictors of HIV-related stigma among young people living with HIV. Health Psychol. 2006;25:501-509.PubMedCrossRef

28.

Goffman E. Stigma: notes on the management of spoiled identity. Englewood Cliffs: Prentice Hall; 1963.

29.

Jones EE, Farina A, Hastorf AH, Markus H, Miller DT, Scott RA. Social stigma: The psychology of marked relationships. New York: W.H. Freeman & Company; 1984.

30.

Pennebaker JW. Confession, inhibition, and disease. In: Berkowitz L, ed. Advances in experimental social psychology, vol. 22. Orlando: Academic; 1989:211-244.

31.

Alonzo AA, Reynolds NR. Stigma, HIV and AIDS: An exploration and elaboration of a stigma trajectory. Soc Sci Med. 1995;41:303-315.PubMedCrossRef

32.

Norman A, Chopra M, Kadiyala S. Factors related to HIV disclosure in 2 South African communities. Am J Public Health. 2007;97:1775-1781.PubMedCrossRef

33.

Vu L, Andrinopoulos K, Mathews C, Chopra M, Kendall C, Eisele TP. Disclosure of HIV status to sex partners among HIV-infected men and women in Cape Town, South Africa. AIDS Behav. 2012;16:132-138.PubMedCrossRef

34.

Patel R, Ratner J, Gore-Felton C, Kadzirange G, Woelk G, Katzenstein D. HIV disclosure patterns, predictors, and psychosocial correlates among HIV positive women in Zimbabwe. AIDS Care. 2012;24:358-368.PubMedCrossRef

35.

Mansergh G, Marks G, Simoni JM. Self-disclosure of HIV infection among men who vary in time since seropositive diagnosis and symptomatic status. AIDS. 1995;9:639-644.PubMedCrossRef

36.

Hays RB, McKusick L, Pollack L, Hilliard R, Hoff C, Coates TJ. Disclosing HIV seropositivity to significant others. AIDS. 1993;7:425-431.PubMedCrossRef

37.

Bogardus ES. Measurement of personal-group relations. Sociometry. 1947;10:306-311.CrossRef

38.

Karakayali N. Social distance and affective orientations. Sociol Forum. 2009;24:538-562.CrossRef

39.

Granovetter M. The strength of weak ties. Am J Sociol. 1973;78:1360-1380.CrossRef

40.

Mayfield Arnold E, Rice E, Flannery D, Rotheram-Borus MJ. HIV disclosure among adults living with HIV. AIDS Care. 2008;20:80-92.PubMedCrossRef

41.

Weiser SD, Tsai AC, Gupta R, et al. Food insecurity is associated with morbidity and patterns of healthcare utilization among HIV-infected individuals in rural Uganda. AIDS. 2012;26:67-75.PubMedCrossRef

42.

Tsai AC, Bangsberg DR, Frongillo EA, et al. Food insecurity, depression and the modifying role of social support among people living with HIV/AIDS in rural Uganda. Soc Sci Med. 2012;74:2012-2019.PubMedCrossRef

43.

Wyrod R. Masculinity and the persistence of AIDS stigma. Cult Health Sex. 2011;13:443-456.PubMedCrossRef

44.

Nattabi B, Li J, Thompson SC, Orach CG, Earnest J. Between a rock and a hard place: Stigma and the desire to have children among people living with HIV in northern Uganda. J Int AIDS Soc. 2012;15:17421.PubMedCrossRef

45.

McGrath JW, Ankrah EM, Schumann DA, Nkumbi S, Lubega M. AIDS and the urban family: Its impact in Kampala, Uganda. AIDS Care. 1993;5:55-70.PubMedCrossRef

46.

Tsai AC, Bangsberg DR, Bwana M, Haberer JE, Frongillo EA, Muzoora C, Kumbakumba E, Hunt PW, Martin JN, Weiser SD. How does antiretroviral treatment attenuate the stigma of HIV? Evidence from a cohort study in rural Uganda. AIDS Behav. 2013; in press.

47.

Campbell C, Skovdal M, Madanhire C, Mugurungi O, Gregson S, Nyamukapa C. “We, the AIDS people…”: How antiretroviral therapy enables Zimbabweans living with HIV/AIDS to cope with stigma. Am J Public Health. 2011;101:1004-1010.PubMedCrossRef

48.

Kalichman SC, Simbayi LC, Cloete A, Mthembu PP, Mkhonta RN, Ginindza T. Measuring AIDS stigmas in people living with HIV/AIDS: The internalized AIDS-related stigma scale. AIDS Care. 2009;21:87-93.PubMedCrossRef

49.

Tsai AC, Weiser SD, Steward WT, et al. Evidence for the reliability and validity of the internalized AIDS-related stigma scale in rural Uganda. AIDS Behav. 2013;17:427-433.PubMedCrossRef

50.

Kling JR, Liebman JB, Katz LF. Experimental analysis of neighborhood effects. Econometrica. 2007;75:83-119.CrossRef

51.

Wu AW, Rubin HR, Mathews WC, et al. A health status questionnaire using 30 items from the medical outcomes study. Preliminary validation in persons with early HIV infection. Med Care. 1991;29:786-798.PubMedCrossRef

52.

Obermeyer CM, Baijal P, Pegurri E. Facilitating HIV disclosure across diverse settings: A review. Am J Public Health. 2011;101:1011-1023.PubMedCrossRef

53.

Gourieroux C, Monfort A, Trognon A. Pseudo maximum likelihood methods: Applications to poisson models. Econometrica. 1984;52:701-720.CrossRef

54.

Carter RE, Lipsitz SR, Tilley BC. Quasi-likelihood estimation for relative risk regression models. Biostatistics. 2005;6:39-44.PubMedCrossRef

55.

Brant R. Assessing proportionality in the proportional odds model for ordinal logistic regression. Biometrics. 1990;46:1171-1178.PubMedCrossRef

56.

Peterson BL, Harrell FE. Partial proportional dods models for ordinal response variables. Appl Statist. 1990;39:205-217.CrossRef

57.

Antelman G, Smith Fawzi MC, Kaaya S, et al. Predictors of HIV-1 serostatus disclosure: a prospective study among HIV-infected pregnant women in Dar es Salaam, Tanzania. AIDS. 2001;15:1865-1874.PubMedCrossRef

58.

Olley BO, Seedat S, Stein DJ. Self-disclosure of HIV serostatus in recently diagnosed patients with HIV in South Africa. Afr J Reprod Health. 2004;8:71-76.PubMedCrossRef

59.

Suzan-Monti M, Blanche J, Bile P, et al. Individual and structural factors associated with HIV status disclosure to main partner in Cameroon: ANRS 12–116 EVAL survey, 2006–2007. J Acquir Immune Defic Syndr. 2011;57(Suppl 1):S22-S26.PubMedCrossRef

60.

Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol consumption questions (AUDIT-C): An effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol use disorders identification test. Arch Intern Med. 1998;158:1789-1795.PubMedCrossRef

61.

Filmer D, Pritchett LH. Estimating wealth effects without expenditure data – or tears: An application to educational enrollments in states of India. Demography. 2001;38:115-132.PubMed

62.

Williams RL. A note on robust variance estimation for cluster-correlated data. Biometrics. 2000;56:645-646.PubMedCrossRef

63.

Froot KA. Consistent covariance matrix estimation with cross-sectional dependence and heteroskedasticity in financial data. J Fin Quant Analysis. 1989;24:333-355.CrossRef

64.

Rogers WH. Regression standard errors in clustered samples. Stata Tech Bull. 1993;13:19-23.

65.

Zou G. A modified poisson regression approach to prospective studies with binary data. Am J Epidemiol. 2004;159:702-706.PubMedCrossRef

66.

Bartus T. Estimation of marginal effects using margeff. Stata J. 2005;5:309-329.

67.

Williams R. Using the margins command to estimate and interpret adjusted predictions and marginal effects. Stata J. 2012;12:308-331.

68.

Dunkle KL, Stephenson R, Karita E, et al. New heterosexually transmitted HIV infections in married or cohabiting couples in urban Zambia and Rwanda: An analysis of survey and clinical data. Lancet. 2008;371:2183-2191.PubMedCrossRef

69.

Chemaitelly H, Cremin I, Shelton J, Hallett TB, Abu-Raddad LJ. Distinct HIV discordancy patterns by epidemic size in stable sexual partnerships in sub-Saharan Africa. Sex Transm Infect. 2012;88:51-57.PubMedCrossRef

70.

Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365:493-505.PubMedCrossRef

71.

Berkman LF, Glass T, Brissette I, Seeman TE. From social integration to health: Durkheim in the new millennium. Soc Sci Med. 2000;51:843-857.PubMedCrossRef

72.

Granovetter M. Getting a job. Cambridge: Harvard University Press; 1974.

73.

Wolitski RJ, Gomez CA, Parsons JT. Effects of a peer-led behavioral intervention to reduce HIV transmission and promote serostatus disclosure among HIV-seropositive gay and bisexual men. AIDS. 2005;19(Suppl 1):S99-S109.PubMedCrossRef

74.

Link BG, Phelan JC. Conceptualizing stigma. Annu Rev Sociol. 2001;27:363-385.CrossRef

75.

Castro A, Farmer P. Understanding and addressing AIDS-related stigma: From anthropological theory to clinical practice in Haiti. Am J Public Health. 2005;95:53-59.PubMedCrossRef

76.

Fafchamps M. Solidarity networks in preindustrial societies: Rational peasants with a moral economy. Econ Dev Cult Change. 1992;41:147-174.CrossRef

77.

Fafchamps M, Lund S. Risk-sharing networks in rural Philippines. J Dev Econ. 2003;71:261-287.CrossRef

78.

de Weerdt J, Dercon S. Risk-sharing networks and insurance against illness. J Dev Econ. 2006;81:337-356.CrossRef

79.

Reidpath DD, Chan KY, Gifford SM, Allotey P. ‘He hath the French pox’: Stigma, social value and social exclusion. Sociol Health Illn. 2005;27:468-489.PubMedCrossRef

80.

Neuberg SL, Smith SM, Asther T. Why people stigmatize: Toward a biocultural framework. In: Heatherton TF, Kleck RE, Hebl MR, Hull JG, eds. The social psychology of stigma. New York: The Guilford Press; 2000:31-61.

81.

Pryor JB, Reeder GD, Vinacco R, Kott TL. The instrumental and symbolic functions of attitudes towards persons with AIDS. J Appl Soc Psychol. 1989;19:377-404.CrossRef

82.

Katz D. The functional approach to the study of attitudes. Public Opin Quart. 1960;24:163-204.CrossRef

83.

Sears DO, Hensler CP, Speer LK. Whites’ opposition to “busing”: Self-interest or symbolic politics? Am Pol Sci Rev. 1979;73:369-384.CrossRef

84.

McConahay JB, Hough JC. Symbolic racism. J Soc Issues. 1976;32:23-45.CrossRef

85.

Goudge J, Ngoma B, Manderson L, Schneider H. Stigma, identity and resistance among people living with HIV in South Africa. SAHARA J. 2009;6:94-104.PubMedCrossRef

86.

Simoni JM, Mason HR, Marks G, Ruiz MS, Reed D, Richardson JL. Women’s self-disclosure of HIV infection: Rates, reasons, and reactions. J Consult Clin Psychol. 1995;63:474-478.PubMedCrossRef

87.

Marsden PV, Campbell KE. Measuring tie strength. Soc Forces. 1984;63:482-501.

88.

Marsden PV, Campbell KE. Reflections on conceptualizing and measuring tie strength. Soc Forces. 2012;91:17-23.CrossRef

89.

Berger BE, Ferrans CE, Lashley FR. Measuring stigma in people with HIV: Psychometric assessment of the HIV stigma scale. Res Nurs Health. 2001;24:518-529.PubMedCrossRef

Title: Internalized Stigma, Social Distance, and Disclosure of HIV Seropositivity in Rural Uganda
Authors: Alexander C. Tsai, MD, PhD
David R. Bangsberg, MD, MPH
Susan M. Kegeles, PhD
Ingrid T. Katz, MD, MHS
Jessica E. Haberer, MD, MS
Conrad Muzoora, MBChB, MMed
Elias Kumbakumba, MBChB, MMed
Peter W. Hunt, MD
Jeffrey N. Martin, MD, MPH
Sheri D. Weiser, MD, MPH
Publication date: 01-12-2013
Publisher: Springer US
Published in: Annals of Behavioral Medicine / Issue 3/2013
Print ISSN: 0883-6612
Electronic ISSN: 1532-4796
DOI: https://doi.org/10.1007/s12160-013-9514-6

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Internalized Stigma, Social Distance, and Disclosure of HIV Seropositivity in Rural Uganda

Abstract

Background

Purpose

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Purpose

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 3/2013

Cue-Induced Smoking Urges Deplete Cigarette Smokers’ Self-Control Resources

“Thinking Healthy” in Pregnancy: a Comment on Christian et al.

Cardiometabolic Risk in Adolescents: Associations with Physical Activity, Fitness, and Sleep—In Response to Kawada

Sleep Duration, Physical Activity, and Metabolic Syndrome for Adolescents

A Mindful Future for Fibromyalgia?: a Comment on Davis and Zautra

Factors Associated with Discontinuation of Bupropion and Counseling Among African American Light Smokers in a Randomized Clinical Trial