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12Volume 2 • Issue 1 • 1000103Madridge J AIDS.
ISSN: 2638-1958
Madridge
Journal of AIDS
Mini-Review Article Open Access
HIV/AIDS Prevention: Reducing Social Stigma to
Facilitate Prevention in the Developing World
Elizabeth Armstrong-Mensah1
*, Kim Ramsey-White1
, Carlos AO Pavão1
, Sarah McCool1
and Keisha Bohannon2
1
Georgia State University, Atlanta, Georgia, USA
2
Karna LLC, Atlanta, Georgia, USA
Article Info
*Corresponding author:
Elizabeth Armstrong-Mensah
School of Public Health
Georgia State University
Atlanta, Georgia
USA
E-mail: earmstrongmensah@gsu.edu
Received: October 3, 2017
Accepted: October 18, 2017
Published: October 25, 2017
Citation: Armstrong-Mensah E, Ramsey-
White K, Pavão CAO, McCool S, Bohannon
K. HIV/AIDS Prevention: Reducing Social
Stigma to Facilitate Prevention in the
Developing World. Madridge J AIDS. 2017;
2(1): 12-16.
doi: 10.18689/mja-1000103
Copyright: © 2017 The Author(s). This work
is licensed under a Creative Commons
Attribution 4.0 International License, which
permits unrestricted use, distribution, and
reproduction in any medium, provided the
original work is properly cited.
Published by Madridge Publishers
Abstract
An approach to preventing new HIV infections is the expectation that people living
with the virus will disclose their status to their partners, healthcare providers, and family
members. While this expectation would most logically contribute to reductions in new
HIV infections, it is widely known that disclosure of status often results in problems for
the person infected with the virus. Too often, status disclosure is not treated as
confidential information and people become stigmatized, ostracized from society, and
discriminated against. This is particularly true in developing countries where much is not
known about the disease, and where being infected with HIV is an automatic sentence
for social isolation. If strides are to be made towards reducing HIV incidence and
prevalence in the developing world, then attitudes towards persons living with the
disease have to change, so as to encourage free reporting and the seeking of appropriate
medical care and counseling. This paper highlights the continued global burden and
trends of HIV/AIDS, discusses the role, barriers, and effects of social stigma on HIV/AIDS
prevention efforts, and proposes strategies for the reduction of stigma and other
negative attitudes that inhibit HIV/AIDS prevention efforts in developing countries.
Keywords: HIV/AIDS; Stigma; Discrimination; Prevention; Developing countries; HIV
counselling and testing; People living with HIV/AIDS.
Introduction
Since 1981, the human immune-deficiency virus (HIV), which causes acquired immune
deficiency syndrome (AIDS), has infected about 78 million people [1-3].and claimed the
lives of 35 million people. Currently, 36.7 million people are living with HIV, the majority
of which reside in developing countries [4]. While some countries have made considerable
strides in slowing down the transmission of HIV, others have not been as successful. Given
that there is no cure for HIV/AIDS, preventing new infections is a key global strategy that
is reflected in the just expired Millennium Development Goal 6 and the newly launched
Sustainable Development Goal target 3.3, which seeks to “by 2030, end the epidemics of
AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-
borne diseases and other communicable diseases” [5].
An approach to preventing new HIV infections is the expectation that people living
with the virus will disclose their status to their partners, healthcare providers, and family
members. While this expectation would most logically contribute to reductions in new
HIV infections, it is widely known that disclosure of status often results in problems for
the person infected with the virus. Too often, status disclosure is not treated as
confidential information and people become stigmatized, ostracized from society, and
discriminated against. This is particularly true in developing countries where much is not
ISSN: 2638-1958
Madridge Journal of Aids
13Volume 2 • Issue 1 • 1000103Madridge J AIDS.
ISSN: 2638-1958
known about the disease, and where being infected with HIV
is an automatic sentence for social isolation. If strides are to
be made towards reducing HIV incidence and prevalence in
the developing world, then attitudes towards persons living
with the disease have to change, so as to encourage free
reporting and the seeking of appropriate medical care and
counselling. This paper highlights the continued global
burden and trends of HIV/AIDS, discusses the role, barriers,
and effects of social stigma on HIV/AIDS prevention efforts,
and proposes strategies for the reduction of stigma and other
negative attitudes that inhibit HIV/AIDS prevention efforts in
developing countries.
Global HIV/AIDS Incidence and
Prevalence
The human immune-deficiency virus causes AIDS. The virus
is transmitted by having unprotected sex with infected persons,
sharing infected needles, receiving infected blood and blood
products, and mother to child transmission during pregnancy
or breastfeeding. The virus attacks and compromises the body’s
immune system, specifically the CD4 cells (T cells), and reduces
the body’s ability to fend off infections and opportunistic
diseases [6]. AIDS is diagnosed when an HIV positive person has
a CD4 count less than 200 cells/mm3
.
As of 2016, 36.7 million people of all ages were living with
HIV/AIDS globally, and an estimated 10 million suffered from
HIV-related illnesses worldwide [2]. The annual incidence of
new HIV infections in 2016, was 1.8 million globally, 39% lower
than in 2000 [7]. Over 95% of the new HIV infections occurred
in developing countries, with about two-thirds in sub-Saharan
Africa, where over 28 million people are living with HIV [8].
In 2015, Eastern and Southern Africa were the region’s
most affected by HIV in sub-Saharan Africa. These regions are
home to about 6.2% of the world’s population and accounted
for over 50% of the total number of people living with HIV
globally [9]. These regions had 960,000 new HIV infections,
about 46% of the global total [3]. South Africa alone accounted
for 40% of the region’s new infections, while Ethiopia, Kenya,
Malawi, Mozambique, Uganda, the United Republic of
Tanzania, Zambia, and Zimbabwe accounted for 50% of the
new infections in sub-Saharan Africa [3].
HIV/AIDS and Social Stigma
Social stigma is extreme disapproval of a person or group
of people based on certain characteristics that distinguish or
make them undesirable by other members of society. It is also
a set of negative and often unfair beliefs that a group of
people have about something [10]. HIV-related stigmas are
the negative beliefs, feelings, and attitudes towards people
living with HIV/AIDS (PLWHA), their families and people who
work with them [11]. These negative beliefs, feelings, and
attitudes often reinforce existing social inequalities, cause
discrimination, render people powerless, create greater
differences, and diminish a person’s social status and self-
worth [12]. HIV-related stigma is the result of a lack of
understanding of the disease, negative media and social
portrayal of the disease, the fact that AIDS is incurable, and
prejudices caused by cultural beliefs [13].
While HIV-related stigma in developing countries has
declined to some extent in the past few years, it continues to
be a barrier to HIV prevention. Indeed, in 2016, the AIDS &
RightsAllianceforSouthernAfrica(ARASA)describedprogress
made towards HIV-related stigma as “inconsistent and
uneven”[14]. Cultural beliefs about HIV create discrimination
and discourage people from seeking counselling, getting
tested, sharing their HIV positive status with loved ones,
seeking care, and sticking to treatment regimens [15]. Studies
conducted by the African Sex Worker Alliance in Kenya, South
Africa, Uganda, and Zimbabwe, found that, sex workers
experienced very high levels of stigma, and were for that
reason, unwilling to disclose their occupation to healthcare
providers [14]. Thus, stigma and discrimination are major
barriers to HIV testing in this population.
Social Stigma and HIV Prevention Efforts
Even though numerous efforts have been made at the
global level to reduce the HIV/AIDS pandemic, many countries
and regions continue to experience little or no change in their
infection rates, and subsequent deaths [16,17]. In developing
countries, especially those in Eastern and Southern Africa,
large-scale HIV/AIDS prevention programs have focused on
HIV education, counseling and testing, condom use, voluntary
medical male circumcision, and antiretroviral treatment (ART).
Nonetheless, these HIV/AIDS prevention efforts have not
resulted in projected reductions in new infections, due in part
to HIV-related stigma [18].
HIV-related stigma and discrimination create barriers,
which negatively impact the ability of PLWHA to protect
themselvesandtostayhealthy.Thefearofstigma,discrimination,
and potential violence, undermines their ability to access and
adhere to treatment and prevention efforts such as condom
use and needle sharing. HIV-related stigma causes PLWHA to
develop low self-esteem and thus, resort to negative motivation
for self-protection; they engage in risky sexual behavior, have
multiple sexual encounters in an attempt to seek self-validation,
or use alcohol or drugs. It also results in negative health
behaviors including the unwillingness to seek voluntary testing,
and obtaining appropriate treatment, care, and support [18].
In Southern and Eastern Africa, men who have sex with
men, sex workers, transgender people, drug users, and key
affected populations often experience increased levels of
stigma and discrimination. Research shows that young men
who have sex with men are disproportionately bullied at
home, in schools, and in communities compared to their
heterosexual counterparts [14]. The stigma associated with
HIV/AIDS also causes people to lose their houses and jobs,
and to be badly treated by some healthcare providers. It must
be noted that, the extent to which people experience HIV-
related stigma varies across countries and within communities.
HIV-related stigma discourages vulnerable populations
Madridge Journal of Aids
14Volume 2 • Issue 1 • 1000103Madridge J AIDS.
ISSN: 2638-1958
from seeking information and programs, for fear it will be
taken to mean that they have HIV, are promiscuous, are
unfaithful, or are members of populations associated with
HIV, like people who inject drugs, sex workers, and gay men
[11]. Consequently, people are less likely to inquire about
their sexual partners HIV status, use clean needles, or access
biomedical prevention options such as male circumcision and
pre-exposure prophylaxis (PrEP). [11].
Practical Steps to Address Stigma and Promote HIV/AIDS
Prevention
Over three million people living with HIV/AIDS in
developing countries now receive ART. However, close to
seven million people in sub-Saharan Africa are still in need of
ART and are awaiting access [19]. This gap in access to medical
and diagnostic pathways contributes significantly to the
continued challenges of reducing new HIV infections.
Prevention is key, but it cannot be effective if stigma and
discrimination impede people from seeking counselling and
testing, and taking the deliberate steps needed to prevent
potential transmission. If people are anxious about disclosing
their status, they will not obtain the help they need.
The devaluation of identity and discrimination associated
with HIV-related stigma does not occur naturally. Indeed, they
are socially constructed by individuals and communities, who
generate and perpetuate stigma as a response to their own
fears [20]. Given that HIV-related stigma exists at various
levels, a social-ecological framework can assist in our approach
to better understand and establish appropriate interventions
at both the micro and macro levels of human interactions.
Practical steps to promote prevention efforts must be targeted
at these levels. A simultaneous multi-level approach must be
used. The Social-Ecological model of health purports that
individual health behavior cannot effectively be addressed
without taking into account the macro and environmental
underpinnings of health [21]. With that in mind, to examine
best practices in dealing with HIV-related stigma, a multi-level
approach would help to inform prevention efforts. To further
identify an in-depth understanding of how stigma and
discrimination can be addressed for PLWHA, we also suggest
that future research, using a community-based participatory
research framework, be implemented to obtain stronger
empirical evidence of how stigma and discrimination is
experienced and what steps are necessary to be taken at both
micro and macro levels, to help reduce personal and structural
barriers to prevention.
Individual Level
At the individual level, PLWHA must be educated on how
they can transmit HIV and what they can do prevent further
transmission. They also need to be provided with information
and given access to services that can protect them and their
human rights when they feel that they have been betrayed by
people they disclosed their status to. A study conducted in
South Africa found that while some PLWHA experienced
stigma through insults and arguments from family members
during disagreements, they knew that disclosing the status
without their consent was a crime. In these instances,
threatening to go to the police, or sometimes actually calling
the police, allowed PLWHA to fight back and maintain their
self-esteem [22].
Community Level
At the community level, social and structural interventions
to change societal beliefs about PLWHA [23]. should be
implemented. Current research on HIV-related stigma
suggests that interventions to reduce stigma in healthcare
settings or in communities have primarily been directed at
raisingHIV/AIDSawareness[23,24].Promotingantidiscrimination
policies, and protecting the human rights of PLWHA [23,25].
But none of the interventions were specifically directed at the
families of PLWHA. National governments in developing
countries need to introduce and implement bold initiatives,
and embark on campaigns that target families and
communities, with the intent of educating and creating
awareness on the need for them to be more supportive of
their loved ones in the event that they test positive for HIV/
AIDS. The link between stigma, negative behavior towards
PLWHA, and potential increased infection should be
highlighted.
Wohl et al. examined social stigma in their article “A
youth-focused case management intervention to engage and
retain young gay men of color in HIV care” [26]. At the social
level, the authors explored some of the difficulties faced by
PLWHA including stigma and isolation from community
members, lack of social support and, the limited access to
needed resources including transportation, mental health
services, housing, and employment assistance. The treatment
of HIV requires lifelong management of the disease, thus
interventions are needed that can help these populations
access and adhere to needed services. The authors concluded
that structural barriers can have a direct effect on health care
access. Given that there is a solid understanding of the
structural barriers that PLWHA face, research should be
conducted and aimed at methods of reducing some of these
barriers, so treatment adherence can be optimal.
Policy Level
Mechanisms to eliminate anti-discriminatory practices
against PLWHA should be introduced and enforced. In Ghana
for example, the Commission on Human Rights and
Administrative Justice, the Ghana AIDS Commission, and the
Health Policy Project have developed a web-based mechanism
that PLWHA can use to report discrimination at the workplace,
and in health care, educational, and other settings. These
reports are anonymous, and result in mediation, investigation,
and legal resolution by human rights and legal organizations
[27].
Health Care Level
The creation of awareness programs and the education of
health workers to deliberately increase their knowledge and
understanding of stigma and its detrimental effects on HIV/
AIDS prevention efforts are essential. Stigma is already a
pressing concern among PLWHA, and this concern can be
Madridge Journal of Aids
15Volume 2 • Issue 1 • 1000103Madridge J AIDS.
ISSN: 2638-1958
magnified when perpetuated by health care providers,
ultimately affecting access to care, treatment adherence, and
overall quality of life. Health workers’ phobias and
misconceptions about HIV and how it is transmitted must be
dispelled and addressed, as the fear of acquiring HIV through
everyday contact with infected persons, causes some providers
to take unnecessary and often stigmatizing actions. The
creation and implementation of an HIV/AIDS health care
provider stigma instrument that is culturally sensitive, is one
way of assessing HIV-related stigma amongst health care
providers. Results from these assessments can be used to
inform training, awareness creation, and education efforts to
reduce stigma [28]. Research efforts in these aforementioned
areas should focus on effectiveness, and the most effective
training, awareness and education programs can then be
modeled and duplicated in various settings. Efforts intended
to increase awareness and education need to provide health
workers with complete information about how HIV is and is
not transmitted, and how treating PLWHA humanely can help
with the prevention of potential new infections. The awareness
creation efforts should also aim at getting health workers to
separatepersonslivingwithHIVfromthebehaviorsconsidered
as improper or immoral.
Program Level
Programs that address negative perceptions and
assumptions about HIV/AIDS are vital to confronting
perceptions that promote stigmatizing attitudes toward
PLWHA. Programs need to target and speak to the shame and
blame directed at PLWHA.
Research Level
While numerous studies have been conducted on HIV-
related stigma, and literature abounds on what PLWHA can
do to stop HIV/AIDS transmission, there is a dearth of research
on the perceptions and lived experiences of PLWHA on HIV-
related stigma, and how discrimination and social isolation
impact their role in HIV prevention efforts. If HIV/AIDS
prevention is to be successful in developing countries, it is
important that research be conducted with PLWHA as
partners, to obtain their views and strategies on how best to
address issues of stigma, discrimination and isolation, the
three factors that current research tells us have such a negative
impact on HIV/AIDS prevention efforts. Collaborating with
PLWHA on examining stigma from their perspectives allows
the researcher to collect narratives at the micro level of the
social-ecological model and to use this information to inform
prevention efforts designed at the individual level.
To begin to understand how to effect change regarding
stigma,discriminationandisolationatthemacro-environmental
level, further research on policy implications at the community,
healthcare, and program levels needs to be conducted. It is no
surprise that policies at all of these levels can exacerbate stigma,
discrimination and isolation for PLWHA. By focusing data
collection efforts on PLWHA and their perceptions of structural
barriers at the macro level, interventions and policy reviews will
be specifically targeted at the direct and indirect forces that
perpetuatethestigma,discrimination,andisolationexperienced
by PLWHA. Additionally, current interventions and policies that
focus on reducing HIV-related stigma in developing countries
need to be assessed for their content, cultural sensitivity, and
the extent to which they embody practices that inherently
increase stigma related bias towards PLWHA.
Globally, prevention is vital in the fight against HIV/AIDS,
but the stigma associated with the disease constricts
prevention efforts and makes significant decreases in new HIV
cases difficult to achieve, particularly in developing
countries. Prevention efforts that are framed using the social
ecological model may be one approach to addressing the
multi-level antecedents that perpetuate the negative effects
of stigma. As previously stated, stigma affects individual’s self-
image and ability to properly advocate for themselves, thereby
limiting disclosure of their status to practitioners and even
their partners. Allaying fears and myths about HIV/AIDS with
family and community support will also serve to help reduce
the deleterious impact of stigma. In developing countries
where the use of prevention efforts do not seem to achieve
the desired reduction in new cases of HIV, research and a
strategic focus on reducing social stigma, isolation,
discrimination, and other negative attitudes towards PLWHA
may be the most appropriate next steps.  
Conflicts of interest statement: Attached for each co-author
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HIV/AIDS Prevention: Reducing Social Stigma to Facilitate Prevention in the Developing World

  • 1. 12Volume 2 • Issue 1 • 1000103Madridge J AIDS. ISSN: 2638-1958 Madridge Journal of AIDS Mini-Review Article Open Access HIV/AIDS Prevention: Reducing Social Stigma to Facilitate Prevention in the Developing World Elizabeth Armstrong-Mensah1 *, Kim Ramsey-White1 , Carlos AO Pavão1 , Sarah McCool1 and Keisha Bohannon2 1 Georgia State University, Atlanta, Georgia, USA 2 Karna LLC, Atlanta, Georgia, USA Article Info *Corresponding author: Elizabeth Armstrong-Mensah School of Public Health Georgia State University Atlanta, Georgia USA E-mail: earmstrongmensah@gsu.edu Received: October 3, 2017 Accepted: October 18, 2017 Published: October 25, 2017 Citation: Armstrong-Mensah E, Ramsey- White K, Pavão CAO, McCool S, Bohannon K. HIV/AIDS Prevention: Reducing Social Stigma to Facilitate Prevention in the Developing World. Madridge J AIDS. 2017; 2(1): 12-16. doi: 10.18689/mja-1000103 Copyright: © 2017 The Author(s). This work is licensed under a Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Published by Madridge Publishers Abstract An approach to preventing new HIV infections is the expectation that people living with the virus will disclose their status to their partners, healthcare providers, and family members. While this expectation would most logically contribute to reductions in new HIV infections, it is widely known that disclosure of status often results in problems for the person infected with the virus. Too often, status disclosure is not treated as confidential information and people become stigmatized, ostracized from society, and discriminated against. This is particularly true in developing countries where much is not known about the disease, and where being infected with HIV is an automatic sentence for social isolation. If strides are to be made towards reducing HIV incidence and prevalence in the developing world, then attitudes towards persons living with the disease have to change, so as to encourage free reporting and the seeking of appropriate medical care and counseling. This paper highlights the continued global burden and trends of HIV/AIDS, discusses the role, barriers, and effects of social stigma on HIV/AIDS prevention efforts, and proposes strategies for the reduction of stigma and other negative attitudes that inhibit HIV/AIDS prevention efforts in developing countries. Keywords: HIV/AIDS; Stigma; Discrimination; Prevention; Developing countries; HIV counselling and testing; People living with HIV/AIDS. Introduction Since 1981, the human immune-deficiency virus (HIV), which causes acquired immune deficiency syndrome (AIDS), has infected about 78 million people [1-3].and claimed the lives of 35 million people. Currently, 36.7 million people are living with HIV, the majority of which reside in developing countries [4]. While some countries have made considerable strides in slowing down the transmission of HIV, others have not been as successful. Given that there is no cure for HIV/AIDS, preventing new infections is a key global strategy that is reflected in the just expired Millennium Development Goal 6 and the newly launched Sustainable Development Goal target 3.3, which seeks to “by 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water- borne diseases and other communicable diseases” [5]. An approach to preventing new HIV infections is the expectation that people living with the virus will disclose their status to their partners, healthcare providers, and family members. While this expectation would most logically contribute to reductions in new HIV infections, it is widely known that disclosure of status often results in problems for the person infected with the virus. Too often, status disclosure is not treated as confidential information and people become stigmatized, ostracized from society, and discriminated against. This is particularly true in developing countries where much is not ISSN: 2638-1958
  • 2. Madridge Journal of Aids 13Volume 2 • Issue 1 • 1000103Madridge J AIDS. ISSN: 2638-1958 known about the disease, and where being infected with HIV is an automatic sentence for social isolation. If strides are to be made towards reducing HIV incidence and prevalence in the developing world, then attitudes towards persons living with the disease have to change, so as to encourage free reporting and the seeking of appropriate medical care and counselling. This paper highlights the continued global burden and trends of HIV/AIDS, discusses the role, barriers, and effects of social stigma on HIV/AIDS prevention efforts, and proposes strategies for the reduction of stigma and other negative attitudes that inhibit HIV/AIDS prevention efforts in developing countries. Global HIV/AIDS Incidence and Prevalence The human immune-deficiency virus causes AIDS. The virus is transmitted by having unprotected sex with infected persons, sharing infected needles, receiving infected blood and blood products, and mother to child transmission during pregnancy or breastfeeding. The virus attacks and compromises the body’s immune system, specifically the CD4 cells (T cells), and reduces the body’s ability to fend off infections and opportunistic diseases [6]. AIDS is diagnosed when an HIV positive person has a CD4 count less than 200 cells/mm3 . As of 2016, 36.7 million people of all ages were living with HIV/AIDS globally, and an estimated 10 million suffered from HIV-related illnesses worldwide [2]. The annual incidence of new HIV infections in 2016, was 1.8 million globally, 39% lower than in 2000 [7]. Over 95% of the new HIV infections occurred in developing countries, with about two-thirds in sub-Saharan Africa, where over 28 million people are living with HIV [8]. In 2015, Eastern and Southern Africa were the region’s most affected by HIV in sub-Saharan Africa. These regions are home to about 6.2% of the world’s population and accounted for over 50% of the total number of people living with HIV globally [9]. These regions had 960,000 new HIV infections, about 46% of the global total [3]. South Africa alone accounted for 40% of the region’s new infections, while Ethiopia, Kenya, Malawi, Mozambique, Uganda, the United Republic of Tanzania, Zambia, and Zimbabwe accounted for 50% of the new infections in sub-Saharan Africa [3]. HIV/AIDS and Social Stigma Social stigma is extreme disapproval of a person or group of people based on certain characteristics that distinguish or make them undesirable by other members of society. It is also a set of negative and often unfair beliefs that a group of people have about something [10]. HIV-related stigmas are the negative beliefs, feelings, and attitudes towards people living with HIV/AIDS (PLWHA), their families and people who work with them [11]. These negative beliefs, feelings, and attitudes often reinforce existing social inequalities, cause discrimination, render people powerless, create greater differences, and diminish a person’s social status and self- worth [12]. HIV-related stigma is the result of a lack of understanding of the disease, negative media and social portrayal of the disease, the fact that AIDS is incurable, and prejudices caused by cultural beliefs [13]. While HIV-related stigma in developing countries has declined to some extent in the past few years, it continues to be a barrier to HIV prevention. Indeed, in 2016, the AIDS & RightsAllianceforSouthernAfrica(ARASA)describedprogress made towards HIV-related stigma as “inconsistent and uneven”[14]. Cultural beliefs about HIV create discrimination and discourage people from seeking counselling, getting tested, sharing their HIV positive status with loved ones, seeking care, and sticking to treatment regimens [15]. Studies conducted by the African Sex Worker Alliance in Kenya, South Africa, Uganda, and Zimbabwe, found that, sex workers experienced very high levels of stigma, and were for that reason, unwilling to disclose their occupation to healthcare providers [14]. Thus, stigma and discrimination are major barriers to HIV testing in this population. Social Stigma and HIV Prevention Efforts Even though numerous efforts have been made at the global level to reduce the HIV/AIDS pandemic, many countries and regions continue to experience little or no change in their infection rates, and subsequent deaths [16,17]. In developing countries, especially those in Eastern and Southern Africa, large-scale HIV/AIDS prevention programs have focused on HIV education, counseling and testing, condom use, voluntary medical male circumcision, and antiretroviral treatment (ART). Nonetheless, these HIV/AIDS prevention efforts have not resulted in projected reductions in new infections, due in part to HIV-related stigma [18]. HIV-related stigma and discrimination create barriers, which negatively impact the ability of PLWHA to protect themselvesandtostayhealthy.Thefearofstigma,discrimination, and potential violence, undermines their ability to access and adhere to treatment and prevention efforts such as condom use and needle sharing. HIV-related stigma causes PLWHA to develop low self-esteem and thus, resort to negative motivation for self-protection; they engage in risky sexual behavior, have multiple sexual encounters in an attempt to seek self-validation, or use alcohol or drugs. It also results in negative health behaviors including the unwillingness to seek voluntary testing, and obtaining appropriate treatment, care, and support [18]. In Southern and Eastern Africa, men who have sex with men, sex workers, transgender people, drug users, and key affected populations often experience increased levels of stigma and discrimination. Research shows that young men who have sex with men are disproportionately bullied at home, in schools, and in communities compared to their heterosexual counterparts [14]. The stigma associated with HIV/AIDS also causes people to lose their houses and jobs, and to be badly treated by some healthcare providers. It must be noted that, the extent to which people experience HIV- related stigma varies across countries and within communities. HIV-related stigma discourages vulnerable populations
  • 3. Madridge Journal of Aids 14Volume 2 • Issue 1 • 1000103Madridge J AIDS. ISSN: 2638-1958 from seeking information and programs, for fear it will be taken to mean that they have HIV, are promiscuous, are unfaithful, or are members of populations associated with HIV, like people who inject drugs, sex workers, and gay men [11]. Consequently, people are less likely to inquire about their sexual partners HIV status, use clean needles, or access biomedical prevention options such as male circumcision and pre-exposure prophylaxis (PrEP). [11]. Practical Steps to Address Stigma and Promote HIV/AIDS Prevention Over three million people living with HIV/AIDS in developing countries now receive ART. However, close to seven million people in sub-Saharan Africa are still in need of ART and are awaiting access [19]. This gap in access to medical and diagnostic pathways contributes significantly to the continued challenges of reducing new HIV infections. Prevention is key, but it cannot be effective if stigma and discrimination impede people from seeking counselling and testing, and taking the deliberate steps needed to prevent potential transmission. If people are anxious about disclosing their status, they will not obtain the help they need. The devaluation of identity and discrimination associated with HIV-related stigma does not occur naturally. Indeed, they are socially constructed by individuals and communities, who generate and perpetuate stigma as a response to their own fears [20]. Given that HIV-related stigma exists at various levels, a social-ecological framework can assist in our approach to better understand and establish appropriate interventions at both the micro and macro levels of human interactions. Practical steps to promote prevention efforts must be targeted at these levels. A simultaneous multi-level approach must be used. The Social-Ecological model of health purports that individual health behavior cannot effectively be addressed without taking into account the macro and environmental underpinnings of health [21]. With that in mind, to examine best practices in dealing with HIV-related stigma, a multi-level approach would help to inform prevention efforts. To further identify an in-depth understanding of how stigma and discrimination can be addressed for PLWHA, we also suggest that future research, using a community-based participatory research framework, be implemented to obtain stronger empirical evidence of how stigma and discrimination is experienced and what steps are necessary to be taken at both micro and macro levels, to help reduce personal and structural barriers to prevention. Individual Level At the individual level, PLWHA must be educated on how they can transmit HIV and what they can do prevent further transmission. They also need to be provided with information and given access to services that can protect them and their human rights when they feel that they have been betrayed by people they disclosed their status to. A study conducted in South Africa found that while some PLWHA experienced stigma through insults and arguments from family members during disagreements, they knew that disclosing the status without their consent was a crime. In these instances, threatening to go to the police, or sometimes actually calling the police, allowed PLWHA to fight back and maintain their self-esteem [22]. Community Level At the community level, social and structural interventions to change societal beliefs about PLWHA [23]. should be implemented. Current research on HIV-related stigma suggests that interventions to reduce stigma in healthcare settings or in communities have primarily been directed at raisingHIV/AIDSawareness[23,24].Promotingantidiscrimination policies, and protecting the human rights of PLWHA [23,25]. But none of the interventions were specifically directed at the families of PLWHA. National governments in developing countries need to introduce and implement bold initiatives, and embark on campaigns that target families and communities, with the intent of educating and creating awareness on the need for them to be more supportive of their loved ones in the event that they test positive for HIV/ AIDS. The link between stigma, negative behavior towards PLWHA, and potential increased infection should be highlighted. Wohl et al. examined social stigma in their article “A youth-focused case management intervention to engage and retain young gay men of color in HIV care” [26]. At the social level, the authors explored some of the difficulties faced by PLWHA including stigma and isolation from community members, lack of social support and, the limited access to needed resources including transportation, mental health services, housing, and employment assistance. The treatment of HIV requires lifelong management of the disease, thus interventions are needed that can help these populations access and adhere to needed services. The authors concluded that structural barriers can have a direct effect on health care access. Given that there is a solid understanding of the structural barriers that PLWHA face, research should be conducted and aimed at methods of reducing some of these barriers, so treatment adherence can be optimal. Policy Level Mechanisms to eliminate anti-discriminatory practices against PLWHA should be introduced and enforced. In Ghana for example, the Commission on Human Rights and Administrative Justice, the Ghana AIDS Commission, and the Health Policy Project have developed a web-based mechanism that PLWHA can use to report discrimination at the workplace, and in health care, educational, and other settings. These reports are anonymous, and result in mediation, investigation, and legal resolution by human rights and legal organizations [27]. Health Care Level The creation of awareness programs and the education of health workers to deliberately increase their knowledge and understanding of stigma and its detrimental effects on HIV/ AIDS prevention efforts are essential. Stigma is already a pressing concern among PLWHA, and this concern can be
  • 4. Madridge Journal of Aids 15Volume 2 • Issue 1 • 1000103Madridge J AIDS. ISSN: 2638-1958 magnified when perpetuated by health care providers, ultimately affecting access to care, treatment adherence, and overall quality of life. Health workers’ phobias and misconceptions about HIV and how it is transmitted must be dispelled and addressed, as the fear of acquiring HIV through everyday contact with infected persons, causes some providers to take unnecessary and often stigmatizing actions. The creation and implementation of an HIV/AIDS health care provider stigma instrument that is culturally sensitive, is one way of assessing HIV-related stigma amongst health care providers. Results from these assessments can be used to inform training, awareness creation, and education efforts to reduce stigma [28]. Research efforts in these aforementioned areas should focus on effectiveness, and the most effective training, awareness and education programs can then be modeled and duplicated in various settings. Efforts intended to increase awareness and education need to provide health workers with complete information about how HIV is and is not transmitted, and how treating PLWHA humanely can help with the prevention of potential new infections. The awareness creation efforts should also aim at getting health workers to separatepersonslivingwithHIVfromthebehaviorsconsidered as improper or immoral. Program Level Programs that address negative perceptions and assumptions about HIV/AIDS are vital to confronting perceptions that promote stigmatizing attitudes toward PLWHA. Programs need to target and speak to the shame and blame directed at PLWHA. Research Level While numerous studies have been conducted on HIV- related stigma, and literature abounds on what PLWHA can do to stop HIV/AIDS transmission, there is a dearth of research on the perceptions and lived experiences of PLWHA on HIV- related stigma, and how discrimination and social isolation impact their role in HIV prevention efforts. If HIV/AIDS prevention is to be successful in developing countries, it is important that research be conducted with PLWHA as partners, to obtain their views and strategies on how best to address issues of stigma, discrimination and isolation, the three factors that current research tells us have such a negative impact on HIV/AIDS prevention efforts. Collaborating with PLWHA on examining stigma from their perspectives allows the researcher to collect narratives at the micro level of the social-ecological model and to use this information to inform prevention efforts designed at the individual level. To begin to understand how to effect change regarding stigma,discriminationandisolationatthemacro-environmental level, further research on policy implications at the community, healthcare, and program levels needs to be conducted. It is no surprise that policies at all of these levels can exacerbate stigma, discrimination and isolation for PLWHA. By focusing data collection efforts on PLWHA and their perceptions of structural barriers at the macro level, interventions and policy reviews will be specifically targeted at the direct and indirect forces that perpetuatethestigma,discrimination,andisolationexperienced by PLWHA. Additionally, current interventions and policies that focus on reducing HIV-related stigma in developing countries need to be assessed for their content, cultural sensitivity, and the extent to which they embody practices that inherently increase stigma related bias towards PLWHA. Globally, prevention is vital in the fight against HIV/AIDS, but the stigma associated with the disease constricts prevention efforts and makes significant decreases in new HIV cases difficult to achieve, particularly in developing countries. Prevention efforts that are framed using the social ecological model may be one approach to addressing the multi-level antecedents that perpetuate the negative effects of stigma. As previously stated, stigma affects individual’s self- image and ability to properly advocate for themselves, thereby limiting disclosure of their status to practitioners and even their partners. Allaying fears and myths about HIV/AIDS with family and community support will also serve to help reduce the deleterious impact of stigma. In developing countries where the use of prevention efforts do not seem to achieve the desired reduction in new cases of HIV, research and a strategic focus on reducing social stigma, isolation, discrimination, and other negative attitudes towards PLWHA may be the most appropriate next steps.   Conflicts of interest statement: Attached for each co-author References 1. Joint United Nations Programme on HIV/AIDS. Fact Sheet - Latest statistics on the status of the AIDS epidemic. UNAIDS. 2017. 2. World Health Organization. Global Health Observatory. Updated 2017 3. Joint United Nations Programme on HIV/AIDS. AIDS Info. 2016. 4. Joint United Nations Programme on HIV/AIDS. Ending AIDS Progress Toward 90-90-90 Targets. UNAIDS; July 20, 2017. 5. World Health Organization. SDG 3: Ensure healthy lives and promote wellbeing for all at all ages. 6. Armstrong-Mensah E. Lecture Notes: Global Health Issues, Challenges and Global Action. New York: John Wiley & Sons; 2017. 7. 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  • 5. Madridge Journal of Aids 16Volume 2 • Issue 1 • 1000103Madridge J AIDS. ISSN: 2638-1958 16. Herek GM. Thinking About AIDS and Stigma: A Psychologist’s Perspective. The Journal of Law, Medicine & Ethics. 2002; 30(4): 594-607. doi: 10.1111/j.1748-720X.2002.tb00428.x 17. Shisana O, Rehle T, Simbayi LC, Parker W. South African National HIV prevalence, HIV incidence, behaviour and communication survey. Human Sciences Research Council: Cape Town; 2005. 18. Brown DC, BeLue R, Airhihenbuwa CO. HIV and AIDS-related stigma in the context of family support and race in South Africa. Ethn Health. 2010; 15(5): 441-58. doi: 10.1080/13557858.2010.486029 19. Lahuerta M, Ue F, Hoffman S, et al. The Problem of Late ART Initiation in Sub-Saharan Africa: A Transient Aspect of Scale-up or a Long-term Phenomenon?. J Health Care Poor Underserved. 2013; 24(1): 359-83. doi: 10.1353/hpu.2013.0014 20. Health Resources Services Administration. HRSA care action: providing HIV/AIDS care in a changing environment. 2003. 21. Golden SD, Earp JAL. Social Ecological Approaches to Individuals and Their Contexts.HealthEducBehav.2012;39(3):364-72.doi:10.1177/1090198111418634 22. Abrahams N, Jewkes R. Managing and resisting stigma: a qualitative study among people living with HIV in South Africa. J Int AIDS Soc. 2012; 15(2): 10.7448/IAS.7415.7442.17330. doi: 10.7448/IAS.15.2.17330 23. Kalichman SC, Simbayi LC. HIV testing attitudes, AIDS stigma, and voluntary HIV counselling and testing in a black township in Cape Town, South Africa. Sexually Transmitted Infections. 2003; 79(6): 442. 24. Blankenship M, Bray SJ, Merson MH. Structural interventions in public health. AIDS. 2000; 14(1): 11-21. doi: 10.1097/00002030-200006001-00003 25. Shriver MD, Everett C, Morin SF. Structural interventions to encourage primary HIV prevention among people living with HIV. AIDS. 2000; 14(1): 57-62. doi: 10.1097/00002030-200006001-00009 26. Wohl AR, Garland WH, Wu J, et al. A youth-focused case management intervention to engage and retain young gay men of color in HIV care. AIDS Care. 2011; 23(8): 988-97. doi: 10.1080/09540121.2010.542125 27. UNAIDS. On the Fast-Track to end AIDS by 2030: Focus on location and population. www.unaids.org/en/resources/documents/2015/. 2015. 28. Wagner AC, Girard T, McShane KE, Margolese S, Hart TA, et al. HIV- Related Stigma and Overlapping Stigmas Towards People Living With HIV Among Health Care Trainees in Canada. AIDS Education and Prevention. 2017; 29(4): 364-76. doi: 10.1521/aeap.2017.29.4.364