Internalized stigma, discrimination, and depression among men and women living with HIV/AIDS in Cape Town, South Africa

Abstract

AIDS stigmas interfere with HIV prevention, diagnosis, and treatment and can become internalized by people living with HIV/AIDS. However, the effects of internalized AIDS stigmas have not been investigated in Africa, home to two-thirds of the more than 40 million people living with AIDS in the world. The current study examined the prevalence of discrimination experiences and internalized stigmas among 420 HIV-positive men and 643 HIV-positive women recruited from AIDS services in Cape Town, South Africa. The anonymous surveys found that 40% of persons with HIV/AIDS had experienced discrimination resulting from having HIV infection and one in five had lost a place to stay or a job because of their HIV status. More than one in three participants indicated feeling dirty, ashamed, or guilty because of their HIV status. A hierarchical regression model that included demographic characteristics, health and treatment status, social support, substance use, and internalized stigma significantly predicted cognitive–affective depression. Internalized stigma accounted for 4.8% of the variance in cognitive–affective depression scores over and above the other variables. These results indicate an urgent need for social reform to reduce AIDS stigmas and the design of interventions to assist people living with HIV/AIDS to adjust and adapt to the social conditions of AIDS in South Africa.

Introduction

HIV/AIDS is perhaps the most stigmatized medical condition in the world. Research conducted across continents has consistently demonstrated that adversarial views of people living with HIV/AIDS are common. AIDS stigmatizing beliefs are the product of multiple social influences including attributions of responsibility for HIV infection and beliefs that individuals with HIV/AIDS are contaminated and tainted. In his classic theory of social stigma, Goffman (1963) identified three aspects of stigma that are characteristic of HIV/AIDS: blemishes of personal character, stained social identity, and physical deformity or defects. AIDS stigmas also reproduce inequalities of class, race, and gender (Parker & Aggleton, 2003). People with HIV infection are often ascribed responsibility for their condition because HIV is contracted from behaviors that are considered avoidable, namely unsafe sex and drug use practices (Herek, 1999). AIDS stigmas are also inextricably enmeshed with other stigmas associated with risk behaviors, such as sexual promiscuity, homosexuality, sexual exchange, and drug use (Novick, 1997). Adverse reactions are greatest toward people with AIDS who contracted HIV through sexual and drug use behaviors relative to those who contracted HIV via blood transfusion (Crawford, 1995). Similarly, individuals who contract HIV via injection drug practices or multiple sex partners are blamed more for their HIV infection than people described as contracting HIV by having sex with only one partner (Herek, Capitanio & Widaman, 2003).

AIDS-related stigmas also interfere with HIV prevention efforts. For example, in a study conducted in the US, Stall et al. (1996) reported that two out of three men who have sex with men who were unaware of their HIV status indicated that AIDS-related stigmas influenced their decisions not to get tested. Among HIV-positive women in sub-Saharan Africa, a primary reason for not disclosing HIV/AIDS and failure to seek assistance are fears of AIDS stigma (Kilewo et al., 2001). Like elsewhere in the world, AIDS stigmas also create a barrier to HIV prevention including HIV testing and counseling in South Africa (Kalichman & Simbayi, 2003; Petros, Airhihenbuwa, Simbayi, Ramlagan, & Brown, 2006).

There have been relatively few studies of AIDS stigmas experienced by people living with HIV/AIDS. Socially constructed views of AIDS can be assimilated and internalized by infected persons. Internalized AIDS stigmas have the potential for adverse behavioral and emotional ramifications including not seeking treatment and care services (Chesney & Smith, 1999), engaging in unsafe sex practices (Wenger, Kusseling, Beck, & Shapiro, 1994), fostering a sense of isolation and emotional distress (Crandall & Coleman, 1992), and self-hatred (Lewis, 1998). Internalized stigma has also been related to the development of depressive symptoms (Wight, 2000). In a study designed to assess the impact of internalized AIDS stigmas in the US, Lee, Kochman, and Sikkema (2002) found that 63% of HIV-positive persons sampled in two US cities indicated that they were embarrassed by their HIV infection and 74% stated that it is difficult for them to tell others that they are HIV positive. Lee and colleagues further showed that internalized AIDS stigmas accounted for a significant and unique proportion of the variance in depression symptoms among people living with HIV/AIDS; internalized stigma was related to depression over and above demographic characteristics, health status, symptoms of grief, and coping responses. These findings suggest that internalized AIDS stigmas may play a crucial role in the emotional reactions and distress experienced by many people living with HIV/AIDS.

Although still prevalent, AIDS stigmas appear to be declining somewhat in the Republic of South Africa. The national HIV/AIDS household survey in South Africa in 2005 showed that endorsements of AIDS stigmatizing beliefs had declined from the previous household survey reported in 2003 (Shisana et al., 2005). Nevertheless, 29% of South Africans stated that they would not buy food from a vendor who has HIV and 20% stated that HIV-positive children should be kept separate from other children to prevent infection (Shisana et al., 2005). Studies have shown that people living in Cape Town, South Africa frequently endorse AIDS stigmatizing beliefs (Deacon, Stephney, & Prosalendis, 2004; Kalichman et al., 2005). For example, 43% of people surveyed in local townships and neighborhoods stated that people living with HIV/AIDS should not be allowed to work with children and 41% felt that people with HIV/AIDS should expect to have restrictions placed on their freedom (Kalichman et al., 2005).

The current study was conducted to examine internalized AIDS stigmas among people living with HIV/AIDS in Cape Town, South Africa. To our knowledge, no previous studies have investigated internalized AIDS stigma in Africa, the region of the world that is home to more than 60% of people living with HIV/AIDS (UNAIDS 2006). Because AIDS stigmas are prevalent in the general population of South Africa, we hypothesized that internalized AIDS stigmas and AIDS-related discrimination experiences would also be prevalent in people living with HIV/AIDS. Following from the results of Lee et al. (2002) discussed above, we predicted that internalized AIDS stigmas would be associated with symptoms of depression over and above other common correlates of depression including health status, social support, and substance use.