A Livelihood Intervention to Reduce the Stigma of HIV in Rural Kenya: Longitudinal Qualitative Study

Abstract

The scale-up of effective treatment has partially reduced the stigma attached to HIV, but HIV still remains highly stigmatized throughout sub-Saharan Africa. Most studies of anti-HIV stigma interventions have employed psycho-educational strategies such as information provision, counseling, and testimonials, but these have had varying degrees of success. Theory suggests that livelihood interventions could potentially reduce stigma by weakening the instrumental and symbolic associations between HIV and premature morbidity, economic incapacity, and death, but this hypothesis has not been directly examined. We conducted a longitudinal qualitative study among 54 persons with HIV participating in a 12-month randomized controlled trial of a livelihood intervention in rural Kenya. Our study design permitted assessment of changes over time in the perspectives of treatment-arm participants (N=45), as well as an understanding of the experiences of control arm participants (N=9, interviewed only at follow-up). Initially, participants felt ashamed of their seropositivity and were socially isolated (internalized stigma). They also described how others in the community discriminated against them, labeled them as being “already dead,” and deemed them useless and unworthy of social investment (perceived and enacted stigma). At follow-up, participants in the treatment arm described less stigma and voiced positive changes in confidence and self-esteem. Concurrently, they observed that other community members perceived them as active, economically productive, and contributing citizens. Participants in the control arm described continued stigma with none of these changes. In summary, our findings suggest a theory of stigma reduction: livelihood interventions may reduce internalized stigma among persons with HIV and also, by targeting core drivers of negative attitudes toward persons with HIV, positively change attitudes toward persons with HIV held by others. Further research is needed to formally test these hypotheses, assess the extent to which these changes endure over the long term, and determine whether this class of interventions can be implemented at scale.

HIV stigma trends in the general population during antiretroviral treatment expansion: analysis of 31 countries in sub-Saharan Africa, 2003–2013

“…Our findings support the hypothesis that ART scale-up reduces desires for social distance by improving physical health and reducing HIV-related symptom burden, allowing PLHIV to reintegrate as productive members of society and diminishing the association of HIV with economic incapacity 30,31 and “social death” 53 . That this effect is more evident in high-prevalence countries compared to low-prevalence countries lends support to the contact hypothesis put forth by Allport 32 .…”

“…Furthermore, we found evidence for a more substantial decrease over time in social distancing in countries with high HIV prevalence compared to countries with low HIV prevalence, whereas similar increases in anticipated stigma were found in high and low prevalence countries. These findings have important implications for policymakers, as they suggest that ART scale-up alone may be insufficient to effect meaningful improvements in HIV-related stigma, and that further initiatives to counter stigma are likely necessary, such as educational campaigns 21,52 , changes to laws that institutionalize stigma 19 , and livelihood interventions for PLHIV 30,31 .…”

“…Although it has been argued that taking ART might increase the risk of PLHIV being subjected to stigma enactments (because the consistent behaviors required for ART adherence may make it more difficult to hide one’s serostatus 24 ), this concern may ultimately be outweighed by ART-related improvements in physical health and HIV-related symptom burden that reduce the extent to which PLHIV internalize stigmatizing beliefs 25,26 and restore or maintain their economic viability and inclusion within social networks 27,28 . These positive changes, in turn, weaken the symbolic and instrumental associations 29 between HIV and economic incapacity, social isolation, and imminent death 30,31 . Consistent with the contact hypothesis put forth by Allport 32 , this theoretical effect of ART scale-up on HIV-related stigma should be most evident in countries with high HIV prevalence.…”

Prevalence and Predictors of Food Insecurity among People Living with HIV Enrolled in Antiretroviral Therapy and Livelihood Programs in Two Rural Zambian Hospitals

“…Although livelihood programs for PLHIV have been implemented and evaluated with promising effects on food access (Wagner et al 2012; Weiser et al 2015), psychosocial functioning (Tsai et al 2017; Wagner et al 2012), and HIV treatment outcomes (Weiser et al 2015), they remain beyond the reach of many treatment-experienced PLHIV in resource-limited settings. Although there are numerous factors that impede adoption of livelihood programs as a component of HIV care in low-resource settings, one barrier is limited evidence on malleable predictors of adequate access to food among treatment-experienced PLHIV.…”

Substance Use and Psychosocial Status among People Living with HIV/AIDS Who Encountered HIV Stigma in China: Stratified Analyses by Socio-Economic Status

“…On the other hand, studies have indicated the PLWHA with higher SES would have better prognosis as they usually possessed more intangible (e.g., social support, access to health care) and tangible resources (e.g., medication, food supplies, housing) compared to their peers who were at lower SES [10–13]. …”