3.1 Descriptive statistics
Overall, a sample of 31,173 people not living with HIV and 3,838 PLWH were included in the study. Table 2 presents socio-demographic characteristics of the sample.
Among persons not living with HIV, 14% and 10% displayed stigmatizing behavior and discriminatory attitudes, respectively, toward people with HIV. The highest percentage of persons expressing both stigmatizing behavior and discriminatory attitudes was observed in Tanzania (16% and 12%, respectively) and the lowest in Malawi (6%). Overall, 15% of individuals showed some prejudice toward PLWH, with the highest percentage observed in Zambia. Among people self-reporting living with HIV, 14% of PLWH expressed internalized stigma. This ranged from 11% in Malawi to 16% in Zambia. Experienced and anticipated stigma were expressed by 2% and 10% of PLWH in this sample, respectively, with the highest prevalence in Tanzania.
In both seronegative and seropositive groups, women were more represented in our sample (56% and 70%, respectively), people who only attained a primary education were predominant (56% and 59%, respectively), as well as people from the highest wealth quintile (24% and 25% respectively). Age distribution was different between the two groups. Among persons not living with HIV, the 25-34 years age-group was the largest, while those 35-44 years made up the majority of PLWH. Contrary to what is observed among people not living with HIV, the majority (62%) of PLWH lived in urban regions.
3.2 Bivariate and multivariable analysis
The bivariate analysis of the association between subnational HIV prevalence and stigma manifestations is shown in Table 3. Among those not living with HIV, we observed that subnational HIV prevalence was negatively significantly associated with stigmatizing behavior, discriminatory attitudes, and prejudice. Participants living in geographic regions with low HIV prevalence compared to those living in high prevalence regions were less likely to express stigmatizing behavior (OR=0.55, 90%CI= (0.49-0.62)), discriminatory attitudes (OR=0.61, 90%CI= (0.53-0.69)) and prejudice (OR=0.88, 90%CI= (0.80-0.96)). No significant association between HIV prevalence and internalized, experienced, and anticipated stigma expressed by PLWH was found overall, before controlling for demographics. However, in our bivariate analysis by country, there was a significant positive association between subnational prevalence and anticipated stigma in Malawi. Compared to PLWH living in low prevalence regions, those living in middle and high prevalence region had higher odds of reporting anticipated stigma (OR=4.8, 90%CI= (1.36-16.91) and OR=9.91, 90%CI= (1.72-20.26) respectively). Among persons not living with HIV, a significant negative association between HIV prevalence and stigma was observed for all the indicators and in all the countries, except for the prejudice measure in Malawi and Tanzania.
Table 4 shows that after controlling for age, sex, education, socioeconomic status, urban region and country fixed-effects, compared to persons living without HIV in low prevalence regions, the odds of expressing stigmatizing behavior were lower for those living in middle (OR = 0.83, 90%CI= (0.73-0.94)) and high (OR = 0.73, 90%CI= (0.64-0.84)) prevalence regions. Similarly, among persons living without HIV, the odds of expressing discriminatory attitudes were lower for those living in middle (OR = 0.89, 90%CI= (0.80-0.99)) and high (OR = 0.67, 90%CI= (0.59-0.77)) prevalence regions compared to low prevalence regions. In addition, those living in high HIV prevalence regions were less likely to express prejudice toward PLWH than those in low prevalence ones (OR = 0.78, 90%CI= (0.70-0.88)).
Table 5 shows that, everything being equal, the odds of expressing internalized stigma is statistically significant, at the 10% level, for PLWH located in high HIV prevalence regions (OR = 1.69, 90%CI= (1.07-2.66)) compared to their peers living in low prevalence ones. Though not significant, we also observed the odds of expressing experienced and anticipated stigma were higher for those living in middle and high HIV prevalence regions compared to those living in low prevalence regions.
The analysis, when considering the nested structure of the data (Table A1 and Table A2), shows very similar results. The odds of expressing stigmatizing behavior towards PLWH was significantly lower for persons not living with HIV living in middle (OR = 0.80, 90%CI= (0.68-0.96)) and high (OR = 0.65, 90%CI= (0.53-0.80)) prevalence regions compared to low prevalence ones. Compared to individuals living in low prevalence region, the odds of expressing discriminatory attitudes were lower for those living in middle (OR = 0.87, 90%CI= (0.78-0.98)) and high (OR = 0.64, 90%CI= (0.56-0.73)) prevalence regions. Similarly, living in middle and high prevalence regions was associated with lower odds of expressing prejudice toward PLWH (OR=0.84, 90%CI= (0.71-0.99) and OR=0.60, 90%CI= (0. .45-0.80) respectively). PLWH living in high prevalence regions were significantly more likely to expressed internalized stigma (OR=1.48, 90%CI= (1.02-2.14).
Regarding the control variables, we observed that among participants not living with HIV, older groups (25+ years) expressed fewer stigmatic attitudes compared to those younger (15-24 years). Similarly, more educated and wealthier people not living with HIV expressed fewer stigmatic attitudes compared to those reporting less education and wealth. Living in urban areas was associated with lower odds of expressing stigmatic attitudes. There was no significant difference between men and women for all outcomes, except stigmatizing behavior. The higher the proportion of individuals with secondary, or greater, education in a region, the higher the odds people expressed discriminatory attitudes and prejudice toward PLWH. Conversely, the higher the proportion of people in the highest wealth quintile in a region, the lower the odds people expressed discriminatory attitudes and prejudice.
Among PLWH, a similar relationship was observed regarding age, education, urban location, and wealth quintile for internalized stigma, though the relationship is in some of the cases non-significant. For anticipated stigma, only some older age-groups (35-44 and 45+ years) expressed significantly less stigma, while people from the fifth wealth quintile expressed more stigma compared to those with less wealth.
A sensitivity analysis using a continuous variable of subnational HIV prevalence is presented in the annex (Table A3 and Table A4) and shows similar results: subnational HIV prevalence was negatively associated with stigmatizing behavior (OR = 0.96, 90%CI= (0.95-0.98)), discriminatory attitudes (OR = 0.96, 90%CI= (0.95-0.98)), and prejudice (OR = 0.98, 90%CI= (0.96-0.99)) of persons not living with HIV toward PLWH. There was a positive association with internalized stigma (OR = 1.06, 90%CI= (1.01-1.11)) expressed by PLWH. A positive, but non-significant, association between subnational HIV prevalence and experienced and anticipated stigma experienced or expressed by PLWH was found.