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AIDS: A case study of selected states in North-West Nigeria
HIV & AIDS Review 10 (2011) 19–25
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HIV/AIDS-related stigma and access to HIV treatments by people living with HIV/AIDS: A case study of selected states in North-West Nigeria Onoja Matthew Akpa a,∗ , Victoria Adeolu-Olaiya a , C. Adenike Olusegun-Odebiri b , Doyin Aganaba c a b c
Department of Mathematical Sciences, Redeemer’s University, P.M.B. 3005, Redemption City, Ogun State, Nigeria University of Ilorin Teaching Hospital, Ilorin, Kwara State, Nigeria The Federal Capital Territory (FCT), Health Services Insurance Scheme, FCT, Abuja, Nigeria
a r t i c l e
i n f o
Article history: Received 7 October 2010 Received in revised form 21 December 2010 Accepted 23 December 2010 Available online 19 January 2011 Keywords: HIV-related stigma Anti-retroviral therapy Treatment adoption HIV/AIDS in Nigeria Logistic regression
a b s t r a c t Objectives: To study the prevalence of HIV-related stigma and the effect of stigma on HIV treatment adoption among PLWHA attending HIV treatment locations in some selected states in the North-West geopolitical zone of Nigeria. Methods: A cross-sectional survey was conducted (using structured questionnaires) among PLWHA in three selected states in the North-West geopolitical zone of Nigeria and Abuja, the Federal Capital Territory (FCT). The multiple logistic regressions analysis was used to determine factors associated with HIV-related stigma and adoption of HIV treatment. Results: It was found that 71(21.3%), 88(26.3%) and 43(12.8%) of the participants were facing HIV-related stigma from their place of works, the public and their family members. Also, the results of the logistic regressions show that PLWHA who have no formal education and those with primary education were less likely to face stigma from the public (OR-0.212; 95% CI-0.064–0.702; p < 0.05) and their employers (OR-0.236; 95% CI-0.072–0.775; p < 0.05) respectively. Conclusion: Although majority of the participants claimed not to be facing any form of HIV-related stigma, the prevalence of HIV-related stigma observed (job related stigma – 21.3%, stigma from the public – 26.3% and stigma from family members-12.8%) among the participants in this study still calls for concern. © 2011 Polish AIDS Research Society. Published by Elsevier Urban & Partner Sp. z.o.o. All rights reserved.
1. Introduction Nigeria is the most populous country on the continent of Africa and it accounts for approximately one-sixth of Africa’s people [2,3,8,9]. Although HIV prevalence rates are much lower in Nigeria than in many other African countries such as South Africa and Swaziland, the number of people living with HIV/AIDS in Nigeria has been estimated to be the largest in the world after India and South Africa; this is attributable to the growing size of Nigeria’s population [3–7]. Since the first case of AIDS was diagnosed in Nigeria in 1986 in a sexually active girl, HIV/AIDS epidemic continue to grow in the general population of Nigeria until date. While recent estimates show some worth decline in the prevalence of HIV/AIDS in Nigeria, results from specific states and sentinel surveillance centers (SSC) call for caution. For instance, in the last and most recent (2008) national HIV sentinel sero-prevalence survey [22] conducted among women 15–49 years attending antenatal clinics in Nigeria (which is the
∗ Corresponding author. Tel.: +234 803 215 9579. E-mail address: [email protected] (O.M. Akpa).
most readily available sources of data that inform trends about HIV/AIDS in sub-Saharan Africa), the prevalence ranged from 1.0% in Ekiti state to 10.6% in Benue State [22]. Seventeen (17) states and the Federal Capital Territory (FCT) had prevalence of 5.0% and above with seven (7) of them and the FCT having a prevalence of 7% or higher. In particular, astonishing HIV prevalence of 22.0% and 19.5% were recorded in Bwari (FCT) and Lafia (Nasarawa), respectively [22]. The rapid spread of HIV in Nigeria has been accounted for by a number of factors; these include sexual networking practices such as polygamy, high prevalence of untreated sexually transmitted infections, low condom use, poverty, low illiteracy, poor health status, low status of women, stigmatization, denial of HIV infection risk among vulnerable groups such as long distance truckers, female sex workers, students, etc. [23,26]. However, HIV-related stigma and discrimination was recognized early on in the AIDS epidemic as a key factor in fueling the spread of HIV [17]. It should be noted that the stigmatization of individuals infected and affected by HIV and the eventual discrimination, which they suffer, are the tragic consequences of HIV disease [26]. Unfortunately, incidence of HIV/AIDS-related stigma in Nigeria is on the increase in some locations, which is in line with
1730-1270/$ – see front matter © 2011 Polish AIDS Research Society. Published by Elsevier Urban & Partner Sp. z.o.o. All rights reserved. doi:10.1016/j.hivar.2010.12.004
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the predictions of Sabatier [27] of an increase in AIDS stigma and discrimination at the individual, community and national levels as the epidemic grows. In fact, since the time HIV was discovered in Nigeria, social responses of fear, denial, stigma and discrimination have accompanied it and this has spread rapidly, giving rise to anxiety and prejudices against the groups most affected as well as individuals infected and affected [26]. A part from that, it has been discovered that stigma and some other factors (like education and religion) have hindered HIV patients from taking advantage of medical care, particularly, HIV status testing [15,20]. Several studies that addressed the issue of HIV-related stigma from different backgrounds and populations have been published [1,2,10–21,24–27]. Specifically, Ogunjuyigbe et al. [2] studied issues pertaining to the attitudes of friends, relatives and neighbours to people living with HIV/AIDS and the implication this will have for infection and spread of HIV/AIDS in Lagos State, Nigeria. Chirwa et al. [11] explored the demographic and social factors, including perceived HIV stigma that influence job satisfaction in nurses from five African countries. In this study, we seek to identify the specific factors that affect HIV patients this way in the selected study locations in Nigeria and to what extent does a particular factor prevents HIV patients from adopting ART. We present a comprehensive and detailed results on a study conducted among people living with HIV/AIDS (PLWHA) in order to assess the degree of stigma prevalent among them, whether stigmatization affects their access to and willingness to adopt HIV drugs and what are the most important factors associated with HIV-related stigma in the population studied. Also, focusing on stigmatization, we would like to know what are the different contexts and manifestations, how does it prevent ART adoptions and what are the varying determinants necessitating stigmatization among the studied population. In addition, we also present recommendations based on our findings. 2. Methods 2.1. Study design and sample sizes We interviewed PLWHA attending receiving treatments at two locations (Kubwa General Hospital, Abuja and Asokoro General Hospital, Abuja) within the Federal Capital Territory, Abuja and three other states of the North-West geopolitical zone of Nigeria: Kaduna state (General Hospital, Sabon-Tasha, Kaduna), Sokoto State (Usman Danfodio University Teaching Hospital (UDUTH), Sokoto) and Kebbi State (General Hospital, Birnin-Kebbi). The states were randomly selected based on the authors’ perceived easy access to PLWHA attending HIV drug distribution centers in the states and in each state, the most popular (and most patronized) center is selected for study. A total of 335 PLWHA from four HIV drug distribution centers (one center from each of the three states and the FCT) were interviewed in this study. From the Kaduna center, a total of 145 (43.3%) PLWHA were interviewed, 136 (40.6%) of the interviewed PLWHA are from the Abuja (FCT) center, 20 (6.0%) were interviewed at the center in Kebbi while 34 (10.1%) were interviewed at Sokoto. 2.2. Ethical considerations and data collection In each center, permission to conduct the study among PLWHA was obtained from the appropriate authorities and the participants. All the participants who gave informed consent were at liberty to withdraw from the study at anytime. PLWHA who gave consent were given a copy of the questionnaires to feel and trained interpreters were used to interpret the meaning of the items in
the questionnaires for participants who do not understand English language perfectly. In addition, participants’ confidentiality was further guaranteed by ensuring that the administration of the anonymous questionnaires and the interviews that backed up the filling of the questionnaires took place in privacy. 2.3. Questionnaire The questionnaire contains standardized questions (which were edited for biases by qualified health survey professionals trained in health surveys) focusing on three fundamental variables: sociodemographic variable, HIV-related stigma and HIV treatment. 2.4. Variables The variables of interest in this research study are broadly divided into three categories: the socio-demographic variables, variables on the HIV-related stigma and variables on HIV drugs adoption. In order not to discourage PLWHA (the respondents) from completing the questionnaires; we deliberately keep our questions (questionnaire items) as straight to the point as possible. 2.4.1. Socio-demographic Items on the socio-demographic variable include, among others; age of participants, place of domicile, sex, marital status, educational status, state of origin, etc. (see Table 1 for details). 2.4.2. HIV-related stigma On the HIV-related stigma, we asked questions such as how did you feel when you were diagnosed to be HIV positive, does your HIV status affects your employment, do people who know you have HIV still relate well with you, does your spouse and children relate well with you, etc. (Table 2). 2.4.3. Adoption of anti-retroviral therapy On the anti-retroviral drug use, we asked questions such as, are you currently on any HIV drugs/treatment, would your taking HIV drugs declare your status to people, if yes to the question above (refereeing the previous question), would you stop taking the drugs because of that, would you always ensure that you take HIV drugs, etc. (Table 3). 2.5. Presentation of data and statistical analysis Preliminary analysis was carried out using frequency tables and percentages to study the distribution of the respondents (PLWHA) across the study locations and also to study how the respondents differ in their responses to the questionnaire items. A part from that, the logistic regression was applied to study the associations between the different variables of the questionnaire via the statistical package for social sciences (SPSS) version 13.0 (SPSS Inc., Chicago, IL, USA). We used the logistic regression to study which of the selected questionnaire items are associated with HIVrelated stigma and HIV treatment. 3. Results A total of 335 PLWHA participated in this study. Tables 1–3, show that 145 (43.3%) participants were interviewed at Kaduna, 136 (40.6%) at Abuja, 20 (6%) at Kebbi and 34 (10.1%) at Sokoto. 3.1. Socio-demographic In Table 1, the results of the socio-demographic characteristics of participants are presented. It was observed that, of the 335
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Table 1 The socio-demographic variables of people living with HIV/AIDS in the selected states of North-West Nigeria. Variables Sex Male Female
Kaduna N = 145 (%)
Abuja N = 136 (%)
Kebbi N = 20 (%)
Sokoto N = 34 (%)
Combined N = 335 (%)
111 (76.6) 34 (23.4)
71 (52.2) 65 (47.8)
13 (65.0) 7 (35.0)
28 (82.4) 6 (17.6)
223 (66.6) 112 (33.4)
Age (years) <20 20–29 30–39 40–49 ≥50
3 (2.1) 40 (27.6) 61 (42.1) 30 (20.7) 11 (7.6)
3 (2.2) 53 (39.0) 48 (35.3) 26 (19.1) 6 (4.4)
2 (10.0) 8 (40.0) 6 (30.0) 4 (20.0) –
– 11 (32.4) 16 (47.1) 5 (14.7) 2 (5.9)
8 (2.4) 112 (33.4) 131 (39.1) 65 (19.4) 19 (5.7)
Marital status Single Married Widowed Divorced Separated
43 (29.7) 82 (56.6) 14 (9.7) 5 (3.4) 1 (0.7)
46 (33.8) 69 (50.7) 9 (6.6) 5 (3.7) 7 (5.1)
6 (30.0) 8 (40.0) 5 (25.0) 1 (5.0) –
12 (35.3) 17 (50.0) 3 (8.8) 1 (2.9) 1 (2.9)
107 (31.9) 176 (52.9) 31 (9.3) 12 (3.6) 9 (2.7)
Educational status None Primary Secondary Tertiary
16 (11.0) 30 (20.7) 67 (46.2) 32 (22.1)
10 (7.4) 9 (6.6) 61 (44.9) 56 (41.2)
5 (25.0) 4 (20.0) 8 (40.0) 3 (15.0)
8 (23.5) 3 (8.8) 8 (23.5) 15 (44.1)
39 (11.6) 46 (13.7) 144 (43.0) 106 (31.6)
Occupation Unemployed Self-employed Civil servant Others
63 (43.4) 43 (29.7) 22 (15.2) 17 (11.7)
52 (38.2) 34 (25.0) 39 (28.7) 11 (8.1)
8 (40.0) 4 (20.0) 5 (25.0) 3 (15.0)
8 (23.5) 5 (14.7) 12 (35.3) 9 (26.5)
131 (39.1) 86 (25.7) 78 (23.3) 40 (11.9)
129 (89.0) 11 (7.6) 5 (3.4)
89 (64) 44 (32.4) 5 (3.7)
7 (35.0) 13 (65.0) –
12 (35.3) 22 (64.7) –
235 (70.1) 90 (26.9) 10 (3.0)
Religion Christianity Islam Others
participants who consented to be interviewed, 223 (66.6%) were male while 112 (33.4%) were female. The highest number of male participants was recorded at Kaduna where 111 (76.6%) of those interviewed were male while the highest number of female par-
ticipants was recorded at Abuja where a total of 65 (47.8) of those interviewed were female. Most of the PLWHA who consented to the interview fall into 20–29 years and 30–39 years of age with 112 (33.4%) and 131 (39.1%) belonging to each age group, respectively.
Table 2 The distribution PLWHA with respect to variables describing HIV-related stigma in the selected states of the North-West Nigeria. Variables
Kaduna N = 145 (%)
Abuja N = 136 (%)
Kebbi N = 20 (%)
Sokoto N = 34 (%)
Combined N = 335 (%)
How did you feel when you first heard that you were HIV positive? Nothing 31 (21.4) 23 (16.9) Suicidal thoughts 20 (13.8) 23 (16.9) Shy 1 (0.7) 11 (8.1) Very sad 90 (62.1) 72 (52.9) Others 3 (2.1) 7 (5.1)
2 (10.0) 6 (30.0) 2 (10.0) 10 (50.0) –
5 (14.7) 5 (14.7) 1 (2.9) 22 (64.7) 1 (2.9)
61 (18.2) 54 (16.1) 15 (4.5) 194 (57.9) 11 (3.3)
Does your HIV status affect your employment? Yes 26 (17.9) No 119 (82.1)
31 (22.8) 105 (77.2)
3 (15.0) 17 (85.0)
11 (32.4) 23 (67.6)
71 (21.2) 264 (78.8)
Is your spouse HIV positive too? Yes 66 (45.5) No 79 (54.5)
61 (44.9) 75 (55.1)
16 (80.0) 4 (20.0)
24 (70.6) 10 (29.4)
167 (49.9) 168 (50.1)
Can you tell people you are HIV positive? Yes 56 (38.6) No 89 (61.4)
78 (57.4) 58 (42.6)
10 (50.0) 10 (50.0)
28 (82.4) 6 (17.6)
150 (44.8) 185 (55.2)
Do people who know you are HIV positive still relate well with you? Yes 105 (72.4) 102 (75.0) No 40 (27.6) 34 (25.0)
16 (80.0) 4 (20.0)
24 (70.6) 10 ((29.4)
247 (73.7) 88 (26.3)
Does your spouse and children still relate with you? Yes 123 (84.8) No 22 (15.2)
123 (90.4) 13 (9.6)
18 (90.0) 2 (10.0)
28 (82.4) 6 (17.6)
292 (87.2) 43 (12.8)
Do people relate well with you before you present HIV status? Yes 134 (92.4) 124 (91.2) No 11 (7.6) 12 (8.8)
17 (85.0) 3 (15.0)
29 (85.3) 5 (14.7)
304 (90.7) 31 (9.3)
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O.M. Akpa et al. / HIV & AIDS Review 10 (2011) 19–25
Table 3 Treatment related variable of PLWHA in the selected states of the North-West Nigeria. Variables
Kaduna N = 145 (%)
Are you currently on medication? Yes 118 (81.4) No 27 (18.6)
Abuja N = 136 (%) 110 (80.9) 26 (19.1)
Kebbi N = 20 (%)
Sokoto N = 34 (%)
Combined N = 335 (%)
14 (70.0) 6 (30.0)
27 (79.4) 7 (20.6)
269 (80.3) 66 (19.7)
Would your taking anti-retroviral therapy declare your status to people? Yes 55 (37.9) 84 (61.8) No 90 (62.7) 52 (38.2)
11 (55.0) 9 (45.0)
8 (23.5) 26 (76.5)
158 (47.2) 177 (52.8)
If yes to the above question, will you stop taking the drugs because of that? Yes 11 (7.6) 8 (5.9) No 134 (92.4) 128 (94.1)
2 (10.0) 18 (90.0)
3 (8.8) 31 (91.2)
24 (7.2) 311 (92.8)
Would you always ensure that you take anti-retroviral therapy? Yes 136 (93.8) 123 (90.4) No 9 (6.2) 13 (9.6)
20 (100.0) –
30 (88.2) 4 (11.8)
309 (92.2) 26 (7.8)
In addition, while more than half of the participants (176/52.9%) were married, many of them (107/31.9%) were singles (unmarried), 31 (9.3%) were either widows or widowers, 12 (3.6%) were divorcees and 9 (2.7%) were separated from their spouses. 82 (56.6%) of those interviewed at Kaduna were married while 69 (50.7%), 8 (40.0%) and 17 (50.0%) of those interviewed at Abuja, Kebbi and Sokoto, respectively, were married. This implies that 46.6%, 39.2%, 4.5% and 9.7% of the 176 married participants were interviewed at Kaduna, Abuja, Kebbi and Sokoto, respectively. Also, 43 (29.7%), 46 (33.8%), 6 (30.0%) and 12 (35.3%) of those interviewed at Kaduna, Abuja, Kebbi and Sokoto were unmarried, implying that, 40.2%, 43.0%, 5.6% and 11.2% of the 107 unmarried participants were interviewed at Kaduna, Abuja, Kebbi and Sokoto, respectively. Majority of the participants (144/43.0%) interviewed have secondary school education, 106 (31.6%) have tertiary education while 39 (11.6%) and 46 (13.7%) of the participants have no formal education and primary school education, respectively. Although most of the participants at Sokoto – 15 (44.1%) have tertiary education, most of the participants in all the other states had secondary school education only (Table 1). Furthermore, majority of the PLWHA (131/39.1%) were unemployed, 86 (25.7%) were self-employed, 78 (23.3%) were civil servants while 40 (11.9%) of them were into other forms of employment status. While most of the participants at Kaduna – 63 (43.4%), Abuja – 52 (38.2%) and Kebbi – 8 (40.0%) were unemployed, majority of those interviewed at Sokoto – 12 (35.3%) were civil servants. This may be attributed to the fact that most of the participants interviewed at Sokoto were people who have tertiary education.
3.2. HIV-related stigma The distribution of participants with respect to their reposes to selected question on HIV-related Stigma is presented in Table 2. A total of 194 (57.9%) felt very sad when they heard the results of their HIV status test, 61 (18.2%) said they felt nothing while 54 (16.1%) had some thoughts of committing suicide. Although suicidal thought was not the most common feelings among participants, 20 (37.0%), 23 (42.6%), 6 (11.1%) and 5 (9.3%) of the 54 who had suicidal thoughts were interviewed at Kaduna, Abuja, Kebbi and Sokoto, respectively. Most of the participants (264/78.8%) said that their HIV status does not affects their jobs while 71 (21.2%) claimed that being HIV positive have had some negative effect on their employments. More than half of the participants (185/55.2%) said they cannot disclose their HIV status to people while 150 (44.8%) said they could disclose their HIV status to people. A closer look at the results reveals that the participants at Kebbi state were equally divided (10/50.0%) each for willingness to and not willing to reveal their HIV status to people. At Kaduna, most of the participants –
89 (61.4%) would not disclose their HIV status while at Abuja and Sokoto, most participants (28/82.4% and 28/82.4%, respectively) would not mind telling people that they are HIV positive. A part from that, many of the participants 247 (73.7%) said that people still relate well with them despite their HIV status while 88 (26.3%) claimed to be facing some levels of difficulties in their relationships (due to their HIV status) with people around them. Also, while majority of the participants (292/87.2%) confirmed that their spouses and children still relate well with them (despite their HIV status), 43 (12.8%) claimed not to be receiving the expected support from their spouses and children (family members). 3.3. Anti-retroviral therapy adoption The responses of participants to selected questions related to, access to and adoption of HIV treatments are presented in Table 3. It was observed that majority of participants (269/80.3%) were already on anti-retroviral medications while 66 (19.7%) of them were yet to be placed on HIV treatments because they were yet to complete their registration processes. In addition, while a total of 158 (47.2%) agreed that taking anti-retroviral therapy will not reveal their HIV status to people, 177 (52.8%) claimed that their HIV status will be revealed to people should they adopt HIV treatment plan. Furthermore, although most of the participants at Kaduna (90/62.7%) and Sokoto (26/76.5%) claimed that taking antiretroviral therapy will reveal their HIV status to people, most of the participants at Abuja (84/61.8%) and Kebbi (11/55.0%) confirmed that taking HIV treatments have nothing to do with revealing their HIV status to people. Nevertheless, an overwhelming majority of the participants (311/92.8%) confirmed that they will not stop antiretroviral therapy even if it will reveal their HIV status to people while only 24 (7.2%) concluded that they will withdraw from HIV treatment plans should they discover that their HIV status will be revealed to people in the process of taking anti-retroviral therapy. Also, while majority of the participants (309/92.2%) confirmed that they will always ensure that they take anti-retroviral therapies, 26 (7.8%) were not sure that they will always take anti-retroviral medications. 3.4. Results of the logistic regressions Multiple logistic regression models were used to determine the association of the HIV-related stigma and anti-retroviral therapy variables with all the factors considered in the study. The results of the selected factors associated with these (HIV-related stigma and anti-retroviral therapy) variables are present in Tables 4 and 5 and described in Sections 3.4.1 and 3.4.2 below.
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Table 4 Results of the logistic regression for factors associated with variables describing HIV-related stigma. Factors
Variables describing HIV-related stigma Odds of HIV status affects employment (95% CI CL)
Odds of willing to reveal HIV status (95% CI CL)
Odds of facing stigma from the public (95% CI CL)
Odds of facing stigma from the family members (95% CI CL)
.529 (.167–1.679) .326* (.915–.116) .650 (1.386–.305)
.212* (.064–.702) 1.149 (.350–3.768) .369* (.158–.860) –
3.313 (.341–32.179) .091** (.020–.412) .480 (.137–1.684) –
.951 (.130–6.374) .915 (.131–6.934) .687 (.083–5.671) .243 (.021–2.843)
Educational status None Primary Secondary Tertiary
–
Marital status Single Married Widowed Divorced Separated
1.053 (.158–7.001) 1.114 (.170–7.325) 2.302 (.130–17.826) .371 (.022–6.388) –
–
.995 (.167–5.936) 1.152 (.196–6.757) 2.857 (.375–21.793) 4.174 (.360–48.400) –
Occupation Unemployed Self-employed Civil servant Others
1.858 (.670–5.153) 1.551 (.502–4.790) .876 (.278–2.760) –
3.450* (1.134–10.501) 4.041* (1.261–12.953) 4.256* (1.270–14.261) –
1.025 (.405–2.596) 1.603 (.546–4.708) .612 (.205–1.827) –
Religion Christianity Islam Others
4.855 (.411–57.299) 2.553 (.211–30.902) –
.450 (.137–1.475) .236* (.775–.072) .464 (.998–.216) –
.243 (.035–1.678) .143 (.020–1.041)
10.625* (1.398–80.725) 14.656** (1.992–107.814) 56.518* (2.318–1378.213) 4.698 (.316–69.860) – 1.216 (.300–4.938) 1.196 (.242–5.925) 1.706 (.342–8.517) –
–
4.657 (.941–23.064) 6.529* (1.240–34.390) –
For how many years have you been HIV positive? <2 years .318** (.153–.662) 2–3 .299* (.107–.837) 4–5 .486 (.170–1.389) 5 –
2.499* (1.156–5.404) 1.479 (.535–4.083) 1.613 (.530–4.910) –
1.066 (.482–2.356) 1.809 (.589–5.554) .780 (.281–2.163) –
Are you currently on any drugs/treatment? Yes .414* (.178–.964) No –
–
–
–
Is your spouse HIV positive too? Yes .670 (.348–1.289) No –
1.030 (.553–1.918) –
1.074 (.563–2.051) –
–
2.332* (1.128–4.822) –
–
.776 (.369–1.631)
Would your taking anti-retroviral therapy declare your status to people? Yes .497 (.243–1.014) .077*** (.040–.149) No – – * ** ***
.802 (.052–12.328) .665 (.043–10.285) – .690 (.207–2.302) .174* (.043–.697) 1.010 (.209–4.882) –
.740 (.348–1.575)
.603 (.210–1.729)
.383* (.150–.978)
.725 (.263–2.004)
p < 0.05. p < 0.01. p < 0.001.
3.4.1. Logistic regression for variables associated with HIV-related stigma The results of the multiple logistic regressions for the HIVrelated stigma are presented in Table 4. The aim was to present results only for factors that were found to be associated with any of the variables describing HIV-related stigma in this study. It was found that PLWHA who has no formal education are less likely to face stigma from the public (OR 0.212; 95% CI 0.064–0.702; p < 0.05) while those with primary school education are less likely to face HIV-related stigma from their employers (OR 0.236; 95% CI 0.072–0.775; p < 0.05) and their family members (OR 0.091; 95% CI 0.02–0.412; p < 0.01). Also, while PLWHA with primary school education are less likely to tell people their HIV status (OR 0.326; 95% CI 0.116–0.915; p < 0.05), those with secondary school education are less likely to be stigmatized by the public (OR 0.369; 95% CI 0.158–0.860; p < 0.05). A part from that, it was also observed that while those whose spouses are HIV positive are less likely to face HIV-related stigma from their family members (OR 0.383; 95% CI 0.150–0.978; p < 0.05), PLWHA who are Muslim are more likely to be stigmatized by the public (OR 6.529; 95% CI 1.240–34.390; p < 0.05) and those who think that taking HIV treatment will reveal their HIV status are less likely to reveal their HIV status to people (OR 0.077; 95% CI 0.040–0.49; p < 0.001).
3.4.2. Logistic regression for variables associated with the adoption of HIV treatment In Table 5, the results of the logistic regressions for factors associated with variables describing anti-retroviral therapy adoptions are presented. It was observed that PLWHA who have primary school education are more likely to continue anti-retroviral therapy (OR 9.084; 95% CI 1.021–80.851; p < 0.05) while those who were diagnosed in less than two years ago are less likely to continue HIV treatments (OR 0.129; 95% CI 0.020–0.846; p < 0.05) and those who agreed that they could reveal their HIV status to people are less likely to think that taking anti-retroviral therapy could reveal their HIV status (OR 0.087; 95% CI 0.046–0.164; p < 0.001). 4. Discussions In this study, we have presented a comprehensive report of a study conducted among PLWHA in selected states from the NorthWest geopolitical zone of Nigeria. In each study locations, effort was made to include all PLWHA (who gave their consents) in the study. Also, while we recognized that interviewing all PLWHA in the various locations would have yielded a more complete study, ethical considerations provide that participation in a study of this nature has to be by choice [19–21,28] and hence, this report covers
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Table 5 Results of the logistic regression for factors associated with variables describing anti-retroviral therapy adoption. Factors
Variables describing anti-retroviral therapy adoption Odds of being currently on any anti-retroviral therapy (95% CI CL)
Odds of taking anti-retroviral therapy will reveal HIV status (95% CI CL)
Odds of stopping drugs to conceal status (95% CI CL)
1.280 (.371–4.418) .767 (.276–2.128) 1.177 (.549–2.522) –
.965 (.336–2.774) 1.512 (.571–4.005) .733 (.360–1.492) –
4.127 (.635–26.810) 1.107 (.176–6.954) 2.028 (.527–7.802) –
12.632 (.766–208.292) 9.084* (1.021–80.851) 2.886 (.764–10.901) –
For how many years have you been HIV positive? <2 years 1.113 (.520–2.385) 2–3 .946 (.355–2.524) 4–5 1.901 (.585–6.176) >5 –
1.087 (.537–2.1990 1.940 (.760–4.951) 1.348 (.503–3.6160 –
.670 (.196–2.286) .573 (.114–2.878) .310 (.032–3.011)
.129* (.020–.846) .392 (.037–4.155) .146 (.009–2.254)
Can you tell people that you are HIV positive? Yes .786 (.375–1.645) No –
–
Educational status None Primary Secondary Tertiary
* ***
–
.087*** (.046–.164)
Odds of continuing anti-retroviral therapy usage (95% CI CL)
– .813 (.231–2.855)
–
.310 (.069–1.386) –
p < 0.05. p < 0.001.
responses from only PLWHA who gave their consents to participate in this study at the various locations. In addition to that, predominant religious sentiments and the low educational status of the general population at the various study locations have in no small way negatively affected the number of PLWHA that consented to participate in this study; we expected more consents than we got. These explain why only twenty participants were interviewed at Kebbi state. Consequently, we may not be able to generalize the results of this study for the population of PLWHA in Nigeria but as far as the specific centers where this study was conducted are concerned, enough effort was made to make this study as representative as possible. It was found that majority of the PLWHA who participated in this study fall within the middle-aged people with a few others below 20 years of age and above 50 years of age. These further substantiated the fact that HIV/AIDS is really an epidemic majorly among the active age group. Past studies conducted among PLWHA revealed that the epidemic is more prevalent among young adult [2,15,20,22,28,29]. It was also found that while majority of the participants were married, more than half of them have spouses who are HIV negative and more than half of those who are married still have sex with their spouses. With this possibilities in place, spouses of PLWHA who are currently HIV negative stands the danger of getting infected in future, more so that majority of the infected people are not willing to reveal their HIV status even to their spouses. In addition, majority of the participants were either unemployed or self-employed. These employment statuses for PLWHA in the studied locations are high because of the rising number of PLWHA quitting jobs or losing jobs due to HIV-related stigmatizations and the unemployed people who are getting infected due to HIV-related risky behaviours. While the predominant religion in the studied locations is Islam, majority of the participants in this study are Christians, except for Kebbi and Sokoto state. This could be due to two related factors: religious sentiments and culture prevents some PLWHA who are Muslims in these part of Nigeria from attending anti-retroviral therapy centers (especially if they are female) and the same reasons also prevent some of them from participating in a study of this nature even if they are attending anti-retroviral therapy centers. This is evident in the low number of participants recorded at Kebbi and Sokoto states, which are considered as core Northern states even
though the number of Muslim participants in these states exceeded the number of Christian participants. Although many of the participants said they felt very sad at the news of their present HIV status, the number of participants who had suicidal thoughts calls for concern. Many of them felt like committing suicide because of the obvious danger of facing stigmatization from the general public, the untold consequence of losing their jobs should their HIV status be known at their place of work, the shame and rejection from their family members and friends, the knowledge of the fact that there is no cure for AIDS, etc. Furthermore, it was found that although majority of the participants claimed that their HIV status does not affects their employments, many of them would not want to disclose their HIV status to anybody either at home or at their place of employment. In addition, while some of the participants claimed that they never faced any form of stigma, from the public or their families, the results of the logistic regressions show that those who are Muslims among them are more likely to face stigmatization from the public and those whose spouses have died are more likely to be stigmatized by their family members. It was found that majority of the participants are already taking anti-retroviral therapy but lack of funds and personnel have been identified as potential problem facing continuation of this provisions. Also, while majority of the participants claimed that they would always ensure that they take HIV drugs, only those with primary school education are more likely to continue HIV treatments at the various centers while those who were diagnosed less than two years ago are less likely to continue HIV treatments.
Acknowledgements The authors are very grateful the management of the Redeemer’s University and the management of the following Institutions: General Hospital Sabon-Tasha, Kaduna; Usman Danfodio University Teaching Hospital (UDUTH) Sokoto; Kubwa General Hospital, Abuja; Asokoro General Hospital, Abuja and General Hospital Birnin-Kebbi where access was granted to PLWHA who participated in this study.
O.M. Akpa et al. / HIV & AIDS Review 10 (2011) 19–25
References [1] K. Sikwese, P. Nweke, R. Mwaniki, J. Hows, G. Reid, Doing it for ourselves: PLHIV led research into stigma in 3 African countries: Kenya, Nigeria, Zambia THPE0948, 2009. [2] P.O. Ogunjuyigbe, E.O. Adeyemi, M.O. Obiyan, Attitudes toward people living with HIV/AIDS: implication for infection and spread of HIV/AIDS in Lagos State, Nigeria, Journal of Chinese Clinical Medicine 4 (3) (2009). [3] Wikipedia, HIV/AIDS in Africa, Wikipedia 2010, available at http://en.wikipedia.org/wiki/HIV/AIDS in Africa. [4] O.M. Akpa, B.A. Oyejola, Modeling HIV/AIDS epidemics in West Africa: results for UNAIDS modeling approach from some selected countries, Research Journal of Applied Sciences 2 (11) (2007) 1148–1155. [5] J. Pennington, HIV and AIDS in Nigeria, Avert 2006, available at www.avert.org/aids-nigeria.htm, 2006. [6] UNAIDS/WHO, 2009 report on the global AIDS epidemic, 2010, available at http://data.unaids.org/pub/Report/2009/JC1700 Epi Update 2009 en.pdf. [7] Kaiser Foundation, The global HIV/AIDS epidemic. Kaiser family foundation 2010, available at http://www.kff.org/hivaids/upload/3030-13.pdf. [8] NPC, Nigerian population by states, National Population Commission (Nigeria) 2010, available at http://www.population.gov.ng/. [9] NPC, Detailed report on the census 2006 and provisional results, Federal Government of Nigeria Official Gazette, 24, 2007. [10] N. Mawar, S. Sahay, A. Pandit, U. Mahajan, The third phase of HIV pandemic: social consequences of HIV/AIDS stigma and discrimination and future needs, Indian Journal of Medical Research 122 (2005) 471–484. [11] M.L. Chirwa, M. Greeff, T.W. Kohi, J.R. Naidoo, L.N. Makoae, P.S. Dlamini, C. Kaszubski, Y.P. Cuca, L.R. Uys, W.L. Holzemer, HIV stigma and nurse job satisfaction in five African countries, Journal of the Association of Nurses in AIDS Care 20 (2009) 14–21. [12] E. Kalipeni, HIV/AIDS in women: stigma and gender empowerment in Africa, Future HIV Therapy 2 (2) (2008) 147–153. [13] D.C.J. Dakas, HIV/AIDS and workplace discrimination in Nigeria: prejudice, stigmatization and legal shenanigans. A brief paper within the framework of the sub theme “Labour and Fundamental Human Rights: Is ‘Discrimination Law’ doing the job it is supposed to do?” Conference on “Labour Law and Labour Markets in the New World Economy”, scheduled for Milan, Italy, from May 20–22, 2010. [14] W.W. Rankin, S. Brennan, E. Schell, J. Laviwa, S.H. Rankin, The stigma of being HIV-positive in Africa: HIV-related stigma is fueling the epidemic, and disempowering women even further, PLoS Medicine 2 (8) (2005) e247. [15] E. Monjok, A. Smesny, E.J. Essien, HIV/AIDS-related stigma and discrimination in Nigeria: review of research studies and future directions for prevention strategies, African Journal of Reproductive Health 13 (3) (2009).
25
[16] C. Reis, M. Heisler, L.L. Amowitz, R.S. Moreland, J.O. Mafeni, C. Anyamele, V. Iacopino, Discriminatory attitudes and practices by health workers toward patients with HIV/AIDS in Nigeria, PLoS Medicine 2 (8) (2005) e246. [17] L.C. Nyblade, Measuring HIV stigma: existing knowledge and gaps, Psychology, Health & Medicine 11 (3) (2006) 335–345. [18] D.D. Reidpatha, K.Y. Chanb, A method for the quantitative analysis of the layering of HIV-related stigma, AIDS Care 17 (4) (2005) 425–432. [19] M.J. Visser, J.D. Makin, A. Vandormael, K.J. Sikkema, B.W.C. Forsyth, HIV/AIDS stigma in a South African community, AIDS Care 21 (2) (2009) 197–206. [20] W. Sambisa, S. Curtis, V. Mishra, AIDS stigma as an obstacle to uptake of HIV testing: evidence from a Zimbabwean national population-based survey, AIDS Care 22 (2) (2010) 170–186. [21] P.J. Surkan, J.S. Mukherjee, D.R. Williams, E. Eustache, E. Louis, T. Jean-Paul, W. Lambert, F.C. Scanlan, C.M. Oswald, M.C.S. Fawzi, Perceived discrimination and stigma toward children affected by HIV/AIDS and their HIV-positive caregivers in central Haiti, AIDS Care 22 (7) (2010) 803–815. [22] FMOH, Technical report of the 2008 national HIV/AIDS sero-prevalence sentinel surveillance survey, Federal Ministry of Health, Federal Republic of Nigeria, 2008. [23] USAID: HIV/AIDS in Nigeria: A USAID Brief, 2002, available at: http://www.aegis.com/files/synergyaids/nigeria.pdf. [24] L. Rahangdale, P. Banandur, A. Sreenivas, J.M. Turan, R. Washington, C.R. Cohen, Stigma as experienced by women accessing prevention of parent-to-child transmission of HIV services in Karnataka, India, AIDS Care 22 (7) (2010) 836–842. [25] D. Rojas Castro, J.M. Le Gall, C. Andreo, B. Spire, Stigma, discrimination, and sexual (dis)satisfaction among people living with HIV: results from the “AIDES et toi” survey, AIDS Care 22 (8) (2010) 961–969 (first published on: 14 June 2010 (iFirst)). [26] C.O. Odimegwu, Prevalence and predictors of HIV-related stigma and knowledge in Nigeria: implications for HIV/AIDS prevention initiatives, Research Report submitted to the 2002/2003 Takemi Program in International Health, 2003, Available at: http://www.hsph.harvard.edu/ research/takemi/files/RP210.pdf. [27] R. Sabatier, Blaming Others: Prejudice, Race and Worldwide AIDS, Wickertsham Printing Company, Washington, 1988. [28] G.O. Atilola, O.M. Akpa, I.O.O. Komolafe, HIV/AIDS and the long-distance truck drivers in South-West Nigeria: a cross-sectional survey on the knowledge, attitude, risk behaviour and beliefs of truckers, Journal of Infection and Public Health 3 (2010) 166–178, doi:10.1016/j.jiph.2010.08.002. [29] NDHS, Nigeria demographic and health survey 2008, National Population Commission Federal Republic of Nigeria Abuja, Nigeria, 2008.
Contents lists available at ScienceDirect
HIV & AIDS Review journal homepage: www.elsevier.com/locate/hivar
HIV/AIDS-related stigma and access to HIV treatments by people living with HIV/AIDS: A case study of selected states in North-West Nigeria Onoja Matthew Akpa a,∗ , Victoria Adeolu-Olaiya a , C. Adenike Olusegun-Odebiri b , Doyin Aganaba c a b c
Department of Mathematical Sciences, Redeemer’s University, P.M.B. 3005, Redemption City, Ogun State, Nigeria University of Ilorin Teaching Hospital, Ilorin, Kwara State, Nigeria The Federal Capital Territory (FCT), Health Services Insurance Scheme, FCT, Abuja, Nigeria
a r t i c l e
i n f o
Article history: Received 7 October 2010 Received in revised form 21 December 2010 Accepted 23 December 2010 Available online 19 January 2011 Keywords: HIV-related stigma Anti-retroviral therapy Treatment adoption HIV/AIDS in Nigeria Logistic regression
a b s t r a c t Objectives: To study the prevalence of HIV-related stigma and the effect of stigma on HIV treatment adoption among PLWHA attending HIV treatment locations in some selected states in the North-West geopolitical zone of Nigeria. Methods: A cross-sectional survey was conducted (using structured questionnaires) among PLWHA in three selected states in the North-West geopolitical zone of Nigeria and Abuja, the Federal Capital Territory (FCT). The multiple logistic regressions analysis was used to determine factors associated with HIV-related stigma and adoption of HIV treatment. Results: It was found that 71(21.3%), 88(26.3%) and 43(12.8%) of the participants were facing HIV-related stigma from their place of works, the public and their family members. Also, the results of the logistic regressions show that PLWHA who have no formal education and those with primary education were less likely to face stigma from the public (OR-0.212; 95% CI-0.064–0.702; p < 0.05) and their employers (OR-0.236; 95% CI-0.072–0.775; p < 0.05) respectively. Conclusion: Although majority of the participants claimed not to be facing any form of HIV-related stigma, the prevalence of HIV-related stigma observed (job related stigma – 21.3%, stigma from the public – 26.3% and stigma from family members-12.8%) among the participants in this study still calls for concern. © 2011 Polish AIDS Research Society. Published by Elsevier Urban & Partner Sp. z.o.o. All rights reserved.
1. Introduction Nigeria is the most populous country on the continent of Africa and it accounts for approximately one-sixth of Africa’s people [2,3,8,9]. Although HIV prevalence rates are much lower in Nigeria than in many other African countries such as South Africa and Swaziland, the number of people living with HIV/AIDS in Nigeria has been estimated to be the largest in the world after India and South Africa; this is attributable to the growing size of Nigeria’s population [3–7]. Since the first case of AIDS was diagnosed in Nigeria in 1986 in a sexually active girl, HIV/AIDS epidemic continue to grow in the general population of Nigeria until date. While recent estimates show some worth decline in the prevalence of HIV/AIDS in Nigeria, results from specific states and sentinel surveillance centers (SSC) call for caution. For instance, in the last and most recent (2008) national HIV sentinel sero-prevalence survey [22] conducted among women 15–49 years attending antenatal clinics in Nigeria (which is the
∗ Corresponding author. Tel.: +234 803 215 9579. E-mail address: [email protected] (O.M. Akpa).
most readily available sources of data that inform trends about HIV/AIDS in sub-Saharan Africa), the prevalence ranged from 1.0% in Ekiti state to 10.6% in Benue State [22]. Seventeen (17) states and the Federal Capital Territory (FCT) had prevalence of 5.0% and above with seven (7) of them and the FCT having a prevalence of 7% or higher. In particular, astonishing HIV prevalence of 22.0% and 19.5% were recorded in Bwari (FCT) and Lafia (Nasarawa), respectively [22]. The rapid spread of HIV in Nigeria has been accounted for by a number of factors; these include sexual networking practices such as polygamy, high prevalence of untreated sexually transmitted infections, low condom use, poverty, low illiteracy, poor health status, low status of women, stigmatization, denial of HIV infection risk among vulnerable groups such as long distance truckers, female sex workers, students, etc. [23,26]. However, HIV-related stigma and discrimination was recognized early on in the AIDS epidemic as a key factor in fueling the spread of HIV [17]. It should be noted that the stigmatization of individuals infected and affected by HIV and the eventual discrimination, which they suffer, are the tragic consequences of HIV disease [26]. Unfortunately, incidence of HIV/AIDS-related stigma in Nigeria is on the increase in some locations, which is in line with
1730-1270/$ – see front matter © 2011 Polish AIDS Research Society. Published by Elsevier Urban & Partner Sp. z.o.o. All rights reserved. doi:10.1016/j.hivar.2010.12.004
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O.M. Akpa et al. / HIV & AIDS Review 10 (2011) 19–25
the predictions of Sabatier [27] of an increase in AIDS stigma and discrimination at the individual, community and national levels as the epidemic grows. In fact, since the time HIV was discovered in Nigeria, social responses of fear, denial, stigma and discrimination have accompanied it and this has spread rapidly, giving rise to anxiety and prejudices against the groups most affected as well as individuals infected and affected [26]. A part from that, it has been discovered that stigma and some other factors (like education and religion) have hindered HIV patients from taking advantage of medical care, particularly, HIV status testing [15,20]. Several studies that addressed the issue of HIV-related stigma from different backgrounds and populations have been published [1,2,10–21,24–27]. Specifically, Ogunjuyigbe et al. [2] studied issues pertaining to the attitudes of friends, relatives and neighbours to people living with HIV/AIDS and the implication this will have for infection and spread of HIV/AIDS in Lagos State, Nigeria. Chirwa et al. [11] explored the demographic and social factors, including perceived HIV stigma that influence job satisfaction in nurses from five African countries. In this study, we seek to identify the specific factors that affect HIV patients this way in the selected study locations in Nigeria and to what extent does a particular factor prevents HIV patients from adopting ART. We present a comprehensive and detailed results on a study conducted among people living with HIV/AIDS (PLWHA) in order to assess the degree of stigma prevalent among them, whether stigmatization affects their access to and willingness to adopt HIV drugs and what are the most important factors associated with HIV-related stigma in the population studied. Also, focusing on stigmatization, we would like to know what are the different contexts and manifestations, how does it prevent ART adoptions and what are the varying determinants necessitating stigmatization among the studied population. In addition, we also present recommendations based on our findings. 2. Methods 2.1. Study design and sample sizes We interviewed PLWHA attending receiving treatments at two locations (Kubwa General Hospital, Abuja and Asokoro General Hospital, Abuja) within the Federal Capital Territory, Abuja and three other states of the North-West geopolitical zone of Nigeria: Kaduna state (General Hospital, Sabon-Tasha, Kaduna), Sokoto State (Usman Danfodio University Teaching Hospital (UDUTH), Sokoto) and Kebbi State (General Hospital, Birnin-Kebbi). The states were randomly selected based on the authors’ perceived easy access to PLWHA attending HIV drug distribution centers in the states and in each state, the most popular (and most patronized) center is selected for study. A total of 335 PLWHA from four HIV drug distribution centers (one center from each of the three states and the FCT) were interviewed in this study. From the Kaduna center, a total of 145 (43.3%) PLWHA were interviewed, 136 (40.6%) of the interviewed PLWHA are from the Abuja (FCT) center, 20 (6.0%) were interviewed at the center in Kebbi while 34 (10.1%) were interviewed at Sokoto. 2.2. Ethical considerations and data collection In each center, permission to conduct the study among PLWHA was obtained from the appropriate authorities and the participants. All the participants who gave informed consent were at liberty to withdraw from the study at anytime. PLWHA who gave consent were given a copy of the questionnaires to feel and trained interpreters were used to interpret the meaning of the items in
the questionnaires for participants who do not understand English language perfectly. In addition, participants’ confidentiality was further guaranteed by ensuring that the administration of the anonymous questionnaires and the interviews that backed up the filling of the questionnaires took place in privacy. 2.3. Questionnaire The questionnaire contains standardized questions (which were edited for biases by qualified health survey professionals trained in health surveys) focusing on three fundamental variables: sociodemographic variable, HIV-related stigma and HIV treatment. 2.4. Variables The variables of interest in this research study are broadly divided into three categories: the socio-demographic variables, variables on the HIV-related stigma and variables on HIV drugs adoption. In order not to discourage PLWHA (the respondents) from completing the questionnaires; we deliberately keep our questions (questionnaire items) as straight to the point as possible. 2.4.1. Socio-demographic Items on the socio-demographic variable include, among others; age of participants, place of domicile, sex, marital status, educational status, state of origin, etc. (see Table 1 for details). 2.4.2. HIV-related stigma On the HIV-related stigma, we asked questions such as how did you feel when you were diagnosed to be HIV positive, does your HIV status affects your employment, do people who know you have HIV still relate well with you, does your spouse and children relate well with you, etc. (Table 2). 2.4.3. Adoption of anti-retroviral therapy On the anti-retroviral drug use, we asked questions such as, are you currently on any HIV drugs/treatment, would your taking HIV drugs declare your status to people, if yes to the question above (refereeing the previous question), would you stop taking the drugs because of that, would you always ensure that you take HIV drugs, etc. (Table 3). 2.5. Presentation of data and statistical analysis Preliminary analysis was carried out using frequency tables and percentages to study the distribution of the respondents (PLWHA) across the study locations and also to study how the respondents differ in their responses to the questionnaire items. A part from that, the logistic regression was applied to study the associations between the different variables of the questionnaire via the statistical package for social sciences (SPSS) version 13.0 (SPSS Inc., Chicago, IL, USA). We used the logistic regression to study which of the selected questionnaire items are associated with HIVrelated stigma and HIV treatment. 3. Results A total of 335 PLWHA participated in this study. Tables 1–3, show that 145 (43.3%) participants were interviewed at Kaduna, 136 (40.6%) at Abuja, 20 (6%) at Kebbi and 34 (10.1%) at Sokoto. 3.1. Socio-demographic In Table 1, the results of the socio-demographic characteristics of participants are presented. It was observed that, of the 335
O.M. Akpa et al. / HIV & AIDS Review 10 (2011) 19–25
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Table 1 The socio-demographic variables of people living with HIV/AIDS in the selected states of North-West Nigeria. Variables Sex Male Female
Kaduna N = 145 (%)
Abuja N = 136 (%)
Kebbi N = 20 (%)
Sokoto N = 34 (%)
Combined N = 335 (%)
111 (76.6) 34 (23.4)
71 (52.2) 65 (47.8)
13 (65.0) 7 (35.0)
28 (82.4) 6 (17.6)
223 (66.6) 112 (33.4)
Age (years) <20 20–29 30–39 40–49 ≥50
3 (2.1) 40 (27.6) 61 (42.1) 30 (20.7) 11 (7.6)
3 (2.2) 53 (39.0) 48 (35.3) 26 (19.1) 6 (4.4)
2 (10.0) 8 (40.0) 6 (30.0) 4 (20.0) –
– 11 (32.4) 16 (47.1) 5 (14.7) 2 (5.9)
8 (2.4) 112 (33.4) 131 (39.1) 65 (19.4) 19 (5.7)
Marital status Single Married Widowed Divorced Separated
43 (29.7) 82 (56.6) 14 (9.7) 5 (3.4) 1 (0.7)
46 (33.8) 69 (50.7) 9 (6.6) 5 (3.7) 7 (5.1)
6 (30.0) 8 (40.0) 5 (25.0) 1 (5.0) –
12 (35.3) 17 (50.0) 3 (8.8) 1 (2.9) 1 (2.9)
107 (31.9) 176 (52.9) 31 (9.3) 12 (3.6) 9 (2.7)
Educational status None Primary Secondary Tertiary
16 (11.0) 30 (20.7) 67 (46.2) 32 (22.1)
10 (7.4) 9 (6.6) 61 (44.9) 56 (41.2)
5 (25.0) 4 (20.0) 8 (40.0) 3 (15.0)
8 (23.5) 3 (8.8) 8 (23.5) 15 (44.1)
39 (11.6) 46 (13.7) 144 (43.0) 106 (31.6)
Occupation Unemployed Self-employed Civil servant Others
63 (43.4) 43 (29.7) 22 (15.2) 17 (11.7)
52 (38.2) 34 (25.0) 39 (28.7) 11 (8.1)
8 (40.0) 4 (20.0) 5 (25.0) 3 (15.0)
8 (23.5) 5 (14.7) 12 (35.3) 9 (26.5)
131 (39.1) 86 (25.7) 78 (23.3) 40 (11.9)
129 (89.0) 11 (7.6) 5 (3.4)
89 (64) 44 (32.4) 5 (3.7)
7 (35.0) 13 (65.0) –
12 (35.3) 22 (64.7) –
235 (70.1) 90 (26.9) 10 (3.0)
Religion Christianity Islam Others
participants who consented to be interviewed, 223 (66.6%) were male while 112 (33.4%) were female. The highest number of male participants was recorded at Kaduna where 111 (76.6%) of those interviewed were male while the highest number of female par-
ticipants was recorded at Abuja where a total of 65 (47.8) of those interviewed were female. Most of the PLWHA who consented to the interview fall into 20–29 years and 30–39 years of age with 112 (33.4%) and 131 (39.1%) belonging to each age group, respectively.
Table 2 The distribution PLWHA with respect to variables describing HIV-related stigma in the selected states of the North-West Nigeria. Variables
Kaduna N = 145 (%)
Abuja N = 136 (%)
Kebbi N = 20 (%)
Sokoto N = 34 (%)
Combined N = 335 (%)
How did you feel when you first heard that you were HIV positive? Nothing 31 (21.4) 23 (16.9) Suicidal thoughts 20 (13.8) 23 (16.9) Shy 1 (0.7) 11 (8.1) Very sad 90 (62.1) 72 (52.9) Others 3 (2.1) 7 (5.1)
2 (10.0) 6 (30.0) 2 (10.0) 10 (50.0) –
5 (14.7) 5 (14.7) 1 (2.9) 22 (64.7) 1 (2.9)
61 (18.2) 54 (16.1) 15 (4.5) 194 (57.9) 11 (3.3)
Does your HIV status affect your employment? Yes 26 (17.9) No 119 (82.1)
31 (22.8) 105 (77.2)
3 (15.0) 17 (85.0)
11 (32.4) 23 (67.6)
71 (21.2) 264 (78.8)
Is your spouse HIV positive too? Yes 66 (45.5) No 79 (54.5)
61 (44.9) 75 (55.1)
16 (80.0) 4 (20.0)
24 (70.6) 10 (29.4)
167 (49.9) 168 (50.1)
Can you tell people you are HIV positive? Yes 56 (38.6) No 89 (61.4)
78 (57.4) 58 (42.6)
10 (50.0) 10 (50.0)
28 (82.4) 6 (17.6)
150 (44.8) 185 (55.2)
Do people who know you are HIV positive still relate well with you? Yes 105 (72.4) 102 (75.0) No 40 (27.6) 34 (25.0)
16 (80.0) 4 (20.0)
24 (70.6) 10 ((29.4)
247 (73.7) 88 (26.3)
Does your spouse and children still relate with you? Yes 123 (84.8) No 22 (15.2)
123 (90.4) 13 (9.6)
18 (90.0) 2 (10.0)
28 (82.4) 6 (17.6)
292 (87.2) 43 (12.8)
Do people relate well with you before you present HIV status? Yes 134 (92.4) 124 (91.2) No 11 (7.6) 12 (8.8)
17 (85.0) 3 (15.0)
29 (85.3) 5 (14.7)
304 (90.7) 31 (9.3)
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O.M. Akpa et al. / HIV & AIDS Review 10 (2011) 19–25
Table 3 Treatment related variable of PLWHA in the selected states of the North-West Nigeria. Variables
Kaduna N = 145 (%)
Are you currently on medication? Yes 118 (81.4) No 27 (18.6)
Abuja N = 136 (%) 110 (80.9) 26 (19.1)
Kebbi N = 20 (%)
Sokoto N = 34 (%)
Combined N = 335 (%)
14 (70.0) 6 (30.0)
27 (79.4) 7 (20.6)
269 (80.3) 66 (19.7)
Would your taking anti-retroviral therapy declare your status to people? Yes 55 (37.9) 84 (61.8) No 90 (62.7) 52 (38.2)
11 (55.0) 9 (45.0)
8 (23.5) 26 (76.5)
158 (47.2) 177 (52.8)
If yes to the above question, will you stop taking the drugs because of that? Yes 11 (7.6) 8 (5.9) No 134 (92.4) 128 (94.1)
2 (10.0) 18 (90.0)
3 (8.8) 31 (91.2)
24 (7.2) 311 (92.8)
Would you always ensure that you take anti-retroviral therapy? Yes 136 (93.8) 123 (90.4) No 9 (6.2) 13 (9.6)
20 (100.0) –
30 (88.2) 4 (11.8)
309 (92.2) 26 (7.8)
In addition, while more than half of the participants (176/52.9%) were married, many of them (107/31.9%) were singles (unmarried), 31 (9.3%) were either widows or widowers, 12 (3.6%) were divorcees and 9 (2.7%) were separated from their spouses. 82 (56.6%) of those interviewed at Kaduna were married while 69 (50.7%), 8 (40.0%) and 17 (50.0%) of those interviewed at Abuja, Kebbi and Sokoto, respectively, were married. This implies that 46.6%, 39.2%, 4.5% and 9.7% of the 176 married participants were interviewed at Kaduna, Abuja, Kebbi and Sokoto, respectively. Also, 43 (29.7%), 46 (33.8%), 6 (30.0%) and 12 (35.3%) of those interviewed at Kaduna, Abuja, Kebbi and Sokoto were unmarried, implying that, 40.2%, 43.0%, 5.6% and 11.2% of the 107 unmarried participants were interviewed at Kaduna, Abuja, Kebbi and Sokoto, respectively. Majority of the participants (144/43.0%) interviewed have secondary school education, 106 (31.6%) have tertiary education while 39 (11.6%) and 46 (13.7%) of the participants have no formal education and primary school education, respectively. Although most of the participants at Sokoto – 15 (44.1%) have tertiary education, most of the participants in all the other states had secondary school education only (Table 1). Furthermore, majority of the PLWHA (131/39.1%) were unemployed, 86 (25.7%) were self-employed, 78 (23.3%) were civil servants while 40 (11.9%) of them were into other forms of employment status. While most of the participants at Kaduna – 63 (43.4%), Abuja – 52 (38.2%) and Kebbi – 8 (40.0%) were unemployed, majority of those interviewed at Sokoto – 12 (35.3%) were civil servants. This may be attributed to the fact that most of the participants interviewed at Sokoto were people who have tertiary education.
3.2. HIV-related stigma The distribution of participants with respect to their reposes to selected question on HIV-related Stigma is presented in Table 2. A total of 194 (57.9%) felt very sad when they heard the results of their HIV status test, 61 (18.2%) said they felt nothing while 54 (16.1%) had some thoughts of committing suicide. Although suicidal thought was not the most common feelings among participants, 20 (37.0%), 23 (42.6%), 6 (11.1%) and 5 (9.3%) of the 54 who had suicidal thoughts were interviewed at Kaduna, Abuja, Kebbi and Sokoto, respectively. Most of the participants (264/78.8%) said that their HIV status does not affects their jobs while 71 (21.2%) claimed that being HIV positive have had some negative effect on their employments. More than half of the participants (185/55.2%) said they cannot disclose their HIV status to people while 150 (44.8%) said they could disclose their HIV status to people. A closer look at the results reveals that the participants at Kebbi state were equally divided (10/50.0%) each for willingness to and not willing to reveal their HIV status to people. At Kaduna, most of the participants –
89 (61.4%) would not disclose their HIV status while at Abuja and Sokoto, most participants (28/82.4% and 28/82.4%, respectively) would not mind telling people that they are HIV positive. A part from that, many of the participants 247 (73.7%) said that people still relate well with them despite their HIV status while 88 (26.3%) claimed to be facing some levels of difficulties in their relationships (due to their HIV status) with people around them. Also, while majority of the participants (292/87.2%) confirmed that their spouses and children still relate well with them (despite their HIV status), 43 (12.8%) claimed not to be receiving the expected support from their spouses and children (family members). 3.3. Anti-retroviral therapy adoption The responses of participants to selected questions related to, access to and adoption of HIV treatments are presented in Table 3. It was observed that majority of participants (269/80.3%) were already on anti-retroviral medications while 66 (19.7%) of them were yet to be placed on HIV treatments because they were yet to complete their registration processes. In addition, while a total of 158 (47.2%) agreed that taking anti-retroviral therapy will not reveal their HIV status to people, 177 (52.8%) claimed that their HIV status will be revealed to people should they adopt HIV treatment plan. Furthermore, although most of the participants at Kaduna (90/62.7%) and Sokoto (26/76.5%) claimed that taking antiretroviral therapy will reveal their HIV status to people, most of the participants at Abuja (84/61.8%) and Kebbi (11/55.0%) confirmed that taking HIV treatments have nothing to do with revealing their HIV status to people. Nevertheless, an overwhelming majority of the participants (311/92.8%) confirmed that they will not stop antiretroviral therapy even if it will reveal their HIV status to people while only 24 (7.2%) concluded that they will withdraw from HIV treatment plans should they discover that their HIV status will be revealed to people in the process of taking anti-retroviral therapy. Also, while majority of the participants (309/92.2%) confirmed that they will always ensure that they take anti-retroviral therapies, 26 (7.8%) were not sure that they will always take anti-retroviral medications. 3.4. Results of the logistic regressions Multiple logistic regression models were used to determine the association of the HIV-related stigma and anti-retroviral therapy variables with all the factors considered in the study. The results of the selected factors associated with these (HIV-related stigma and anti-retroviral therapy) variables are present in Tables 4 and 5 and described in Sections 3.4.1 and 3.4.2 below.
O.M. Akpa et al. / HIV & AIDS Review 10 (2011) 19–25
23
Table 4 Results of the logistic regression for factors associated with variables describing HIV-related stigma. Factors
Variables describing HIV-related stigma Odds of HIV status affects employment (95% CI CL)
Odds of willing to reveal HIV status (95% CI CL)
Odds of facing stigma from the public (95% CI CL)
Odds of facing stigma from the family members (95% CI CL)
.529 (.167–1.679) .326* (.915–.116) .650 (1.386–.305)
.212* (.064–.702) 1.149 (.350–3.768) .369* (.158–.860) –
3.313 (.341–32.179) .091** (.020–.412) .480 (.137–1.684) –
.951 (.130–6.374) .915 (.131–6.934) .687 (.083–5.671) .243 (.021–2.843)
Educational status None Primary Secondary Tertiary
–
Marital status Single Married Widowed Divorced Separated
1.053 (.158–7.001) 1.114 (.170–7.325) 2.302 (.130–17.826) .371 (.022–6.388) –
–
.995 (.167–5.936) 1.152 (.196–6.757) 2.857 (.375–21.793) 4.174 (.360–48.400) –
Occupation Unemployed Self-employed Civil servant Others
1.858 (.670–5.153) 1.551 (.502–4.790) .876 (.278–2.760) –
3.450* (1.134–10.501) 4.041* (1.261–12.953) 4.256* (1.270–14.261) –
1.025 (.405–2.596) 1.603 (.546–4.708) .612 (.205–1.827) –
Religion Christianity Islam Others
4.855 (.411–57.299) 2.553 (.211–30.902) –
.450 (.137–1.475) .236* (.775–.072) .464 (.998–.216) –
.243 (.035–1.678) .143 (.020–1.041)
10.625* (1.398–80.725) 14.656** (1.992–107.814) 56.518* (2.318–1378.213) 4.698 (.316–69.860) – 1.216 (.300–4.938) 1.196 (.242–5.925) 1.706 (.342–8.517) –
–
4.657 (.941–23.064) 6.529* (1.240–34.390) –
For how many years have you been HIV positive? <2 years .318** (.153–.662) 2–3 .299* (.107–.837) 4–5 .486 (.170–1.389) 5 –
2.499* (1.156–5.404) 1.479 (.535–4.083) 1.613 (.530–4.910) –
1.066 (.482–2.356) 1.809 (.589–5.554) .780 (.281–2.163) –
Are you currently on any drugs/treatment? Yes .414* (.178–.964) No –
–
–
–
Is your spouse HIV positive too? Yes .670 (.348–1.289) No –
1.030 (.553–1.918) –
1.074 (.563–2.051) –
–
2.332* (1.128–4.822) –
–
.776 (.369–1.631)
Would your taking anti-retroviral therapy declare your status to people? Yes .497 (.243–1.014) .077*** (.040–.149) No – – * ** ***
.802 (.052–12.328) .665 (.043–10.285) – .690 (.207–2.302) .174* (.043–.697) 1.010 (.209–4.882) –
.740 (.348–1.575)
.603 (.210–1.729)
.383* (.150–.978)
.725 (.263–2.004)
p < 0.05. p < 0.01. p < 0.001.
3.4.1. Logistic regression for variables associated with HIV-related stigma The results of the multiple logistic regressions for the HIVrelated stigma are presented in Table 4. The aim was to present results only for factors that were found to be associated with any of the variables describing HIV-related stigma in this study. It was found that PLWHA who has no formal education are less likely to face stigma from the public (OR 0.212; 95% CI 0.064–0.702; p < 0.05) while those with primary school education are less likely to face HIV-related stigma from their employers (OR 0.236; 95% CI 0.072–0.775; p < 0.05) and their family members (OR 0.091; 95% CI 0.02–0.412; p < 0.01). Also, while PLWHA with primary school education are less likely to tell people their HIV status (OR 0.326; 95% CI 0.116–0.915; p < 0.05), those with secondary school education are less likely to be stigmatized by the public (OR 0.369; 95% CI 0.158–0.860; p < 0.05). A part from that, it was also observed that while those whose spouses are HIV positive are less likely to face HIV-related stigma from their family members (OR 0.383; 95% CI 0.150–0.978; p < 0.05), PLWHA who are Muslim are more likely to be stigmatized by the public (OR 6.529; 95% CI 1.240–34.390; p < 0.05) and those who think that taking HIV treatment will reveal their HIV status are less likely to reveal their HIV status to people (OR 0.077; 95% CI 0.040–0.49; p < 0.001).
3.4.2. Logistic regression for variables associated with the adoption of HIV treatment In Table 5, the results of the logistic regressions for factors associated with variables describing anti-retroviral therapy adoptions are presented. It was observed that PLWHA who have primary school education are more likely to continue anti-retroviral therapy (OR 9.084; 95% CI 1.021–80.851; p < 0.05) while those who were diagnosed in less than two years ago are less likely to continue HIV treatments (OR 0.129; 95% CI 0.020–0.846; p < 0.05) and those who agreed that they could reveal their HIV status to people are less likely to think that taking anti-retroviral therapy could reveal their HIV status (OR 0.087; 95% CI 0.046–0.164; p < 0.001). 4. Discussions In this study, we have presented a comprehensive report of a study conducted among PLWHA in selected states from the NorthWest geopolitical zone of Nigeria. In each study locations, effort was made to include all PLWHA (who gave their consents) in the study. Also, while we recognized that interviewing all PLWHA in the various locations would have yielded a more complete study, ethical considerations provide that participation in a study of this nature has to be by choice [19–21,28] and hence, this report covers
24
O.M. Akpa et al. / HIV & AIDS Review 10 (2011) 19–25
Table 5 Results of the logistic regression for factors associated with variables describing anti-retroviral therapy adoption. Factors
Variables describing anti-retroviral therapy adoption Odds of being currently on any anti-retroviral therapy (95% CI CL)
Odds of taking anti-retroviral therapy will reveal HIV status (95% CI CL)
Odds of stopping drugs to conceal status (95% CI CL)
1.280 (.371–4.418) .767 (.276–2.128) 1.177 (.549–2.522) –
.965 (.336–2.774) 1.512 (.571–4.005) .733 (.360–1.492) –
4.127 (.635–26.810) 1.107 (.176–6.954) 2.028 (.527–7.802) –
12.632 (.766–208.292) 9.084* (1.021–80.851) 2.886 (.764–10.901) –
For how many years have you been HIV positive? <2 years 1.113 (.520–2.385) 2–3 .946 (.355–2.524) 4–5 1.901 (.585–6.176) >5 –
1.087 (.537–2.1990 1.940 (.760–4.951) 1.348 (.503–3.6160 –
.670 (.196–2.286) .573 (.114–2.878) .310 (.032–3.011)
.129* (.020–.846) .392 (.037–4.155) .146 (.009–2.254)
Can you tell people that you are HIV positive? Yes .786 (.375–1.645) No –
–
Educational status None Primary Secondary Tertiary
* ***
–
.087*** (.046–.164)
Odds of continuing anti-retroviral therapy usage (95% CI CL)
– .813 (.231–2.855)
–
.310 (.069–1.386) –
p < 0.05. p < 0.001.
responses from only PLWHA who gave their consents to participate in this study at the various locations. In addition to that, predominant religious sentiments and the low educational status of the general population at the various study locations have in no small way negatively affected the number of PLWHA that consented to participate in this study; we expected more consents than we got. These explain why only twenty participants were interviewed at Kebbi state. Consequently, we may not be able to generalize the results of this study for the population of PLWHA in Nigeria but as far as the specific centers where this study was conducted are concerned, enough effort was made to make this study as representative as possible. It was found that majority of the PLWHA who participated in this study fall within the middle-aged people with a few others below 20 years of age and above 50 years of age. These further substantiated the fact that HIV/AIDS is really an epidemic majorly among the active age group. Past studies conducted among PLWHA revealed that the epidemic is more prevalent among young adult [2,15,20,22,28,29]. It was also found that while majority of the participants were married, more than half of them have spouses who are HIV negative and more than half of those who are married still have sex with their spouses. With this possibilities in place, spouses of PLWHA who are currently HIV negative stands the danger of getting infected in future, more so that majority of the infected people are not willing to reveal their HIV status even to their spouses. In addition, majority of the participants were either unemployed or self-employed. These employment statuses for PLWHA in the studied locations are high because of the rising number of PLWHA quitting jobs or losing jobs due to HIV-related stigmatizations and the unemployed people who are getting infected due to HIV-related risky behaviours. While the predominant religion in the studied locations is Islam, majority of the participants in this study are Christians, except for Kebbi and Sokoto state. This could be due to two related factors: religious sentiments and culture prevents some PLWHA who are Muslims in these part of Nigeria from attending anti-retroviral therapy centers (especially if they are female) and the same reasons also prevent some of them from participating in a study of this nature even if they are attending anti-retroviral therapy centers. This is evident in the low number of participants recorded at Kebbi and Sokoto states, which are considered as core Northern states even
though the number of Muslim participants in these states exceeded the number of Christian participants. Although many of the participants said they felt very sad at the news of their present HIV status, the number of participants who had suicidal thoughts calls for concern. Many of them felt like committing suicide because of the obvious danger of facing stigmatization from the general public, the untold consequence of losing their jobs should their HIV status be known at their place of work, the shame and rejection from their family members and friends, the knowledge of the fact that there is no cure for AIDS, etc. Furthermore, it was found that although majority of the participants claimed that their HIV status does not affects their employments, many of them would not want to disclose their HIV status to anybody either at home or at their place of employment. In addition, while some of the participants claimed that they never faced any form of stigma, from the public or their families, the results of the logistic regressions show that those who are Muslims among them are more likely to face stigmatization from the public and those whose spouses have died are more likely to be stigmatized by their family members. It was found that majority of the participants are already taking anti-retroviral therapy but lack of funds and personnel have been identified as potential problem facing continuation of this provisions. Also, while majority of the participants claimed that they would always ensure that they take HIV drugs, only those with primary school education are more likely to continue HIV treatments at the various centers while those who were diagnosed less than two years ago are less likely to continue HIV treatments.
Acknowledgements The authors are very grateful the management of the Redeemer’s University and the management of the following Institutions: General Hospital Sabon-Tasha, Kaduna; Usman Danfodio University Teaching Hospital (UDUTH) Sokoto; Kubwa General Hospital, Abuja; Asokoro General Hospital, Abuja and General Hospital Birnin-Kebbi where access was granted to PLWHA who participated in this study.
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References [1] K. Sikwese, P. Nweke, R. Mwaniki, J. Hows, G. Reid, Doing it for ourselves: PLHIV led research into stigma in 3 African countries: Kenya, Nigeria, Zambia THPE0948, 2009. [2] P.O. Ogunjuyigbe, E.O. Adeyemi, M.O. Obiyan, Attitudes toward people living with HIV/AIDS: implication for infection and spread of HIV/AIDS in Lagos State, Nigeria, Journal of Chinese Clinical Medicine 4 (3) (2009). [3] Wikipedia, HIV/AIDS in Africa, Wikipedia 2010, available at http://en.wikipedia.org/wiki/HIV/AIDS in Africa. [4] O.M. Akpa, B.A. Oyejola, Modeling HIV/AIDS epidemics in West Africa: results for UNAIDS modeling approach from some selected countries, Research Journal of Applied Sciences 2 (11) (2007) 1148–1155. [5] J. Pennington, HIV and AIDS in Nigeria, Avert 2006, available at www.avert.org/aids-nigeria.htm, 2006. [6] UNAIDS/WHO, 2009 report on the global AIDS epidemic, 2010, available at http://data.unaids.org/pub/Report/2009/JC1700 Epi Update 2009 en.pdf. [7] Kaiser Foundation, The global HIV/AIDS epidemic. Kaiser family foundation 2010, available at http://www.kff.org/hivaids/upload/3030-13.pdf. [8] NPC, Nigerian population by states, National Population Commission (Nigeria) 2010, available at http://www.population.gov.ng/. [9] NPC, Detailed report on the census 2006 and provisional results, Federal Government of Nigeria Official Gazette, 24, 2007. [10] N. Mawar, S. Sahay, A. Pandit, U. Mahajan, The third phase of HIV pandemic: social consequences of HIV/AIDS stigma and discrimination and future needs, Indian Journal of Medical Research 122 (2005) 471–484. [11] M.L. Chirwa, M. Greeff, T.W. Kohi, J.R. Naidoo, L.N. Makoae, P.S. Dlamini, C. Kaszubski, Y.P. Cuca, L.R. Uys, W.L. Holzemer, HIV stigma and nurse job satisfaction in five African countries, Journal of the Association of Nurses in AIDS Care 20 (2009) 14–21. [12] E. Kalipeni, HIV/AIDS in women: stigma and gender empowerment in Africa, Future HIV Therapy 2 (2) (2008) 147–153. [13] D.C.J. Dakas, HIV/AIDS and workplace discrimination in Nigeria: prejudice, stigmatization and legal shenanigans. A brief paper within the framework of the sub theme “Labour and Fundamental Human Rights: Is ‘Discrimination Law’ doing the job it is supposed to do?” Conference on “Labour Law and Labour Markets in the New World Economy”, scheduled for Milan, Italy, from May 20–22, 2010. [14] W.W. Rankin, S. Brennan, E. Schell, J. Laviwa, S.H. Rankin, The stigma of being HIV-positive in Africa: HIV-related stigma is fueling the epidemic, and disempowering women even further, PLoS Medicine 2 (8) (2005) e247. [15] E. Monjok, A. Smesny, E.J. Essien, HIV/AIDS-related stigma and discrimination in Nigeria: review of research studies and future directions for prevention strategies, African Journal of Reproductive Health 13 (3) (2009).
25
[16] C. Reis, M. Heisler, L.L. Amowitz, R.S. Moreland, J.O. Mafeni, C. Anyamele, V. Iacopino, Discriminatory attitudes and practices by health workers toward patients with HIV/AIDS in Nigeria, PLoS Medicine 2 (8) (2005) e246. [17] L.C. Nyblade, Measuring HIV stigma: existing knowledge and gaps, Psychology, Health & Medicine 11 (3) (2006) 335–345. [18] D.D. Reidpatha, K.Y. Chanb, A method for the quantitative analysis of the layering of HIV-related stigma, AIDS Care 17 (4) (2005) 425–432. [19] M.J. Visser, J.D. Makin, A. Vandormael, K.J. Sikkema, B.W.C. Forsyth, HIV/AIDS stigma in a South African community, AIDS Care 21 (2) (2009) 197–206. [20] W. Sambisa, S. Curtis, V. Mishra, AIDS stigma as an obstacle to uptake of HIV testing: evidence from a Zimbabwean national population-based survey, AIDS Care 22 (2) (2010) 170–186. [21] P.J. Surkan, J.S. Mukherjee, D.R. Williams, E. Eustache, E. Louis, T. Jean-Paul, W. Lambert, F.C. Scanlan, C.M. Oswald, M.C.S. Fawzi, Perceived discrimination and stigma toward children affected by HIV/AIDS and their HIV-positive caregivers in central Haiti, AIDS Care 22 (7) (2010) 803–815. [22] FMOH, Technical report of the 2008 national HIV/AIDS sero-prevalence sentinel surveillance survey, Federal Ministry of Health, Federal Republic of Nigeria, 2008. [23] USAID: HIV/AIDS in Nigeria: A USAID Brief, 2002, available at: http://www.aegis.com/files/synergyaids/nigeria.pdf. [24] L. Rahangdale, P. Banandur, A. Sreenivas, J.M. Turan, R. Washington, C.R. Cohen, Stigma as experienced by women accessing prevention of parent-to-child transmission of HIV services in Karnataka, India, AIDS Care 22 (7) (2010) 836–842. [25] D. Rojas Castro, J.M. Le Gall, C. Andreo, B. Spire, Stigma, discrimination, and sexual (dis)satisfaction among people living with HIV: results from the “AIDES et toi” survey, AIDS Care 22 (8) (2010) 961–969 (first published on: 14 June 2010 (iFirst)). [26] C.O. Odimegwu, Prevalence and predictors of HIV-related stigma and knowledge in Nigeria: implications for HIV/AIDS prevention initiatives, Research Report submitted to the 2002/2003 Takemi Program in International Health, 2003, Available at: http://www.hsph.harvard.edu/ research/takemi/files/RP210.pdf. [27] R. Sabatier, Blaming Others: Prejudice, Race and Worldwide AIDS, Wickertsham Printing Company, Washington, 1988. [28] G.O. Atilola, O.M. Akpa, I.O.O. Komolafe, HIV/AIDS and the long-distance truck drivers in South-West Nigeria: a cross-sectional survey on the knowledge, attitude, risk behaviour and beliefs of truckers, Journal of Infection and Public Health 3 (2010) 166–178, doi:10.1016/j.jiph.2010.08.002. [29] NDHS, Nigeria demographic and health survey 2008, National Population Commission Federal Republic of Nigeria Abuja, Nigeria, 2008.