Literature Review on Effects of Hiv/aids Stigmatization on Patients

J Trop Med. 2009; 2009: 145891.

Stigma of People with HIV/AIDS in Sub-Saharan Africa: A Literature Review

Ngozi C. Mbonu

Department of Wellness Promotion, School of Public Wellness and Master Care CAPHRI, Faculty of Health, Medicine and Life Sciences, Maastricht University, P.O. Box 616, 6200 Doctor Maastricht, The Netherlands

Bart van den Borne

Department of Health Promotion, School of Public Health and Primary Care CAPHRI, Kinesthesia of Wellness, Medicine and Life Sciences, Maastricht University, P.O. Box 616, 6200 Medico Maastricht, The Netherlands

Nanne K. De Vries

Department of Health Promotion, Schoolhouse of Public Wellness and Primary Care CAPHRI, Kinesthesia of Health, Medicine and Life Sciences, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands

Received 2008 November 25; Revised 2009 May 3; Accustomed 2009 Jun xvi.

Abstract

The aim of this literature review is to elucidate what is known nigh HIV/AIDS and stigma in Sub-Saharan Africa. Literature nearly HIV/AIDS and stigma in Sub-Saharan Africa was systematically searched in Pubmed, Medscape, and Psycinfo up to March 31, 2009. No starting date limit was specified. The material was analyzed using Gilmore and Somerville'south (1994) four processes of stigmatizing responses: the definition of the problem HIV/AIDS, identification of people living with HIV/AIDS (PLWHA), linking HIV/AIDS to immorality and other negative characteristics, and finally behavioural consequences of stigma (distancing, isolation, discrimination in care). It was found that the cultural construction of HIV/AIDS, based on beliefs almost contamination, sexuality, and religion, plays a crucial role and contributes to the strength of distancing reactions and bigotry in club. Stigma prevents the commitment of effective social and medical care (including taking antiretroviral therapy) and also enhances the number of HIV infections. More than qualitative studies on HIV/AIDS stigma including stigma in wellness intendance institutions in Sub-Saharan Africa are recommended.

1. Introduction

Although the electric current data show that the global HIV/AIDS epidemic is stabilizing, statistics still report an unacceptably high level of infection and progress is uneven in many countries [1]. In 2007, approximately 33 meg people worldwide were infected with the human immunodeficiency virus (HIV) [1]. Sub-Saharan Africa remains the near affected region in the world and it is home to near 67% of all people living with HIV (an estimated 22.5 million [1]). In 2007, an estimated 1.seven million adults and children in this region became newly infected, while 1.6 meg died of acquired immune deficiency syndrome (AIDS).

People living with HIV/AIDS (PLWHA) face not merely medical bug but also social problems associated with the disease. One of the barriers to reaching those who are at risk or infected with HIV/AIDS is stigma [2]. Stigma enhances secrecy and denial, which are also catalysts for HIV transmission [3]. Although the reaction to PLWHA varies, with some PLWHA receiving support which positively affects them, HIV/AIDS stigma negatively affects seeking HIV testing, seeking intendance after diagnosis, quality of care given to HIV patients, and finally the negative perception and treatment of PLWHA past their communities and families, including partners [4, 5]. It isolates people from the customs and affects the overall quality of life of HIV patients [2, three, half-dozen, 7].

Currently, there is an increasing number of enquiry on HIV-related stigma in Sub-Saharan Africa. It is beingness increasingly acknowledged, withal, that effective treatment and care strategies require an agreement of the cultural context [6, 8] in which stigma exists. The aim of this literature review is to elucidate what is known about HIV/AIDS stigma in Sub-Saharan Africa, the origins and contents of stigma, contributing factors and the gender dimension of stigma.

two. Methodology

The analyses in this review newspaper were based on Gilmore and Somerville'south [9] classification of stigmatization in sexually-transmitted diseases, which for this paper was practical to the various factors that touch stigmatization of PLWHA.

3. Materials

Literature nearly HIV/AIDS stigma in Sub-Saharan Africa was systematically searched in Pubmed, Medscape, and Psycinfo upwards to March 31, 2009. No starting engagement was specified.

A first search in Medline, PsycInfo and Pubmed with "HIV/AIDS", "stigma" and "Africa" as key words gave 292 abstracts, of which 91 abstracts came from Medline, 57 from PsycInfo, and 144 from Pubmed; some other search with "HIV/AIDS", "discrimination" and "Africa" gave an additional 192 abstracts (Medline 73, PsycInfo 15, and Pubmed 104). A total of 484 abstracts were examined. From this list, papers relevant to the aim of this review were selected on the footing of their abstracts; uncertainties were reconciled through discussion with all the authors of this paper. The completeness of the search was checked by ways of the reference lists of reviewed articles. Books or volume capacity were included whenever applicable. Exclusion criteria included paper articles, campaign posters, manufactures not in the English language linguistic communication and articles not related to the topic. On the basis of this selection, 64 original manufactures were critically evaluated.

iv. Outcome Pick

HIV stigma every bit a phenomenon was considered to be the major topic of the review and was not limited to any geographical region. Although HIV/AIDS stigma is a general phenomenon which affects PLWHA in all parts of the world, in this paper, we focused on an analysis of the factors contributing to stigma identified from empirical studies in Sub-Saharan Africa, books, theoretical, and review papers. They include cultural constructions, stereotypes and specific beliefs, access to and the role of antiretroviral therapy, religion, and gender.

v. Results and Discussion

Effigy 1 shows the flow chart of the search results. A total of 64 articles were selected. Twenty of these articles were theoretical papers, review papers and articles on stigma non express to whatsoever geographical location while 45 articles were empirical studies from Sub-Saharan Africa. For the analysis of the contributing factors to HIV/AIDS stigma, 45 articles from empirical studies inside Sub-Saharan Africa were used. In addition, books, theoretical papers and review papers were also used. Table 1 shows the method, report objective, study population and country of report of these papers; 21 manufactures addressed origin and contents of stigma, xxx articles addressed cultural constructions of HIV, stereotypes and specific behavior, 25 articles addressed admission to and the role of ART, 16 articles addressed religion, 30 articles addressed gender and twenty manufactures addressed consequences of stigma.

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Table ane

Characteristics of the empirical studies used.

Number	Writer	Location number on reference list	Year of publication	Methods	Study objectives	Study population	State
i	Greeff et al.	[2]	2008	Qualitative research design focus group word	To increase understanding of disclosure equally a circumstance that is affected by HIV/AIDS stigma and bigotry	225	Five African countries (Tanzania, Kingdom of lesotho, S Africa, Swaziland, and Malawi)

two	Campbell et al.	[six]	2007	Qualitative research In-depth interview including focused group discussion	Study on complex interplay of psychological and social forces that drive HIV/AIDS stigma	120	South Africa

iii	Neville and Rubin	[7]	2007	Semistructured focused group word	Identity of typical targets of disclosure of positive sero-status, commonly used avenues for disclosure, motivations for disclosure and nondisclosure of sero-status	twoscore	Republic of kenya

4	Strebel et al.	[13]	2006	Interview and focus grouping word	Structure of gender identities and roles, how women and men understand gender-based violence and what they believe nearly links betwixt gender relations and HIV/AIDS risk	78	S Africa

5	Simbayi et al.	[16]	2007	Quantitative study	Examination of internalized AIDS stigmas among PLWHA	1063	South Africa

half-dozen	Wood and Lambert	[17]	2008	Participant observation, semistructured interview, focused group discussions	Description of family and community responses to HIV/AIDS epidemic: use of indirect communication	152	Due south Africa

7	Muula	[18]	2005	Theoretical review	What should HIV/AIDS be called in Malawi?		Malawi

8	Uys et al.	[19]	2005	Focus group discussion	Identification of terminology used to talk about HIV/AIDS and PLWHA	261	Five African countries (Lesotho, South Africa, Malawi, Swaziland, and Tanzania)

9	Visser et al.	[20]	2009	Questionnaire	Assessment of stigmatizing attitudes amongst members of a customs compared with perceived stigma within the community and the extent to which stigmatizing attitudes are afflicted by sociodemographic characteristics	1077	Southward Africa

x	Iwelunmor	[21]	2006	Focus group word	Family system responses to HIV and AIDS	204	South Africa

11	Ulasi et al.	[22]	2009	Questionnaire	Predictors of stigma and the perception of communities toward PLWHA	104	Ghana

12	Hartwig et al.	[23]	2006	Focused group discussion	A instance study providing insights into how some local church leaders view HIV stigma, and changes some of them take made in their own church leadership behavior	15	Tanzania

thirteen	Okoror et al.	[24]	2007	Focused group discussion	Role of food equally an instrument in expressing and experiencing stigma used by HIV-positive women and their families	249	South Africa

14	Otolok-Tanga et al.	[25]	2007	Semistructured interview	Exploration of Uganda-based key decision-makers well-nigh the by, nowadays and optimal future roles of faith-based organizations involved in HIV/AIDS work, including actions to promote or dissuade stigma and discrimination	150	Uganda

15	Chimwaza and Watkins	[26]	2004	Quantitative and interview	Focus on the caregivers' diagnoses of the illness of their patients, the type and duration of the care they provided, the support they received from relatives and other members of the community, and the extent to which caregiving was experienced as an emotional, physical and financial burden	15	Republic of malaŵi

16	Duffy	[27]	2005	Focused group discussion, interview	Perspective on HIV-related stigma	28	Republic of zimbabwe

17	Petros et al.	[28]	2006	Focus group discussion, interview	Exploring the concept and practice of "othering" in relation to HIV and AIDS today	418	Due south Africa

18	Kalichman et al.	[29]	2005	Questionnaire	Development of a brief measure of AIDS-related stigma that could be readily used in multiple settings and contexts	1371	Southward Africa

19	Plummer et al.	[thirty]	2006	Qualitative research (participant observation)	Examination of beliefs about general disease, STI and AIDS treatment practices	Participant observation	Tanzania

twenty	Muyinda et al.	[31]	1997	Qualitative enquiry (in-depth interview)	Noesis, attitudes and practices of families caring for PLWHA in relation to stigma-related conditions	127	Uganda

21	Hatchett et al.	[32]	2004	Qualitative research (interview)	Exploration of traditional and mod wellness-seeking in Malawi	46	Malawi

22	Thorsen et al.	[33]	2008	Qualitative enquiry (interview, nonparticipant observation)	Potential facilitation of stigmatization through inadvertent disclosure of HIV + status via PMTCT program components and attributes	42	Republic of malaŵi

23	Daniel and Oladapo	[34]	2006	Quantitative study (questionnaire)	Assessment of acceptability of prenatal HIV screening amidst pregnant women attending primary healthcare centres in a suburban population	333	Nigeria

24	Hutchinson and Mahlalela	[35]	2006	Quantitative (survey data using questionnaire)	Examination of patterns and determinants of use of VCT services	3374	South Africa

25	Nyblade et al.	[36]	2001	Quantitative (questionnaire), laboratory and counselling data	Assessment of self-selection in those who chose to participate in VCT and those who chose not to participate in the showtime-up phase of a long-term VCT plan	ten 950	Uganda

26	Maedot et al.	[37]	2007	Case command report	Identification of factors that make up one's mind VCT uptake among pregnant women attending ANC services	402	Ethiopia

27	Kalichman and Simbayi	[38]	2003	Quantitative inquiry (venue intercept study)	Exam of the human relationship between HIV testing, history, attitudes toward testing and AIDS stigma	500	South Africa

28	Nachega et al.	[39]	2005	Quantitative enquiry (questionnaire)	Investigation of noesis, attitudes, beliefs and practices of PLWHA regarding HIV/AIDS and ART in an HIV outpatient clinic	105	South Africa

29	Turan et al.	[40]	2008	Qualitative research (in-depth interview)	How HIV-related fears may bear on where women deliver and the difficulties motherhood workers confront caring for HIV-positive women with unknown HIV condition	37	Kenya

30	Orner et al.	[41]	2008	Qualitative inquiry (focused group discussion, in-depth interview)	Exploration of perceptions and experiences of PLWHA of reproductive age in relation to HIV/AIDS care and treatment	viii	S Africa

31	Akani and Erhabor	[42]	2006	Quantitative enquiry (questionnaire)	Evaluation of rate, patterns, barriers to HIV sero-status disclosure	187	Nigeria

32	Blackstock	[43]	2005	Narrative case study	Curing stigma—the limits of antiretroviral access	1	Ghana

33	Kayombo et al.	[44]	2005	Qualitative enquiry (interview)	Role of traditional healers in supporting orphans, how they get the orphans, the basic needs they can provide, techniques used for psychosocial support and problems encountered when taking the orphans	25	Tanzania

34	Mshana et al.	[45]	2006	Qualitative research (focused group give-and-take, interview)	Place and mitigate barriers to seek ART betwixt the stages of testing for HIV and enrolling in the new government Fine art program	18	Tanzania

35	Campbell et al.	[46]	2005	Qualitative inquiry (focused grouping give-and-take, interview)	Identification of forms taken by stigma and its effects; identification of material, symbolic and contexts associated with stigmatisation of PLWHA	99	South Africa

36	Thomas	[47]	2006	Qualitative research (interview, diaries)	Exploration of how affliction, the daily and long-term duties of caring among a sample of households in the Caprivi region	12	Namibia

37	Skinner and Mfecane	[48]	2004	Qualitative research (focused group give-and-take, interviews)			South Africa

38	Amuyunzu-Nyamongo et al.	[49]	2007	Quantitative (survey) and qualitative (in-depth interview)	Test of complex human relationship between gender, poverty, susceptibility to HIV and vulnerability to AIDS through drawing on the lived experiences of infected women and exploring the coping strategies they adopt; how the specific conditions of informal settlements influence these challenges and support mechanisms	390 (survey) xx (interview)	Kenya

39	Factory	[fifty]	2003	Qualitative research (in-depth interview, focused group word)	Findings related to breaking the news of HIV infection to women and their maintenance of secrecy following diagnosis	56	Ghana

forty	Antelman et al.	[51]	2001	Quantitative research	Examination of sociodemographic and behavioral factors predictive of an HIV-positive test upshot	1078	Tanzania

41	Maman et al.	[52]	2001	Qualitative research (interview)	Presentation of individual, relational and environmental factors that influence the decision to test for HIV-1 and to share test results with partners	62	Tanzania

42	Ndinya-Achola et al.	[53]	1995	Quantitative research	The correct not to know HIV test upshot later existence tested	5274	Republic of kenya

43	Sanjobo et al.	[54]	2008	Qualitative inquiry (interview, focus group give-and-take)	Exploration of patients' and health intendance professionals' perceived barriers to and facilitation of patients' adherence to Art	72	Republic of zambia

44	Ncama et al.	[55]	2008	Quantitative research	Test of characteristics related to social support and antiretroviral medication adherence	149	Due south Africa

45	Weiser et al.	[56]	2006	Quantitative research	Cess of knowledge of and attitudes toward routine testing in Botswana with a focus on human rights concerns related to policy; factors associated with whether respondents had heard of routine testing and had positive attitudes toward the policy; the prevalence and correlations of HIV testing, barriers to and facilitation of testing and reported experiences of testing 11 months afterwards introduction of routine testing	1268	Botswana

6. Origin and Content of Stigma

Etymologically, the concept of "stigma" derives from a Greek word referring to a tattoo mark. Information technology generally has two meanings. Ane derived from Christianity and denotes bodily marks which resemble those of the crucifixion of Jesus Christ—they are attributed to divine favour. The 2d significant is secular, namely marks of disgrace, discredit, or infamy [9]. Today, the term "stigma" is applied more to social disgrace than to whatsoever actual signs [10]. Stigma is generally recognized equally an "aspect that is deeply discrediting" that reduces the bearer "from a whole and usual person to a tainted, discounted one" [11]. Stigma is as well used to ready the affected persons or groups apart from the normalized social club ("u.s.a." against "them") and this separation implies devaluation [2, 9, 12, 13]. HIV stigma is shaped not only by individual perceptions and interpretations of microlevel interactions but also by larger social and economical forces [6]. Information technology is a social construct, which has significant impact on the life experiences of individuals both infected and afflicted by HIV [14]. Stigma includes prejudice and tin lead to active discrimination directed toward persons either perceived to be or really infected with HIV and the social groups and persons with whom they are associated [15]. Since not all stigmatizing attitudes upshot in overtly discriminatory behaviors, Campbell et al. [vi] described discrimination as negative behavior and stigmatization as any negative thoughts, feelings, or actions toward PLWHA irrespective of whether people are discriminated because they know that they are devalued. In other words, discrimination has to exist acted out externally while stigmatization can be overt or constitute libel, slander, or defamation of persons who are stigmatized [9].

Stigma can exist external or internal [3]. External stigma refers to the actual experience of bigotry [57]. Internal stigma (felt or imagined stigma) is the shame associated with HIV/AIDS and PLWHAs' fear of being discriminated against [2, 58]. Internal stigma is a powerful survival mechanism aimed at protecting oneself from external stigma and often results in thoughts or beliefs such every bit the refusal or reluctance to disclose a positive HIV status, denial of HIV/AIDS and unwillingness to accept aid [ii, 7, 16, 17]. This commonage public denial in societies is reflected by avoidance of mentioning any terminal illness including HIV/AIDS, a demand to proceed hope alive for therapeutic success, stigma fastened to HIV/AIDS, and unwillingness to face matters related to sexuality [17]. Many authors have theorized and produced models of stigmatization, but this newspaper volition utilise Gilmore and Somerville's [9] categorization of stigmatization in sexually transmitted diseases. They argued that whatsoever stigmatizing response has at least 4 processes [ix].

The problem. The problem (in the context of this paper, HIV/AIDS) which Goffman [11] describes as the discredited attribute and Link and Phelan [59] draw in the component of conceptualizing stigma equally distinguishing and labellizing, has to be such that the response in some mode permits the stigmatizer to be spared, saved, or gives power to command the problem.
Identification of the person or group who are targeted for stigmatization. This ways PLWHA must be recognizable and therefore accept some identifying characteristics that can be used to recognise them correctly or erroneously, for example, loss of weight, skin rash, so along [2, 7, viii, 17–19, threescore]. This process was also described past Link and Phelan [59] in the component of conceptualizing stigma as distinguishing and labellizing.
Application of stigma to the target person. Hither specific persons are labelled with stigma. The stigma and the negative characteristics associated with it are perceived equally belonging to them, for example, someone who is stigmatized is perceived as immoral [2, half-dozen, 20]. This co-ordinate to Link and Phelan [59] in the component of conceptualizing stigma relates to negative stereotyping.
The outcome is usually a response to the stigmatized person such that they are distanced, disempowered or controlled by the stigmatizer. In this process, at that place is a change in the relationship or interaction between stigmatizer and the stigmatized [6].

In this literature review these four processes of stigmatization will be illustrated in an analysis of the various factors that affect HIV/AIDS stigma.

vii. Factors in HIV/AIDS Stigma

Everywhere HIV/AIDS has been accompanied by stigma and discrimination but stigma in Sub-Saharan Africa seems to exist particularly mutual [2, 7, 55]. What happens to i person concerns the whole community [2, 3, vi, seven, 17, 21, 22, 61]. The communal life in itself poses a dilemma because, on the one hand, information technology can bring about stigmatization when PLWHA are not able to interact owing to fearfulness of existence exposed [ii, half-dozen, thirteen, 17, 21, 23, 48, 55], but, on the other paw, communal life too ensures help and intendance for ill people [2, 6, seven, 21, 22, 24]. Information technology is important to empathize how stigma is used past individuals and communities, in cultures where communal life is common, to produce and reproduce inequality [62]. Stigmatization is function of a bourgeois reassertion of power relations, poverty, or moral authority resting on the ability to command sexuality [6]. Considering PLWHA are labelled as the "other" by the community, people try to secure the social structure, safety and solidarity past casting out offenders or reaffirming societal values [9]. PLWHA are assumed non to be able to contribute to the societal evolution [2]. For instance, some studies show that women will non disembalm their HIV status to avert being isolated from participating in the sociocultural attribute of food preparation since food is regarded as an expression of support and credence [21, 24], or people refuse to buy food from PLWHA [16]. Other studies show that family members of a person who died of HIV/AIDS or family unit members who live with PLWHA are stigmatized; therefore family members encourage PLWHA to remain silent to avoid social rejection [17, 22]. In some instances, receiving food assistance from the authorities too enhances a perception of difference from other members of the community since it is assumed that just PLWHA are offered such support in a customs where about everybody is poor and needs back up [2, 57]. People from highly collectivist communities are more likely to be concerned with harmony and equality in the group [7]. We also need to further understand whether stigma is more or less likely to manifest itself in cultures with an extensive communal life and how stigma finds its origins in subcultural behavior, religion, or individually conceived causal processes [vi, 17, 63].

Factors that seem to mediate stigma include:

cultural constructions, stereotypes and specific beliefs,
admission to and the office of antiretroviral therapy,
organized religion,
gender.

eight. Cultural Constructions of HIV, Stereotypes and Specific Beliefs

The clan with specific sexual behavior that is considered socially unacceptable by many people contributes to the stigma associated with HIV infection [six, 17, 22, 25]. HIV/AIDS provides an example of how disease, despite the biological characteristics of its signs and symptoms, e'er carries a second reality expressed in cultural images and metaphors [eight–10, 17, 19, 26, 61]. Campbell et al. argue that fifty-fifty when Fine art is available and the outcome of HIV/AIDS not ever fatal, the link betwixt HIV/AIDS and bad (sexual) behavior is notwithstanding a business organization for PLWHA because of shame and embarrassment [half-dozen]. The second and third processes (identification and linking to immorality) apply here. Fears associated with illness, disease and sex activity therefore need to exist viewed in their broader social and cultural context [six, 64]. To illustrate the unacceptability associated with the disease, terms such as "a long illness" or "a short illness" are deemed culturally acceptable in the obituary of someone who dies from HIV/AIDS rather than mention of the real cause of decease [2, 17, twenty, 27, 61]. There is likewise reluctance to mention the name "AIDS" while the illness is ongoing [half dozen, xix, 26]. This procedure can be a style of denying HIV/AIDS or simple avoidance of explicitness or specificity as a way of coping with the serious threat of HIV/AIDS [ii, vi, 13, 17, 19, 23]. Since club acts strongly confronting threats to tangible assets such as life, rubber, property or values, it tries to sanctify the trouble to protect its self-identity or reduce the negative outcome [9]. The 4th process (distancing, disempowerment or control) apply here. The practise of indirection has also been noted in areas exterior HIV/AIDS, such as the use of coded linguistic communication in relation to certain subjects in the presence of children [6, 17]. Furthermore, mentioning HIV/AIDS can be viewed as disrespectful to the deceased [vi, 61]. In some cases, acknowledging the decease of a relative as due to AIDS could put the family at risk of losing the financial benefits from insurance companies since some insurance companies may not pay out benefits resulting from expiry due to AIDS [61]. However non acknowledging the crusade of death to insurance companies tin can be viewed every bit a moral risk thereby complicating the rights of dead persons who are seen as vulnerable [61]. Furthermore, in a qualitative written report in Zimbabwe, denial and miss-attributions of HIV/AIDS causes (e.1000., witches, unhappy ancestors, etc.) were common [27]. Less than exact terms are also used by people, including health care professionals [27], to describe HIV/AIDS to avoid insensitivity to culturally sensitive issues but non necessarily denying HIV/AIDS: for example, wellness care professionals in Malawi calling it ELISA disease, immunosuppression, and then forth, or lay people calling it Kaliwondewonde (slim illness), Ntengano (the disease that leads to wife and married man dying together or one later on the other) [61] or other indirect descriptions [vi, 17, 27]. Denial is also a way of reinforcing that HIV/AIDS is a disease of others not of the self [28] and one of the means people as individual, group or society respond to a frightening or intolerable situation [nine]. This fits with the first and second processes.

HIV/AIDS is stigmatizing because it carries many symbolic associations with danger. Attribution of contamination, incurability, immorality and punishment for sinful acts is common in many societies [half dozen, 9, x, 16, 19, 22, 25]. In terms of the 3rd process, whatsoever person diagnosed with HIV is perceived to be immoral. Quam [65] argues that beliefs about AIDS as a "polluted disease" reflect people's negative evaluations of the routes through which HIV enters the body. Sexually-transmitted infections are considered to be agents of contagion or pollution in a study about HIV/AIDS prevention among African traditional healers [29]. This polluting quality of AIDS and fear of the disease are translated into stigmatizing responses such every bit avoidance and isolation which is where the fourth process applies (distancing).

Self-diagnosis and self-handling remain widespread [26, 30] attributable to stigmatization. The pursuit of different therapeutic options is sometimes a issue of the problematic social complexity linked to AIDS [17]. Witches and witchcraft remain an option for self-diagnosis of illnesses [23, 26] too as for diagnosis by traditional healers [6]. This fits with the showtime and second processes. Commonly, people say that HIV/AIDS hides behind witchcraft since information technology is more culturally acceptable and it avoids personal shame [27]. People prefer to merits that they are bugged or have (normal) tuberculosis rather than accept that they accept HIV/AIDS [6, 17, 31, 32].

Stigmatization is a stereotyping response to negatively perceived characteristics of a person or group [16]. The stereotyped individuals, the context of this paper, are PLWHA; they often look, act or alive differently and do not fit into the societal norms [9]. Every bit regards to the second process, identification of PLWHA, and the third process, linking HIV/AIDS to immoral behavior, the dissimilar languages used to describe PLWHA transport clear messages [3, nineteen]. Examples are equally follows: he is a walking corpse [iii] or Kakokoolo (scarecrow), or Kamuyoola (was defenseless in a trap) in Uganda [31] and ashawo (prostitute) in Nigeria. An private's past social history may also exist recalled to justify why they have AIDS [31]. PLWHA are seen as a reflection of evil and sin, leading to powerful stigma confronting those who have contracted the disease. In a study carried out in Tanzania, a distinction between "truthful" AIDS and "faux" AIDS emerged, of which the onetime is more stigmatized and regarded as more hopeless than the latter, which is attributed to malice such every bit witchcraft [thirty]. Fear of stigma limits the efficacy of HIV-testing programs across Sub-Saharan Africa [33–35] because in most communities anybody knows sooner or later who visits test centers [31, 36]. The procedure of identification applies here. For some individuals, not knowing one's HIV sero-status is far preferable for being tested. For case, a written report carried out in Botswana on attitudes, practices and human being correct concerns of routine VCT showed that 33% of the respondents did non get for voluntary counseling and testing (VCT) considering a positive HIV test effect volition force them to stop some of their sexual practices [56] The belief is that information technology is better to endure the affliction quietly and hidden than to find out through HIV testing, because of the stigma associated with receiving a positive test effect, in addition to the feeling that "what yous don't know can't damage yous" [48].

9. Admission to and the Role of Antiretroviral Therapy

Although admission to antiretroviral therapy (ART) has increased more than tenfold in low- and middle-income countries including Sub-Saharan Africa in the concluding six years [66], reaching the potential beneficiaries has been hard, as the PLWHA do not identify themselves to the medical professionals [37, 56]. Individuals who were non tested for HIV demonstrated significantly greater AIDS-related stigmas ascribing greater shame, guilt and social disapproval to PLWHA [38, 56]. Studies take shown that many Sub-Saharan Africans are reluctant to disclose their HIV status even when they have already gone for VCT; moreover, those who practice disembalm information technology are selective in choosing their audition [2, 6, seven, xiii, 21, 39–41, 57]. In a study carried out in the Niger Delta, Nigeria, 23% of the PLWHA respondents had not disclosed their status, while of the 77% who had disclosed their status, 22.3% disclosed it to parents, nine.vii% to siblings, 27.8% to pastors, 6.3% to friends, ten.4% to family members and 23.6% to sexual partners [42]. The first and second processes (HIV/AIDS as a problem and identification) apply here. Fears of stigmatization, of victimization, of confidants spreading the give-and-take, of accusation, of infidelity, and of abandonment were all noted to be barriers to disclosure. Like findings resulted from a study carried out in Cape Town, South Africa which showed that nearly one in 4 participants never talked with a friend nearly their HIV status [xvi]. Nonetheless a unlike written report showed that respondents who personally knew someone infected with HIV or AIDS tended to report less stereotypical and less discriminatory attitudes, fewer feelings of discomfort and less intolerant attitudes [4]. Attempts to talk over HIV make many people withdraw or feel that the discussion should exist discontinued. Some of them come upwardly with questions about the very existence of HIV [half-dozen, 56]. Evidence also shows that noninfected people intentionally distance themselves from PLWHA [67].

A study carried out in Ghana showed that fifty-fifty though PLWHA regain their force with Art and the physically devastating consequence of HIV/AIDS is tempered, they still face up psychological isolation and condemnation from their family, friends and society [43] because people around them are enlightened of their HIV condition. This is linked to the beginning, 2d and 4th processes. Some other problem PLWHA face is that combinations of health-seeking strategies make information technology difficult to know the effectiveness of ART [44]. Many stop taking Art when the symptoms are gone and resort to traditional medications. In a report in Tanzania, many people consult both traditional and medical facilities when faced with AIDS [30]. Traditional healers are accessible, affordable and culturally acceptable [44]. They are at the grass-roots level with sufferers and can provide psychosocial support [44].

ART has also been shown to be less effective when initiated in someone with advanced disease [68] and so delay in intendance seeking should be avoided. Autonomously from the medical benefits, in that location are also psychosocial benefits associated with seeking treatment. PLWHA who opt for an ART program can have comfort from participating because they get counselling from professionals trained to handle the psychosocial problems [41, 45]. Ironically, widespread utilise of Fine art may decrease transmission concerns [2] and increase risky behaviors [69, 70]. Patients and their partners may believe that considering their viral load is undetectable and they feel and so much amend, the virus is absent or dead and they are incapable of transmitting HIV to others [thirty, 69]. Their motivation to continue rubber use or other risk reduction behaviors wanes [lxx].

10. Faith

In Sub-Saharan African, many people are religious [vii, 17, 22, 28]. Religious institutions accept been documented as playing both supportive and detrimental roles toward PLWHA [6, 7, 21, 23, 46]. Religious leaders have the possibility as any other leaders in position to exist tempted to practise power over others [3, 6]. I of the strategies used by some churches to regain their lost moral authority is vigorously linking sexual transgressions and AIDS with sin and immorality [46, 47]. The tertiary procedure (linking to immorality) applies hither. AIDS has been targeted by some religious groups in gild to enhance their own behavior, morality and credo [nine, 28]. This is because sexual activity is both biological and socially-constructed behavior which reflects and can claiming stiff public and private religious, cultural and political values [25, 46, 71]. The religious approach warrants stigmatizing people as "saved" or "sinner", "pure" or "impure", "us" or "them", and it strengthens the broader social stratifications within which stigma flourishes [3, 7, nine, 23, 25]. The 4th process applies here, where PLWHA are distanced, disempowered or controlled. In Zambia, churches sometimes impose mandatory HIV testing before allowing wedlock and individuals with HIV have been excommunicated from churches because they were deemed "sinners" [6, 61]. It is also hard to find people openly critical of the religious authorities. At the aforementioned fourth dimension, many people living with HIV/AIDS express faith and organized religion as important in coping with HIV. Religion gives people the opportunity to accept that they are incorrect but through prayer afterwards to take hope that they are forgiven and volition go to a better place afterwards death [47]; this comfort is in addition to the care and support they get, which have increased [2, 7, 21, 23, 25, 49]. Such spiritual locus-of-control beliefs are important [two]. Consultative dialog betwixt PLWHA and religious leaders is pivotal to a successful faith-based HIV intervention [25].

11. Gender Problems in HIV in Africa

Stigmatization has been linked with power [6, 9, 62]. In Sub-Saharan Africa, women are traditionally expected to conduct children, melt for the family [24, 28] and submit to the sexual desires of their husbands [6, 13]. Gender inequality is one of the main influential factors in women'due south inability to protect themselves [6, 27, 49]. Many cultures consider ignorance of sexual matters as a sign of purity, making women reluctant to seek reproductive health information and services [six, 46, 72]. Several means of transmission of HIV have been recognized, but in Africa manual past heterosexual contact is by and large understood to be the cause [6, seven, 13, 22, 33, 60]. People believe that infection must issue from indecent sexual behavior [ii, six, 17, xix, 20, 28]. The third process applies here.

Gild is more intolerant of females living with HIV/AIDS than of their male counterparts [13, 16, 27, 35]. A study carried out in Kenya shows that 56% of women are ordinarily viewed to exist targets of stigma compared with 12% of men [49]. Much of the social control over women's movements, voice and opportunities is based on the belief that they will become promiscuous if granted too much freedom and this could lead to contamination of the patriarchal lineage [27]. PLWHA have become scapegoats generally [9], only females feel an added intensity of this phenomenon, a double stigma with a bigger social disadvantage [half dozen, xiii, 27]. Women are frequently blamed as vectors of HIV transmission, although reverse to the factual procedure [3, 28, 31]. Most societies in Africa expect their women to be monogamous but expect men to have extramarital affairs [13, 23, 72] or to exist polygamous [6, xiii]. Yet a woman's monogamy does not protect her from the infection if her spouse has other sexual partners [72]. This gender aspect is even stronger in Sub-Saharan Africa because most women are dependent on their husbands for nutrient, shelter and clothing [13, 57]. In terms of all 4 processes, many women refrain from testing and (if positive) would rather conceal their status. A study carried out in Ghana showed that secrecy affected women's access to treatment, and fiscal and emotional support from families [50]. The principal reasons for not disclosing HIV status were fearfulness of stigma and divorce [49, 51], fright of losing confidentiality [51], women's depression decision-making power, communication patterns betwixt partners and male person partners' mental attitude to voluntary counselling and testing (VCT) [52]. In line with the female person's sex activity function she may not insist on condom use when a partner refuses which is important for prevention and spread of HIV infection [51, 72]. Studies have shown that women who share HIV examination results with their partners may experience a range of reactions from support and agreement to accusations, discrimination, concrete violence and abandonment [2, vii, 21, 24, 49, 52, 53] This relates to the fourth process which is distancing, disempowerment or control. Therefore, a woman exhibiting the independence needed to protect her health risks the condemnation from her family and of the community [3]. Although the bulk of the studies show female stigmatization, a study carried out in South Africa [16] showed that men were more than likely than women never to have discussed AIDS with friends, more likely to have been treated differently since testing, more likely to report experiencing internalized stigma, and more than probable to have suffered loss of a place to stay or job owing to AIDS. Part of the explanation for this could be the fact that men are more likely to take been working earlier the sickness and are primarily responsible for providing shelter [xiii, 16].

12. Consequences of HIV/AIDS Stigma and Discrimination

Stigmatization tin can have many consequences for PLWHA and people affected past HIV/AIDS [6, 22, 47]. Some of the consequences of HIV/AIDS stigma include lower uptake of maternity wellness services by women, fearfulness of health workers getting infected and less provision of wellness care workers' services because they take into business relationship the HIV status of patients [37, 40, 45]. There is also a serious implication for prevention considering people do non want to go for VCT [ii, 27, 56] and even those people who go for testing exercise not disclose their HIV condition to their sexual partners attributable to HIV/AIDS stigma [53] and are more probable to engage in sexually-transmitted risk behaviors and this has implications for the spread of HIV/AIDS [9, 27]. Conversely, when PLWHA are shown compassion, they are likely to accept protective precautions in sexual behavior [six] and be more open about their HIV status [2]. Some spouses end up knowing of their positive HIV long after their partners are dead because they were not informed [7]. Stigma too has ongoing effects on the adherence to Art by PLWHA thus affecting their quality of life and increasing complications [2, 6, 39, 54–56]. It also leads to collective public denial of HIV/AIDS, which does not aid to reduce the HIV/AIDS infection and does not aid in fighting stigma [half dozen, 17, 46]. Information technology worsens the stress PLWHA alive with, equally they are forced to be silent nigh their condition, which on its ain is crushing [ii, 21, 41, 43] especially for people who need to continue their source of livelihood by keeping their jobs [2]. It affects access to social support networks either within PLWHA that will assistance their psychology, sharing of experiences [2, six, 55] or from authorities that tin offer them food supplements to improve their health or from their family unit as well as from their communities [21, 43, 46]. It hampers HIV-prevention and promotional efforts as people may not be willing to attend the educational programs aimed at reducing the spread of HIV/AIDS.

13. Conclusion

Although current literature shows that stigma in some countries, for instance, the Republic of Due south Africa, has started to pass up over the years [13, 16], especially when it involves a close relative [33], it nevertheless is highly nowadays [20, 22, 27, 31, 43, 55, 61]. This review was based on a systematic compilation and evaluation of literature on HIV/AIDS stigma in Sub-Saharan Africa. Detailed evaluation became possible owing to selected literature of sufficient quality and the number of publications bachelor in Pubmed, Medscape and Psycinfo. At the same fourth dimension, this implies a articulate brake. Papers on HIV/AIDS not related to stigma were non considered.

Despite the electric current progress of good prognostic wellness outcomes for HIV/AIDS, the Sub-Saharan African response still stands at a crossroads. In this paper, we debate that cultural constructions of HIV/AIDS, based on behavior about contagion, sexuality and organized religion, play a crucial role and contribute to the forcefulness of distancing reactions and discrimination in Sub-Saharan Africa past enhancing inequality. The public denial of HIV/AIDS is real and stems from a cultural undertone with a view which allows the pursuit of unlike handling options, although deprival on its ain can be relative because it tin be a way of coping with the disease while withal acknowledging its being. Deprival tin can too be farther enhanced when the PLWHA exercise not bear witness some of the manifestations generally associated with HIV/AIDS by the customs such as weight loss especially those on Fine art every bit people do not believe that they have HIV/AIDS even when they disembalm their HIV condition [2].

PLWHA experience stigma throughout their lifetime. Bug of stigma, discrimination and deprival are yet poorly understood and often marginalized within national and international programs and responses [27, 62]. Stigma prevents the delivery of constructive social and medical care, enhances the number of HIV-infections and diminishes the public wellness furnishings of ART because PLWHA are not able to collaborate with their families and the communities which is supposed to make them feel complete and be a part of the order.

The identification of HIV patients poses a problem, considering people try to hide the affliction simply perceivers assume that people accept HIV if they are sicker than normal. Linking HIV/AIDS to immorality is common considering of religious practices and a culture of repose. This could be remedied past instituting programs that permit people to hash out sexuality based on their cultural norms and beliefs during which some of the myths surrounding HIV/AIDS can be corrected. Putting people in touch with individual and commonage strength is a central strategy to mobilizing them in such circuitous issues such as stigma [2, vi, 43, 46]. More qualitative studies are needed in Sub-Saharan Africa on HIV/AIDS for better understanding of stigma given that stigma regarding HIV/AIDS is rooted in local beliefs, religion and gender.

Acquittance

The authors thank the anonymous reviewers for their helpful comments on the paper.

References

2. Greeff M, Phetlhu R, Makoae LN, et al. Disclosure of HIV status: experiences and perceptions of persons living with HIV/AIDS and nurses involved in their care in Africa. Qualitative Wellness Inquiry. 2008;18(three):311–324. [PubMed] [Google Scholar]

3. Rankin WW, Brennan South, Schell E, Laviwa J, Rankin SH. The stigma of existence HIV-positive in Africa. PLoS Medicine. 2005;2(viii):p. e247. [PMC free commodity] [PubMed] [Google Scholar]

4. Gerbert B, Sumser J, Maguire BT. The impact of who you know and where you live on opinions almost AIDS and health care. Social Science and Medicine. 1991;32(6):677–681. [PubMed] [Google Scholar]

five. Herek GM, Glunt EK. An epidemic of stigma: public reactions to AIDS. American Psychologist. 1988;43(eleven):886–891. [PubMed] [Google Scholar]

vi. Campbell C, Nair Y, Maimane S, Nicholson J. 'Dying twice': a multi-level model of the roots of AIDS stigma in two South African communities. Journal of Health Psychology. 2007;12(three):403–416. [PubMed] [Google Scholar]

7. Miller AN, Rubin DL. Factors leading to self-disclosure of a positive HIV diagnosis in Nairobi, Republic of kenya: people living with HIV/AIDS in the Sub-Sahara. Qualitative Health Enquiry. 2007;17(5):586–598. [PubMed] [Google Scholar]

eight. Goldin CS. Stigmatization and AIDS: critical issues in public wellness. Social Science and Medicine. 1994;39(ix):1359–1366. [PubMed] [Google Scholar]

ix. Gilmore N, Somerville MA. Stigmatization, scapegoating and discrimination in sexually transmitted diseases: overcoming 'them' and 'us' Social Science and Medicine. 1994;39(9):1339–1358. [PubMed] [Google Scholar]

10. Hardon A, Boonmongkon P, Streefland P, et al. Applied Health Enquiry Manual Anthropology of Wellness and Wellness Care. The Netherlands: The Hague: CIP-Data, Koninklijke Bibliotheek; 1995. [Google Scholar]

11. Goffman Eastward. Stigma: Notes on the Management of Spoiled Identity. New York, NY, Usa: Simon and Schuster; 1963. [Google Scholar]

12. Mawar Northward, Saha S, Pandit A, Muhajan U. The 3rd stage of HIV pandemic: social consequences of HIV/AIDS stigma & discrimination & future needs. Indian Periodical of Medical Research. 2005;122(6):471–484. [PubMed] [Google Scholar]

13. Strebel A, Crawford M, Shefer T, et al. Social constructions of gender roles, gender-based violence and HIV/AIDS in 2 communities of the Western Cape, Southward Africa. SAHARA. 2006;3(iii):516–528. [PubMed] [Google Scholar]

14. Taylor B. HIV, stigma and health: integration of theoretical concepts and the lived experiences of individuals. Journal of Avant-garde Nursing. 2001;35(five):792–798. [PubMed] [Google Scholar]

16. Simbayi LC, Kalichman S, Strebel A, Cloete A, Henda North, Mqeketo A. Internalized stigma, discrimination, and depression among men and women living with HIV/AIDS in Cape Town, South Africa. Social Science and Medicine. 2007;64(9):1823–1831. [PMC free article] [PubMed] [Google Scholar]

17. Wood K, Lambert H. Coded talk, scripted omissions: the micropolitics of AIDS talk in South Africa. Medical Anthropology Quarterly. 2008;22(3):213–233. [PubMed] [Google Scholar]

xviii. Muula As. What should HIV/AIDS be called in Malawi? Nursing Ethics. 2005;12(2):187–192. [PubMed] [Google Scholar]

19. Uys L, Chirwa M, Dlamini P, et al. "Eating plastic,", "Winning the lotto,", "Joining the www"... descriptions of HIV/AIDS in Africa. Journal of the Association of Nurses in AIDS Intendance. 2005;16(iii):xi–21. [PubMed] [Google Scholar]

20. Visser MJ, Makin JD, Vandormael A, Sikkema KJ, Forsyth BWC. HIV/AIDS stigma in a Southward African community. AIDS Intendance. 2009;21(2):197–206. [PMC free article] [PubMed] [Google Scholar]

21. Iwelunmor J, Airhihenbuwa CO, Okoror TA, Brownish DC, Belue R. Family systems and HIV/AIDS in South Africa. International Quarterly of Community Wellness Pedagogy. 2006;27(4):321–335. [PMC free article] [PubMed] [Google Scholar]

22. Ulasi CI, Preko PO, Baidoo JA, et al. HIV/AIDS-related stigma in Kumasi, Ghana. Health and Place. 2009;fifteen(1):255–262. [PMC free article] [PubMed] [Google Scholar]

23. Hartwig KA, Kissioki S, Hartwig CD. Church leaders face up HIV/AIDS and stigma: a example study from Tanzania. Journal of Community and Applied Social Psychology. 2006;16(6):492–497. [Google Scholar]

24. Okoror TA, Airhihenbuwa CO, Zungu Chiliad, Makofani D, Brown DC, Iwelunmor J. "My mother told me i must not cook anymore"—food, civilisation, and the context of HIV- and aids-related stigma in three communities in S Africa. International Quarterly of Community Wellness Teaching. 2007;28(3):201–213. [PMC free article] [PubMed] [Google Scholar]

25. Otolok-Tanga Due east, Atuyambe L, Murphy CK, Ringheim KE, Woldehanna South. Examining the actions of faith-based organizations and their influence on HIV/AIDS-related stigma: a example report of Uganda. African Health Sciences. 2007;7(ane):55–60. [PMC free article] [PubMed] [Google Scholar]

26. Chimwaza AF, Watkins SC. Giving care to people with symptoms of AIDS in rural Sub-Saharan Africa. AIDS Care. 2004;sixteen(7):795–807. [PubMed] [Google Scholar]

27. Duffy L. Suffering, shame, and silence: the stigma of HIV/AIDS. Journal of the Clan of Nurses in AIDS Intendance. 2005;16(1):thirteen–twenty. [PubMed] [Google Scholar]

28. Petros G, Airhihenbuwa CO, Simbayi L, Ramlagan S, Chocolate-brown B. HIV/AIDS 'othering' in South Africa: the arraign goes on. Culture, Wellness and Sexuality. 2006;viii(ane):67–77. [PubMed] [Google Scholar]

29. Kalichman SC, Simbayi LC, Jooste Southward, et al. Development of a brief calibration to measure AIDS-related stigma in S Africa. AIDS and Behavior. 2005;9(2):135–143. [PubMed] [Google Scholar]

thirty. Plummer M, Mshana G, Wamoyi J, et al. 'The man who believed he had AIDS was cured': AIDS and sexually-transmitted infection treatment-seeking behaviour in rural Mwanza, Tanzania. AIDS Care. 2006;18(v):460–466. [PubMed] [Google Scholar]

31. Muyinda H, Seeley J, Pickering H, Barton T. Social aspects of AIDS-related stigma in rural Uganda. Health and Identify. 1997;iii(3):143–147. [PubMed] [Google Scholar]

32. Hatchett LA, Kaponda CPN, Chihana CN, et al. Health-seeking patterns for AIDS in Malawi. AIDS Care. 2004;16(seven):827–833. [PubMed] [Google Scholar]

33. Thorsen VC, Sundby J, Martinson F. Potential initiators of HIV-related stigmatization: upstanding and programmatic challenges for PMTCT programs. Developing World Bioethics. 2008;eight(1):43–fifty. [PubMed] [Google Scholar]

34. Daniel OJ, Oladapo OT. Acceptability of prenatal HIV screening at the chief care level in Nigeria. Journal of Obstetrics and Gynaecology. 2006;26(iii):191–194. [PubMed] [Google Scholar]

35. Hutchinson PL, Mahlalela X. Utilization of voluntary counseling and testing services in the Eastern Cape, South Africa. AIDS Care. 2006;eighteen(5):446–455. [PubMed] [Google Scholar]

36. Nyblade LC, Menken J, Wawer MJ, et al. Population-based HIV testing and counseling in rural Uganda: participation and adventure characteristics. Journal of Caused Allowed Deficiency Syndromes. 2001;28(5):463–470. [PubMed] [Google Scholar]

37. Maedot P, Haile A, Lulseged S, Belachew A. Determinants of vct uptake amid pregnant women attending two ANC clinics in Addis Ababa City: unmatched case control study. Ethiopian Medical Journal. 2007;45(4):335–342. [PubMed] [Google Scholar]

38. Kalichman SC, Simbayi LC. HIV testing attitudes, AIDS stigma, and voluntary HIV counselling and testing in a black township in Cape Boondocks, Due south Africa. Sexually Transmitted Infections. 2003;79(6):442–447. [PMC free article] [PubMed] [Google Scholar]

39. Nachega JB, Lehman DA, Hlatshwayo D, Mothopeng R, Chaisson RE, Karstaedt AS. HIV/AIDS and antiretroviral treatment knowledge, attitudes, behavior, and practices in HIV-infected adults in Soweto, Due south Africa. Periodical of Acquired Immune Deficiency Syndromes. 2005;38(2):196–201. [PubMed] [Google Scholar]

40. Turan JM, Miller S, Bukusi EA, Sande J, Cohen CR. HIV/AIDS and maternity intendance in Kenya: how fears of stigma and discrimination affect uptake and provision of labor and commitment services. AIDS Care. 2008;twenty(viii):938–945. [PMC complimentary article] [PubMed] [Google Scholar]

41. Orner P, Cooper D, Myer 50, Zweigenthal Five, Bekker 50-G, Moodley J. Clients' perspectives on HIV/AIDS care and treatment and reproductive wellness services in South Africa. AIDS Care. 2008;20(10):1217–1223. [PubMed] [Google Scholar]

42. Akani CI, Erhabor O. Charge per unit, design and barriers of HIV serostatus disclosure in a resource-limited setting in the Niger Delta of Nigeria. Tropical Doctor. 2006;36(2):87–89. [PubMed] [Google Scholar]

43. Blackstock O. Curing stigma—the limits of antiretroviral access. New England Journal of Medicine. 2005;353(8):p. 752. [PubMed] [Google Scholar]

44. Kayombo EJ, Mbwambo ZH, Massila One thousand. Function of traditional healers in psychosocial support in caring for the orphans: a case of Dar-es Salaam Urban center, Tanzania. Journal of Ethnobiology and Ethnomedicine. 2005;1:p. 3. [PMC gratuitous commodity] [PubMed] [Google Scholar]

45. Mshana GH, Wamoyi J, Busza J, et al. Barriers to accessing antiretroviral therapy in Kisesa, Tanzania: a qualitative report of early rural referrals to the national program. AIDS Patient Care and STDs. 2006;20(9):649–657. [PubMed] [Google Scholar]

46. Campbell C, Foulis CA, Maimane S, Sibiya Z. "I accept an evil child at my house": stigma and HIV/AIDS managament in a Southward African community. American Journal of Public Health. 2005;95(five):808–815. [PMC free article] [PubMed] [Google Scholar]

47. Thomas F. Stigma, fatigue and social breakup: exploring the impacts of HIV/AIDS on patient and carer well-being in the Caprivi Region, Namibia. Social Scientific discipline and Medicine. 2006;63(12):3174–3187. [PubMed] [Google Scholar]

48. Skinner D, Mfecane Southward. Stigma, discrimination and the implications for people living with HIV/AIDS in S Africa. SAHARA. 2004;1(3):157–164. [PubMed] [Google Scholar]

49. Amuyunzu-Nyamongo One thousand, Okeng'o L, Wagura A, Mwenzwa E. Putting on a brave face: the experiences of women living with HIV and AIDS in breezy settlements of Nairobi, Kenya. AIDS Care. 2007;xix(supplement i):S25–S34. [PubMed] [Google Scholar]

50. Factory JE. Shrouded in secrecy: breaking the news of HIV infection to Ghanaian women. Journal of Transcultural Nursing. 2003;14(1):6–16. [PubMed] [Google Scholar]

51. Antelman G, Smith Fawzi MC, Kaaya Southward, et al. Predictors of HIV-1 serostatus disclosure: a prospective study among HIV-infected meaning women in Dar es Salaam, Tanzania. AIDS. 2001;15(14):1865–1874. [PMC free article] [PubMed] [Google Scholar]

52. Maman S, Mbwambo J, Hogan NM, Kilonzo GP, Sweat M. Women's barriers to HIV-i testing and disclosure: challenges for HIV-one voluntary counselling and testing. AIDS Care. 2001;13(v):595–603. [PubMed] [Google Scholar]

53. Ndinya-Achola J, Ambani J, Temmerman One thousand, Piot P. The correct not to know HIV-test results. Lancet. 1995;345(8955):969–970. [PubMed] [Google Scholar]

54. Sanjobo North, Frich JC, Fretheim A. Barriers and facilitators to patients' adherence to antiretroviral treatment in Zambia: a qualitative written report. SAHARA. 2008;5(three):136–143. [PubMed] [Google Scholar]

55. Ncama BP, McInerney PA, Bhengu BR, et al. Social support and medication adherence in HIV affliction in KwaZulu-Natal, South Africa. International Journal of Nursing Studies. 2008;45(12):1757–1763. [PubMed] [Google Scholar]

56. Weiser SD, Heisler M, Leiter K, et al. Routine HIV testing in Botswana: a population-based report on attitudes, practices, and human rights concerns. PLoS Medicine. 2006;3(vii):p. e261. [PMC free article] [PubMed] [Google Scholar]

58. Policy project, center for the written report of AIDS/Academy of Pretoria, USAID and primary directorate: HIV, AIDS and tuberculosis/ section of health. HIV/AIDS stigma indicators. A tool for measuring the progress of HIV/AIDS stigma mitigation. Due south Africa. Siyam'kela. The policy project; 2003.

59. Link BG, Phelan JC. Conceptualizing stigma. Annual Review of Folklore. 2001;27:363–385. [Google Scholar]

threescore. Mosam A, Dlova NC. HIV/AIDS in Sub-Saharan Africa. Dermatologic Clinics. 2006;24(4):421–429. [PubMed] [Google Scholar]

61. Muula AS, Mfutso-Bengo JM. When is public disclosure of HIV seropositivity acceptable? Nursing Ethics. 2005;12(3):288–295. [PubMed] [Google Scholar]

62. Parker R, Aggleton P. HIV and AIDS-related stigma and discrimination: a conceptual framework and implications for activity. Social Science and Medicine. 2003;57(1):13–24. [PubMed] [Google Scholar]

63. Alonzo AA. An illness behavior paradigm: a conceptual exploration of a situational-accommodation perspective. Social Science and Medicine. 1984;19(v):499–510. [PubMed] [Google Scholar]

64. Malcolm A, Aggleton P, Bronfman Yard, Galvao J, Mane P, Verrall J. HIV-related stigmatization and bigotry: its forms and contexts. Critical Public Health. 1998;8(4):347–370. [Google Scholar]

65. Quam MD. The sick part, stigma and pollution: the example of AIDS. In: Feldman DA, editor. Culture and AIDS. New York, NY, U.s.: Praeger; 1990. pp. 29–44. [Google Scholar]

67. Stevenson MR. Social altitude from persons with AIDS. Journal of Psychology & Human Sexuality. 1991;4:13–20. [Google Scholar]

68. Camp R. Antiretroviral pipeline. In: Huff B, editor. What's in the Pipeline: New Drugs, Vaccines, Microbicides, HCV and TB Therapies in Clinical Trials. New York, NY, The states: Handling Action committee; 2006. pp. ii–20. [Google Scholar]

69. Holstad MM, DiIorio C, Magowe MK. Motivating HIV positive women to adhere to antiretroviral therapy and risk reduction behavior: the KHARMA Project. Online Periodical of Issues in Nursing. 2006;xi(1):p. 5. [PubMed] [Google Scholar]

70. Crepaz N, Hart TA, Marks G. Highly active antiretroviral therapy and sexual take chances behavior: a meta-analytic review. Journal of the American Medical Association. 2004;292(two):224–236. [PubMed] [Google Scholar]

71. Gilmore Due north. Man immunodeficiency virus infection and AIDS: concepts and constructs. In: Jager JC, Ruitenberg EJ, editors. AIDS Impact Assessment Modelling and Scenario Analysis. Amesterdam, Holland: Elsevier; 1992. pp. 161–188. [Google Scholar]

72. Ankrah EM, Henry Yard. Empowering women may assist retard HIV. Network. 1994;15(2):twenty–21. [PubMed] [Google Scholar]

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