HIV in rural Tanzania and its implications for prevention.

HIV in rural Tanzania and its implications for prevention.

Once effective therapy for a previously untreatable condition is made available, a normalisation of the disease often occurs. Part of a broader initiative monitoring the implementation of the national antiretroviral therapy programme, this qualitative study investigated the impact of antiretroviral therapy availability on HIV perceptions in a rural ward of North Tanzania and its implications for prevention. A mix of qualitative methods was used including semi-structured interviews with 53 antiretroviral therapy clinic clients and service providers. Four group activities were conducted with persons living with HIV. Data were analyzed using the qualitative software package NVIVO7. People on ART often reported feeling increasingly comfortable with their status reflecting a certain “normalization” of the disease. This was attributed to their seeing other people affected by HIV, regaining physical health, returning to productive activities and receiving emotional support from health service providers. Overcoming internalised feelings of shame facilitated disclosure of HIV status, helped to sustain treatment, and stimulated voluntary counselling and testing uptake. However “blaming” stigma -where HIV+ people were considered responsible for acquiring a “moral disease” - persisted in the community and anticipating it was a key barrier to disclosure and voluntary counselling and testing uptake. Attributing HIV symptoms to witchcraft seemed an effective mechanism to transfer “blame” from the family unit to an external force but could lead to treatment interruption. As long as an HIV diagnosis continues to have moral connotations, a de-stigmatisation of HIV paralleling that occurring with diseases like cancer is unlikely to occur. Maximizing synergies between HIV treatment and prevention requires an enabling environment for HIV status disclosure, sustaining treatment, and safer sexual behaviours. Local leaders should be informed and sensitised and communities mobilised to address the blame-dimension of HIV stigma.

Editor’s note: These authors differentiate self-stigma (internalised feelings of shame which result from accepting others’ judgements), enacted stigma (discrimination based on blame, fear, or perceived burden) and anticipated stigma (reactions that people expect from others if it were to become known that they are living with HIV). In this study, provision of HIV treatment had a powerful impact reducing self-stigma, which facilitated disclosure and encouragement of others to access voluntary testing and counselling. However, the potential of these effects was eroded by persistent blaming attitudes in this community that then reinforced anticipated stigma and HIV denial. ‘Normalisation’, whereby people living with HIV are progressively integrated into productive and social life, requires opinion leaders to speak out against blame and marginalisation, promote inclusion of people living with HIV, and come forward for HIV testing themselves.