HIV Stigma Partly to Blame for Vertical Transmission

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This post is by the Global Center’s Rabita Aziz.

The International Center for Research on Women (ICRW) has released a report on how social stigma and discrimination surrounding HIV may result in higher prevalence rates, particularly in relation to increases in mother-to-child transmission when women are reluctant to accept HIV testing, disclose their status, or seek care.   The findings from their study, done in conjunction with the London School of Hygiene and Tropical Medicine, suggest that stigma may be responsible for more than half of transmissions in some settings.  However, up to 33 percent of these infections can be averted through the implementation of programs that may effectively reduce stigma.  This in turn would lower overall prevalence rates, as reducing vertical transmission rates would make a huge impact in the fight against HIV. 

The ICRW has been exploring the issue of stigma and its effect on prevalence rates for a decade, and has found that women bear a disproportionate share of blame for HIV and are more harshly condemned.  They have also found that HIV stigma, and women’s fear of violence if their status becomes known, are significant barriers to universal access and care.  This can translate into higher prevalence rates as pregnant, HIV infected women are less likely to seek treatment for fear of violence if levels of stigma are high in their communities.  For example, the ICRW reports that 22 percent of infected, pregnant women in Zimbabwe do not disclose their positive status for fear of domestic violence or divorce.  Eight percent of women in Nigeria and seven percent of women in Uganda opt out of HIV testing at antenatal care clinics for fear of involuntary disclosure should they test positive.  Furthermore, many women avoid taking advantage of antenatal care services altogether because they fear being tested, and of involuntary disclosure if they’re found to be infected.  Studies have shown that women who refuse testing are more likely to be infected.  All of this translates into higher infection rates as infected women fail to seek treatment for fear of retribution.

The ICRW conducted their latest study by reviewing literature about stigma and discrimination, and using their findings to develop a mathematical model that projects the impact.s of stigma on HIV service use and infant infections under different scenarios, including varying levels of stigma,  HIV prevalence rates among women accessing antenatal care services, and the relative  health system capacity in these different contexts.  Through this modeling, they found that at least 26 percent of vertical transmissions occur due to stigma no matter the prevalence rate, and the percentage can go up to 53 percent in communities with high levels of stigma.  The modeling goes on to predict that in a high-functioning health system, while 98 percent of women accept HIV testing when, theoretically, no stigma exists, 89 percent of women accept a test when stigma does exist.  When no stigma exists, 49.6 percent of women and children accept nevirapine while the child receives exclusive breastfeeding.  That number goes down to 12.6 percent in scenarios with high stigma.  In a low functioning health system, the success of the intervention reaching women and their infants is even lower.

Investments in programs to reduce stigma of between $1 and $10 per woman attending ANC services would be cost-effective in reducing overall prevalence rates, and could and should be an important and cost-effective addition to current prevention of mother-to-child transmission programming.

More information about ICRW’s work on stigma reduction can be found here.  A toolkit for stigma reduction can be found here.

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