HIV stigma beliefs in context: Country and regional variation in the effects of instrumental stigma beliefs on protective sexual behaviors in Latin America, the Caribbean, and Southern Africa

https://doi.org/10.1016/j.socscimed.2020.113565Get rights and content

Highlights

  • Southern Africans who stigmatize less likely to practice safe sex.

  • Latin Americans & Caribbeans who stigmatize more likely to practice safe sex.

  • Association between stigma beliefs and sexual behavior varies across regions.

  • Association is widest in Southern African countries.

Abstract

Does the relationship between the expression of HIV stigma beliefs and the practice of protective sexual behaviors vary by social context? To answer this question, we apply multilevel techniques to Demographic and Health Survey data from seven low HIV prevalence Latin American and Caribbean countries and seven high HIV prevalence Southern African countries to examine contextual variation in this relationship. We examine whether the relationship between stigma beliefs and sexual behaviors differs across these two sets of countries and across regions within each set of countries. We first find that in high prevalence Southern African countries, one unit increases in HIV stigma beliefs are associated with 8% declines in the odds of practicing protective sexual behaviors. Conversely, in low prevalence Latin American and Caribbean countries, unit increases in HIV stigma beliefs are associated with 8% increases in the odds of those same sexual behaviors. Second, the relationship between stigma beliefs and protective sexual behaviors varies across regions within each set of countries, with a wider variance in regional stigma effects located in Southern Africa than in Latin America and the Caribbean. Third, in Southern Africa, the negative effect of stigma beliefs is even more negative in regions where conservative stigma beliefs are pronounced. Overall, our findings demonstrate the importance of taking country and regional context into account when examining the degree to which HIV beliefs affect personal sexual behaviors, which in turn, can contribute to the spread of HIV. Importantly, the implications of our results offer potential guidance to experts who wish to design policies and programs aimed at reducing the expression of negative HIV beliefs towards those infected with HIV.

Introduction

Although medical advances have increased life expectancy for people who are HIV positive, HIV prevalence remains high in several countries, especially in Southern Africa. One of the main consequences of having HIV is living with the social stigma attached to the disease. We define social stigma as an ideology which suggests that people with HIV are different from others in “normal” society and that this difference goes beyond merely being infected with the disease (Deacon 2005; 2006; Joffe 1999; Link and Phelan 2001). Stigmatized individuals often face discrimination and isolation, leading to and exacerbating poor health outcomes. Consequently, they are less likely to practice several protective sexual behaviors (PSBs) such as condom use and sexual fidelity, which slow the spread of HIV (Clum, Chung, and Ellen 2009; Hatzenbuehler et al., 2011). This literature provides valuable insight into the health and behavioral consequences of being stigmatized (Dlamini et al., 2009; Greeff and Phetlhu 2007; Herek and Capitanio 1997; Holzemer et al., 2007; Mahajan et al., 2008; Malcolm et al., 1998).

While these findings are clear, we know surprisingly little about how being a stigmatizer – or holding stigmatizing beliefs toward those infected with HIV – affects the PSBs of those doing the stigmatizing in sub-Saharan Africa and elsewhere. Except for the one study described below, no work has systematically examined the relationship between expressing stigmatizing beliefs and PSBs. The studies that do exist treat stigma beliefs as a control variable, not a variable of conceptual importance (Gazimbi and Magadi 2017; Magadi and Desta 2011; Stephenson 2009). Focusing on stigmatizers is important because although stigma is associated with harmful health practices, it is unclear whether participating in stigmatizing ideologies is also associated with unhealthy sex practices.

To address this gap in the literature, Cort and Tu (2018) use Demographic and Health Surveys (DHS) to examine the relationship between HIV stigma beliefs and PSBs among unpartnered individuals across 34 sub-Saharan African countries. They find that across these 34 countries, unpartnered stigmatizers are less likely to practice safer PSBs than riskier ones. This negative relationship is most pronounced in Southern and Eastern African countries, where HIV prevalence is highest, implying that social context can alter the strength of important biomedical and social relationships.

In this paper, we extend that work in two ways. First, we determine whether the finding of contextual differences in the relationship between stigma beliefs and PSBs is confined to Africa or can be more broadly applied to regions outside of the continent. If we find broader applicability of that contextual finding, this will provide more support for Cort and Tu's (2018) results. Indeed, they argue that in African countries where HIV prevalence is low, people have less exposure to the social consequences of HIV than those in high-prevalence countries, making weak or positive relationships unsurprising. We choose Latin American and Caribbean (LA&C) countries as our comparison, where HIV prevalence remains low (García and Cárcamo 2014). However, LA&C still contains several countries (like Haiti, the Bahamas, and Guyana) where the epidemic is still an epidemiological concern for several vulnerable demographic groups, like men who have sex with men. Moreover, they are, for the most part, culturally conservative countries, a characteristic shared by many sub-Saharan African countries.

Importantly, even though we choose LA&C countries as a comparison to Southern African countries, we understand that there are characteristics of these groups of countries – beyond the their differing levels of HIV prevalence – that could explain any differences in the pattern of the relationship between stigma beliefs and PSBs. We are not arguing that HIV prevalence is the only characteristic that explains differences the relationship between stigma beliefs and PSBs. We are using LA&C countries as a comparison to Southern African countries to provide a starting point for discussion concerning the extent to which differences in the relationship pertain only to sub-Saharan African, or if they can be more broadly generalized outside that continent. As such, we intend to treat our results as speculative, providing a foundation for future research.

Second, we determine whether the relationship between stigma beliefs and PSBs varies across regions or provinces within countries, and the extent of this variation. We do so because groups of countries that are similar in terms of overall HIV prevalence and other unmeasured factors likely contain internal variation in HIV prevalence, which may affect how stigma determines behavior. We aim to develop theoretically grounded hypotheses about the contextual effects of stigma beliefs. This is an important innovation because although there is a literature on the contextual effects of various factors on PSBs (see Ward-Peterson et al., 2018), much of it, with just a few notable exceptions (Benefo 1995; 2006; 2008; Burgard and Lee-Rife 2009; Gazimbi and Magadi 2017), does not use sociological theories to construct hypotheses about the contextual effects of critical independent variables.

To theoretically support our analyses, we engage recent work that argues that both HIV positive and negative individuals participate in stigmatizing discourses toward people who are infected with HIV (Cort and Tu 2018; Deacon 2005; 2006; Joffe 1999). We then develop competing hypotheses about the effects of HIV stigma beliefs on PSBs (Cort and Tu 2018). Empirically, we use DHS data from seven Southern African countries (Lesotho, Malawi, Mozambique, Namibia, Swaziland, Zambia, and Zimbabwe) and seven LA&C countries (Bolivia, Columbia, Dominican Republic, Guatemala, Guyana, Haiti, and Honduras), and multilevel analyses to test all of our hypotheses.

Section snippets

Background

Over the past two decades, scholars have informed our understanding of the social and epidemiological consequences of experiencing HIV stigma beliefs and broadened our knowledge about the relationship between stigma beliefs and PSBs (Burkholder et al., 1999; Clum, Chung, and Ellen 2009; Greeff and Phetlhu 2007; Herek and Capitanio 1997; Holzemer et al., 2007; Mahajan et al., 2008; Malcolm et al., 1998; Preston et al., 2007). Yet, this literature lacks a systematic focus on the effects of

Contextual variation across countries

The Avoidance and Safety Response Hypotheses imply that relationships between stigma beliefs and PSBs are uniformly negative or positive. However, the direction of this relationship may depend on the social context in which it occurs. After all, context matters for various biomedical and social outcomes (Barber 2004; Pescosolido et al., 2008; Ruiter and De Graaf 2006; Yang et al., 2007).

Since we argue that social contexts matter, we expect that the relationship between stigma beliefs and PSBs

Data

Our data come from the Demographic and Health Surveys (DHS), nationally representative repeated cross-sectional household surveys designed to document demographic and health indicators in developing countries. The DHS collects data every few years for most countries, but some countries are only collected once. These data include two important components for our study. First, they contain measures of HIV stigma and PSBs. Second, for some countries, they have the region or state of residence for

Descriptive findings

In Table 2, Table 3, we present weighted means and percentages for all variables used in our models by country group. Since a major focus of our study is contextual effects of HIV stigma beliefs, we examine the mean of instrumental stigma for both groups of countries and contrast that measure with HIV prevalence rate. Analyses show that when LA&C countries are compared to those in Southern Africa, instrumental stigma rates are higher in LA&C countries, where HIV rates are the lowest.

Multivariate findings: main effects

While this

Discussion

We find that instrumental stigma rates are higher in LA&C countries, where HIV rates are the lowest, compared to those in Southern Africa. This preliminary finding suggests that Latin Americans and Caribbeans who, compared to Southern Africans, have had less experience interacting with HIV positive people, and dealing with the HIV epidemic may be less understanding of those who live with the disease. While this country-region finding regarding instrumental stigma levels is important, we are

Credit author statement

Katie R. Billings: Conceptualization, Methodology, Writing-Reviewing, & Editing. David A. Cort: Conceptualization, Methodology, Writing-Reviewing, & Editing, Project Administration. Tannuja D. Rozario: Conceptualization ,Writing-Reviewing, & Editing. Derek P. Siegel: Conceptualization ,Writing-Reviewing, & Editing.

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