Scaling up stigma?The Effect of ARV provision on stigma and VCT
uptake
Maria Roura, Mark Urassa, Joanna Busza, Benjamin Nhandi, Doris Mbata, Alison Wringe, Ray Nsigaye, Basia Zaba
TAZAMA / NACP seminar
Dar-es-Salaam, September 19th 2008
OverviewOverview
BackgroundBackground MethodsMethods FindingsFindings ConclusionsConclusions Policy recommendationsPolicy recommendations
VCT uptake
HIV treatment
Reduced stigma
HIV PREVENTION (safer behaviours)
Maximised Synergies
BackgroundBackground
BackgroundBackground
VCT Uptake-Kisesa trade centerAug 2005-June 2007
106
63
34
66
6765
6852
0
20
40
60
80
100
120
Peo
ple
test
ed Referral system established
Methods - Methods - data collectiondata collection
Trade center Rural areas TOTAL
Community leaders 33 58 91Village leaders 4 6 10
Ten-cell & Sub-village leaders 18 40 58Faith leaders 3 4 7
Village advisers (“maarufu”) 6 6 12Traditional Healers 2 2 4
PLHA 39 38 77Male 20 18 38
Female 19 20 39
Health providers 9 7 16Facility based 7 4 11
Community based 2 3 5TOTAL 184
ENACTED ENACTED (discrimination)(discrimination) EXPECTED (anticipated)EXPECTED (anticipated) INTERNALISED INTERNALISED (self-stigma)(self-stigma)
Types of stigmaTypes of stigma
Sources of stigmaSources of stigma BURDEN BURDEN BLAMEBLAME NEW SOURCES related to ARVsNEW SOURCES related to ARVs
Emerging topicsEmerging topics
Preliminary coding
framework
Ongoing process
NORMALISATIONNORMALISATION COLLECTIVE DENIAL COLLECTIVE DENIAL ““OTHERING” – blaming othersOTHERING” – blaming others
Methods - Methods - data analysisdata analysis
Back to productive activitiesBack to productive activities
Not being ‘the only one’Not being ‘the only one’
Increased social support Increased social support
ART contributes to HIV normalisationART contributes to HIV normalisation(ART users views)(ART users views)
REDUCED SELF-REDUCED SELF-STIGMASTIGMA
Positive impact on VCT Positive impact on VCT uptakeuptake
Findings IFindings I
“It has become just like fever, it is for everybody, so I feel good” (ART user, trade centre)
“I am not the only one…it takes even members of parliament” (male, trade centre)
Towards a normalisation of HIVTowards a normalisation of HIV
“Because of my health, I have taken four guys to the VCT centre” (ART user, trade centre)
Findings IFindings I
Pervasive blamingPervasive blaming(Community views)(Community views)
Wide diversity of attitudesWide diversity of attitudes
Exemptions from blame: accidental infection, Exemptions from blame: accidental infection, powerlessness & extreme povertypowerlessness & extreme poverty
HIV = MORAL CHOICEHIV = MORAL CHOICE
ANTICIPATED ANTICIPATED STIGMASTIGMA
Negative impact on VCT Negative impact on VCT uptake uptake
Findings IIFindings II
“…maybe s/he was very promiscuous. Now s/he has been caught” (VL2, semi rural)
Pervasive blaming Pervasive blaming
“A person fears a lot to be isolated by the community in case s/he is found with HIV” (group activity, ART users: males remote rural areas)
Findings IIFindings II
NewNew sources of stigma related to sources of stigma related to ARVsARVs(Village Leaders views)(Village Leaders views)
Findings IIIFindings III
ART users perceived to ‘spread the disease’
‘Moral outrage’
‘‘SolutionsSolutions’’ mentioned mentioned by VLsby VLs::
Marking ART users with a sign, isolation Marking ART users with a sign, isolation camps, impotencecamps, impotence
“…when he will see that his health is good then he will continue spreading infections…” (VL10, remote rural)
“Let him take these medicines and become fat but he should be made impotent “ (VL 1, semi rural)
NewNew sources of stigma related to sources of stigma related to ARVsARVs
Findings IIIFindings III
“ “Othering” and collective denialOthering” and collective denial
Attribution of AIDS symptoms to witchcraft Attribution of AIDS symptoms to witchcraft Perceived advantages of ‘Kondela’:Perceived advantages of ‘Kondela’:
– Keeps hope in a definitive traditional cureKeeps hope in a definitive traditional cure– Turns ‘guilty’ into ‘victims’ : ‘cures’ stigmaTurns ‘guilty’ into ‘victims’ : ‘cures’ stigma– Perpetuates uncertainty and ambiguity when Perpetuates uncertainty and ambiguity when
HIV test is not performedHIV test is not performed
COLLECTIVE DENIAL COLLECTIVE DENIAL Negative impact on VCT Negative impact on VCT
uptakeuptake
Findings IVFindings IV
““Othering” and collective denialOthering” and collective denial
“Their relationship with him/her is good because they believe that s/he is bewitched… If they really knew that this person has AIDS it’s tough in the village. S/he is not taken care of. They say: ‘s/he wanted it, s/he liked it…s/he got it through sex”.
(Maarafu 7, semi rural)
Findings IVFindings IV
ARV provisionPLHA live longer, regain vigour and healthy appearance
- BURDEN-related stigma decreases - SOCIAL SUPPORT from closest social networks increases (families, CTC, HBC providers).
Reduced self- stigma
NORMALISATION
VCT uptake
- BLAME related stigma persists- NEW SOURCES emerge: FEAR sexual transmission exacerbated + moral outrage
Pervasive anticipated stigma
COLLECTIVE DENIAL
+ sensit. Campaigns + attrib. of HIV to WC
-+
DiscussionDiscussion
ConclusionConclusion
The persistence of blaming attitudes The persistence of blaming attitudes and emergence of and emergence of new sources of new sources of stigma directly related to ARV stigma directly related to ARV provision provision feed into high levels of HIV feed into high levels of HIV denial and counter-balance the denial and counter-balance the potential positive impact of HIV potential positive impact of HIV normalization on VCT uptake normalization on VCT uptake
NORMALISATION
NATIONAL LEVELTesting of government leaders
(Tanzania – Kikwete campaign)
LOCAL LEVEL
- VCT local leaders (VEO, Blz, Vt, ‘Maarufu’,THs)
- Involving FLs in VCT promotion
- Strengthening of VACs (training +budget)
-Increased visibility + participation ART users
-Raising awareness detrm. effects of stigmaon VCT, ART and HIV transmission
NATIONAL LEVELCriminalization of HIV
(many European and African countries)
STIGMA SCALE-UP
LOCAL LEVEL
- Misinformation over HIV transmission risks (recently infected vs ART users) FEAR - Moral exploitation of HIV to control behaviours BLAME
- Highly visible food support only to PLHA MORAL OUTRAGE
Policy implicationsPolicy implicationsHIV Normalisation or scaling-up stigma?HIV Normalisation or scaling-up stigma?
Policy recommendationsPolicy recommendations
• Multilevel interventions emphasising community Multilevel interventions emphasising community levellevel
• Wide coverage of training for MAC at village levelWide coverage of training for MAC at village level
• Need to target: Need to target:
1.1. PLHA + their familiesPLHA + their families2.2. Opinion Leaders Opinion Leaders general population general population
• Improved image of PLHA Improved image of PLHA Chart of rights and Chart of rights and responsibilitiesresponsibilities
Role of opinion leaders Role of opinion leaders VCT uptake -VCT uptake - Kisesa trade centreKisesa trade centre (March 2006- July (March 2006- July
2008)2008)
14th July 2008Kikwete testing - National campaign
52
204
786663
104 106
210
274
0
50
100
150
200
250
300
Peo
ple
teste
d
14th July 2007Launching of National campaign
TESTING OF TOP GOVERNMENT LEADERS
15% tested(nat level)
36%(3.2 million)
Regional launchMWANZA22nd sept
Thanks!Thanks!
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