University of the Witwatersrand (Odimegwu, Akinyemi, Alabi); University of Ibadan (Akinyemi); Federal University (Alabi)
This paper reviews research studies, policies, and programmes related to HIV stigma in Nigeria, the country with the second largest number of people living with HIV (PLHIV) in the world. In March 2017, the authors searched electronic databases PubMed, African Journal Online, and JSTOR for articles on HIV-stigma in Nigeria between 1999 and 2016. The paper shares the findings from this investigation, also exploring policies and programmes related to HIV-stigma in Nigeria, the National HIV/AIDS Stigma Reduction Strategy, and the legal environment assessment for HIV/AIDS response (LEA) in Nigeria.
Before delving into the results of the review, the authors provide some background. Several studies have shown that stigma and discrimination affect HIV testing, disclosure of serostatus, retention, and adherence to treatment. A meta-analysis of 64 studies conducted in different settings demonstrated significant effects of HIV-stigma on mental health, quality of life, use of health services, and physical health of PLHIV. Manifestations or expression of stigma are influenced by sociocultural, political, and economic factors - all of which translates into different forms of inequalities in access to HIV care, treatment, and support. The consequence of these multilevel influences is that HIV-stigma operates at individual, family, community, and institutional levels, and many of these factors also vary across cultures, thereby necessitating context-specific strategies to address the phenomena.
A review of studies on HIV-related stigma in Nigeria between 1987 and 2008 found that HIV-stigma manifests mostly as negative attitudes against PLHIV by individuals and community members and unwillingness to treat PLHIV by healthcare workers. The potential of educational interventions to reduce HIV-related stigma was also demonstrated among secondary school pupils, students in nursing schools, and practicing healthcare workers. "Although the measures used have not been consistent, there is evidence to show that the level of HIV-stigma in Nigeria has declined in the past two decades."
On that note, systematic reviews and other forms of research studies have provided evidence on various interventions to reduce HIV-stigma around the world. Examples include: information-based approaches such as behaviour change communication; capacity building (training of healthcare providers and other allied workers); counselling and support for PLHIV (support groups and network); and involvement of PLHIV in different activities as a way of humanising the infection such that it is seen as any other chronic health condition.
Of the 32 articles included in the present review, 13 were population-based studies. The remaining 19 articles were based in health facilities (11 among PLHIV; 1 among men who have sex with men (MSM); and 7 among health workers). About 60% of all articles used quantitative techniques, while qualitative papers constituted 21.9%. Substantive findings from review of research articles are summarised according to the study population: general population (community members); healthcare workers; and PLHIV. For example, among PLHIV, prevalence of stigmatising experiences varied widely, ranging from 8% to 60%. This wide variation is due to the diverse indices/measures used for stigma. In fact, no two studies defined or measured HIV-stigma in the same manner. This posed limitations to study comparisons and generalisation from one study setting to another. The burden of stigma among PLHIV may be higher than documented in quantitative studies, as findings from FGD participants in Lagos, Nigeria, showed that almost 75% reported that life has become very traumatic due to stigmatisation from friends, family members, healthcare workers, and the workplace.
The paper next reviews policies related to HIV-stigma in Nigeria, including national HIV/AIDS policy, the 2010-2015 HIV/AIDS National Strategic Plan (NSP), the Nigeria National Workplace Policy on HIV and AIDS, Nigeria's HIV and AIDS Antidiscrimination Act (2014), and the National HIV/AIDS Stigma Reduction Strategy, 2016. As reported here, the most common programme targeted at HIV-stigma and discrimination reduction in Nigeria is media and awareness campaigns aimed at educating the populace about HIV and ultimately reducing stigma and discrimination. Two other programmes related to HIV-stigma in Nigeria covered in the paper are the PLHIV stigma index measurement and the legal environment assessment in the HIV response (LEA). For instance, the stigma index was designed to collect data on stigma, discrimination, and rights of people living with HIV. It was also aimed at serving as an advocacy tool and a way to operationalise the principle of Greater Involvement of People Living with HIV (GIPA). As of September 2013, it has been used in more than 50 countries, including Nigeria.
This review revealed that the Government of Nigeria with support from development partners has done a lot to confront HIV-stigma. National policies and strategic plans have been revised several times to align with international best practices as well as respond to the epidemiological and structural dynamics of the HIV epidemic in the country. A robust multisectoral approach with stakeholders' involvement, political will, and policy advocacy at national and state levels have all contributed to general awareness about the urgent need to eliminate stigma and curtail HIV spread.
To further improve on the successes recorded so far, some recommendations are made that could strengthen stigma reduction programmes in the country:
- There is a need for reliable, validated empirical measures of HIV-stigma. Availability of reliable and validated measures will facilitate objective assessment, which is necessary for the monitoring of both the recent stigma reduction strategy in the country and the impact of the 2014 antidiscrimination law. Another reason for new measures of stigma stems from the scale-up of antiretrovial therapy (ART) services to secondary and primary healthcare facilities. It is expected that a deeper population penetration of ART would help correct the misconception that HIV is a death sentence. This faulty belief was responsible for abandonment in the early 2000s and also heightened the fear of casual transmission via mere physical contact. Now that treatment is closer to the grassroots, it ought to have indirectly mitigated some of the stigma.
- Much of what is known about HIV-stigma in Nigeria have come largely from research studies in North Central, South East, South West, and South South regions. Considering the evidence about the dynamic sociocultural nature of stigma, there is need for complementary evidence from the North East and North West regions. In the North East, site of the Boko Haram insurgency, there is anecdotal evidence of increased new HIV infections in internally displaced persons (IDP) camps. The experiences of those affected and how they coped with the challenges could provide useful lessons for stigma reduction programmes in Nigeria.
- Ideas where research gaps exist include: (i) HIV-stigma studies in Nigeria tend to focus on tertiary health facilities, which means they provide information about urban areas. Could stigma be higher in rural areas? Evidence from population-based surveys suggests that stigmatising attitudes towards PLHIV was associated with lower education, poverty, and poor knowledge of HIV. These features are characteristic of rural settings in Nigeria. (ii) The legislative environment in Nigeria is not favourable to key populations at risk of HIV such as MSM. This may also explain why investigation of HIV-stigma in this population is rare in Nigeria.
In conclusion, this review identified the need for a consistent valid and objective measure of stigma at different levels of the HIV response. Empirical evidence on the awareness and effect of anti-HIV discrimination law and other interventions is urgently needed. Nigeria is not lacking in policies, as this review has shown. What needs to be strengthened is programme design, planning, monitoring, and evaluation. It is necessary to intensify advocacy, awareness, and enforcement of the anti-HIV discrimination law. It is also important to develop systems for evaluating the impact of stigma and discrimination reduction programmes at national and subnational levels.
AIDS Research and Treatment Volume 2017, https://doi.org/10.1155/2017/5812650. Image credit: International Reporting Project