HIV/AIDS stigma-associated attitudes in a rural Ethiopian community: characteristics, correlation with HIV knowledge and other factors, and implications for community intervention.

BACKGROUND: Whether scale-up of HIV prevention and care will reduce negative attitudes and discriminatory practices towards persons living with HIV/AIDS (PLWH) is uncertain. An HIV knowledge and attitude survey was conducted in a rural Ethiopian community where HIV prevention and treatment was being rapidly scaled up. Data were analyzed to identify prevalence of and factors associated with stigma-associated attitudes towards PLWH. METHODS: We surveyed 561 adults from 250 randomly selected households in the rural town of Arba Minch and surrounding villages about positive or negative attitudes towards PLWH, as well as demographic characteristics, and knowledge about HIV transmission and treatment. RESULTS: Eighty percent of respondents agreed with ≥ 1 negative statements indicating blame or shame towards PLWH and 41% agreed with ≥ 1 negative statements associated with distancing themselves from PLWH. However, only 14% expressed negative responses about whether PLWH should receive support from their communities. In multivariate analysis, a greater number of negative attitudes towards PLWH was significantly (p < 0.05) associated with: female gender (Odds Ratio [OR] = 1.51), living in a rural village (vs. town neighborhood) (OR = 3.44), not knowing PLWH can appear healthy (OR = 1.78), lack of knowledge about perinatal transmission (OR = 1.49), lack of knowledge about how HIV is not transmitted (e.g. casual contact) (OR = 2.05), lack of knowledge about HIV treatment (OR = 1.80), and not personally knowing a PLWH (OR = 1.41). CONCLUSIONS: In a rural Ethiopian setting in which rapid scale-up of HIV treatment occurred, many respondents still characterized HIV as associated with shame or blame, or indicated PLWH would be isolated or discriminated against. HIV stigma can hamper both prevention and treatment programs. We identified multiple issues which, if addressed, can help promote a more positive cycle in which PLWH are appreciated as members of one's own community who are affirmatively interacted with and supported. Stigma reduction programs should address knowledge gaps such as fears of casual contact contagion, and lack of awareness of medical interventions to help prevent HIV disease, as well as building upon community-based attitudes of the importance of supporting and showing compassion for PLWH.

Failure to test for HIV in rural Ethiopia: knowledge and belief correlates and implications for universal test and treat strategies.

Goals of universal "test and treat" will never be fully realized if testing acceptance remains low, including rural areas, where HIV is increasingly recognized. We surveyed 250 randomly selected households from a rural Ethiopian town (Arba Minch) and surrounding villages about HIV testing experience, knowledge, and attitudes. Of the 558 adults, 45% were never HIV tested. Those never tested for HIV were more likely to be (P < .05) ≥45 years, rural villagers, and unaware of the benefits of antiretroviral therapy treatment and that persons with HIV can appear healthy; they were more likely to believe HIV-infected persons would be stigmatized and unsupported by their communities. Of those never tested, 70% were interested in HIV testing if offered. Despite recommendations that all persons be HIV tested, almost half of the adult residents in this rural community were never tested. Programs to increase HIV testing must include measures to address stigma/discrimination and knowledge deficits including benefits of early diagnosis and treatment.

Barriers to retention in care as perceived by persons living with HIV in rural Ethiopia: focus group results and recommended strategies.

Inability to retain HIV-infected patients in care undermines the benefits of starting millions in low-income countries on antiretroviral therapy (ART). In a hospital HIV clinic in rural southern Ethiopia, we conducted focus groups of HIV-infected men and women to learn more about experiences with and barriers to attending clinic appointments. Respondents reported multiple barriers, including those that were patient related (eg, misunderstandings about ART, mistaken belief in AIDS cures, and drug/alcohol use), clinic related (eg, negative provider interactions, lack of familiarity with patients' medical situation, and overcrowding), medication related (eg, side effects), social (eg, stigma and discrimination and lack of support), and situational/resource related (eg, distance to clinic, lack of funds, competing domestic/work priorities, and lack of food). Based on the lessons learned from these focus groups, we implemented a community intervention to improve retention, using trained community support workers who provide patient education, counseling, social support, problem-solving assistance, needed referrals, and improved communication/linkage to the patients' HIV clinic.