Treatment adherence in HIV stigmatized environments in South Africa: stigma avoidance and medication management

Abstract

Stigmatization of HIV infection undermines antiretroviral therapy (ART) adherence. The current study examined strategies that people living with HIV employ to manage their ART in stigmatized environments. We conducted an anonymous survey with 439 patients receiving ART at a community clinic in Cape Town, South Africa. Measures included demographic and health characteristics, ART adherence, stigma experiences, efforts to conceal ART to avoid stigma (stigma–medication management strategies), and beliefs that ART nonadherence itself is stigmatizing. One in four participants had forgone taking their ART in social settings to avoid stigmatization, a behavior associated with younger age, experiencing greater stigma, and poorer ART adherence. Regression models found stigma–medication management strategies significantly predicted ART nonadherence over and above age, gender, alcohol use, and HIV stigma experiences. We also found that a significant majority of participants believed that having unsuppressed HIV and ART nonadherence are irresponsible and should be reprimanded by clinicians. Results show that the behavioral effects of stigma directly impede ART adherence. The behaviors that patients may employ to avoid stigma are amenable to interventions to directly improve ART adherence while managing stigma concerns.

The end of AIDS? HIV and the new landscape of illness in rural South Africa

“…Like previous research, we find both a perceived reduction in HIV-related stigma, alongside evidence that this perception is driven, at least in part, by the concealability of HIV as a result of ART (Treves-Kagan et al 2015). We also find evidence that stigma attached to non-adherent HIV-positive patients in clinics (Bernays et al 2017;Kalichman et al 2019) extends out into the community, as reflected by moralised community discourses blaming AIDS-related deaths on non-adherence to ART. These perspectives have also been observed in other African settings such as Malawi and Lesotho, where individuals who do not seek ART or 'default' are seen to be choosing death and are thus subject to blame (Ashforth & Watkins 2015;Kenworthy 2017).…”

“…In the latter view, ART has transformed HIV from being a 'discredited stigma' where HIV is visible and 'marked' to a 'discredible stigma', where HIV is concealable and allows people with HIV to 'pass' as HIV negative (Goffman 1963 as discussed by Treves-Kagan et al 2015). However, anticipated fear of stigma and discrimination from an HIV-positive status can also result in delayed or non-disclosure (Klopper et al 2014), delay in testing and treatment uptake, and non-adherence (Treves-Kagan et al 2015;Kalichman et al 2019). Indeed, clinics themselves can be spaces where HIV-positive patients experience stigma for non-adherence or less than perfect adherence, such as harsh scolding, threats and judgement from health workers (Bernays et al 2017;Kenworthy 2017).…”

“It’s because I think too much”: Perspectives and experiences of adults with hypertension engaged in HIV care in northern Tanzania

“…In addition, stigma avoidant behaviors, i.e. those actions patients take to avoid experiencing stigma such as concealing ART or non-disclosure of HIV status, may also contribute to nonadherence and disengagement with the medical system [42]. Furthermore, evidence suggests that chronic mental health conditions such as depression may also be a predictor for hypertension treatment nonadherence in similar settings [43].…”

Universal HIV testing and treatment and HIV stigma reduction: a comparative thematic analysis of qualitative data from the HPTN 071 (PopART) trial in South Africa and Zambia

“…In respective studies, Kalichman et al . (2019a) and Mackworth‐Young et al . (2020) for instance, noted that many PLHIV in southern Africa hide their treatment as a strategy to avoid identification and stigma.…”