**3.1.2 Association with promiscuity**

According to the participants, people associate HIV/AIDS with promiscuity and perceive this as a barrier to caring for PLWHA. Many of them reported that HIV/AIDS is contracted from unprotected sexual intercourse. The general impression among our participants is that HIV/AIDS is acquired when the person has had much sexual activity with different persons. It was common for the participants in this study to depersonalize themselves from the belief of associating promiscuity with HIV/AIDS by shifting the belief to other people, for instance:

'Most people believe HIV is contracted through sexual transmission so immediately they see someone with HIV they automatically believe the person is promiscuous and goes around sleeping around but it can be got from different ways like blood transfusion.' (Male, married)

#### **3.1.3 Blame**

According to our respondents, a person with HIV/AIDS in society is frequently an object of blame. When people blame PLWHA for contracting the illness, it makes them stigmatize those people. Many of the participants said that society expects people to stick to their steady or wedded partners, as that is the way of avoiding contracting HIV/AIDS; infected people deserved to be blamed, in their view for instance:

*'I think people blame HIV persons. Some people feel HIV persons get HIV because they are prostitutes or go about having sexual intercourse with men or flirting about. So if people find out someone has HIV, people will see the person as somebody who is not responsible. The society feels if the person has not been going from person to person sexually, why should they come in contact with such illness?' (Male, single)* 

Another participant put it this way:

*If you are married to somebody, you are not supposed to go to another woman. You should stick to your wife. Then the single person has to be careful with their movement. People with HIV/AIDS should be blamed because they met someone; that is why they got HIV/AIDS.' (Male, single)* 

#### **3.1.4 Societal reaction to caregivers**

There was a consensus among participants that the reactions to people who care for PLWHA originate from their immediate environment, such as communal reactions, neighbors' influence and spousal reactions or from healthcare professionals. A participant expressed the idea that people care for one another with the expectation of reciprocity, that is, that they themselves may have a need for the care of another person in the future. Unfortunately, caring for a person with HIV/AIDS may not fit into this method of care because they are regarded as people who will die soon. Many of the participants were also concerned about the way other people will react to them when caring for a person with HIV/AIDS. A female participant described what happened when she went to hospital to learn the result of a HIV/AIDS test of a relative visiting her, which turned out to be positive. She received this response in the hospital:

*Laboratory worker: 'Oh madam, how long has this HIV person been staying with you in your house? Woman: She has been staying for three months* 

*Laboratory worker: You have to bring all your children for a HIV test. No, No, infact any help you want to give her let it be from a distance. She should be sent packing [sic] (sent away) from your house.' (Female, married)* 

This exchange indicates the extent of stigmatizing reactions even from health care professionals. In some cases, people fear that neighbors might spread the word that a family is caring for a person with HIV/AIDS, thereby affecting the possibilities of family marriage. One of the common procedures in marriage is that the family of the groom asks around for information about a potential bride before going into marriage. This implies that neighbors' judgments can be significant. Some participants felt that their desire for marriage and to have children overrides caring for a person with HIV/AIDS. This concern was shown vividly in the following comment:

*'Of course, caring for a person with HIV matters to me, because people around me can know about it or how else do people get husbands? They (potential suitors) can ask questions around about me where I live. I will not care for a person with HIV/AIDS even if she is my twin sister. Do you want me to get AIDS? I do mind as long as it is HIV/AIDS or do you want me to die young. You know it is a very serious disease that has no cure. You can see I am not married. I am a single girl. I do not want anything that will stain my image.' (Female, single)* 

#### **3.1.5 Media**

212 Social and Psychological Aspects of HIV/AIDS and Their Ramifications

*'The hair of people with HIV starts falling out with boils all over the skin and they are slim.' (Female,* 

People felt confirmed in this judgment strategy, and looked for outward HIV/AIDS features. Some participants, without knowing the exact illness of a person, assume the HIV status of that person and feel they are right if they see prototypical HIV/AIDS features. For

*'I know someone has HIV when someone is real lean and before you know it the person is sick. When they take the person to the hospital the doctor will examine and find out that the person is HIV* 

According to the participants, people associate HIV/AIDS with promiscuity and perceive this as a barrier to caring for PLWHA. Many of them reported that HIV/AIDS is contracted from unprotected sexual intercourse. The general impression among our participants is that HIV/AIDS is acquired when the person has had much sexual activity with different persons. It was common for the participants in this study to depersonalize themselves from the belief of associating promiscuity with HIV/AIDS by shifting the belief to other people,

'Most people believe HIV is contracted through sexual transmission so immediately they see someone with HIV they automatically believe the person is promiscuous and goes around sleeping around but it can be got from different ways like blood transfusion.' (Male, married)

According to our respondents, a person with HIV/AIDS in society is frequently an object of blame. When people blame PLWHA for contracting the illness, it makes them stigmatize those people. Many of the participants said that society expects people to stick to their steady or wedded partners, as that is the way of avoiding contracting HIV/AIDS; infected

*'I think people blame HIV persons. Some people feel HIV persons get HIV because they are prostitutes or go about having sexual intercourse with men or flirting about. So if people find out someone has HIV, people will see the person as somebody who is not responsible. The society feels if the person has not been going from person to person sexually, why should they come in contact with* 

*If you are married to somebody, you are not supposed to go to another woman. You should stick to your wife. Then the single person has to be careful with their movement. People with HIV/AIDS* 

There was a consensus among participants that the reactions to people who care for PLWHA originate from their immediate environment, such as communal reactions, neighbors' influence and spousal reactions or from healthcare professionals. A participant expressed the idea that people care for one another with the expectation of reciprocity, that is, that they themselves may have a need for the care of another person in the future. Unfortunately, caring for a person with HIV/AIDS may not fit into this method of care because they are regarded as people who will die soon. Many of the participants were also

*should be blamed because they met someone; that is why they got HIV/AIDS.' (Male, single)* 

*single)* 

*positive.' (Male, single)* 

for instance:

**3.1.3 Blame** 

*such illness?' (Male, single)* 

Another participant put it this way:

**3.1.4 Societal reaction to caregivers** 

instance, in the words of one interviewee:

**3.1.2 Association with promiscuity** 

people deserved to be blamed, in their view for instance:

According to some participants, the media have created an image that HIV/AIDS is contracted by people who have sex with multiple partners, or who visit sex workers. One participant had the following to say:

*'People react to a person with HIV in the same way, no matter how you get it. The reason why it is like that is that the first awareness of HIV publicity said HIV was for people sleeping around. The media always said stick to one partner, use a condom. This made people feel that once people stick to one partner, they will not get HIV, not realizing that it is possible the one partner already has HIV.' (Female, married)* 

Participants said that the information people get from radio and television is that HIV/AIDS can be guarded against. This helps in fuelling the negative public reaction people give to PLWHA by shifting the responsibility to the individual. The next participant was concerned by the way media send HIV/AIDS messages to the public using words as for instance "obirinajocha" (means you end up in the white sand underground), which can contribute to how people respond to HIV/AIDS:

*'What is being chumed out in the media is also an issue. One begins to wonder whether they are out to create an undesired effect because we hear all over the media that this is an incurable disease and people should better not attempt by any means to pick it up. The media create an atmosphere of helplessness for HIV positive people, as well as their care givers'. (Male, married)* 

#### **3.1.6 Poverty**

Poverty is seen as an underlying factor in preventing care for people suffering from HIV/AIDS. Poor people are often looked down upon in the society. Thus, HIV/AIDS only

Societal Beliefs and Reactions About People Living with HIV/AIDS 215

Our data show that women living with HIV experience more problems because their position is often marginal and inferior. Many of the participants expressed the concern that women encounter more problems because they are largely dependent on their husbands in almost every aspect: financially, emotionally, and in decision-making. Many of the participants said some women may be willing to care for a person with HIV/AIDS, but they need the approval of their husbands before they can go ahead. Chastity are also expected from women so when they contract HIV/AIDS, they are blamed to a larger extent, which may affect the willingness to care for them. The following illustrates a classic example of

*'The person I know living with HIV is a girl. It will be different for a man because people will not think immediately of sex as a cause of the HIV. They will think he got it from barbing salon.' (Female,* 

When a woman is infected with HIV, she is easily labeled a prostitute, as one participant

*'Women seem to suffer in everything. You find out that when a lady is HIV positive, nobody wants to hear anything apart from the fact that she has been fornicating and moving from place to place. They* 

This male participant showed concern that women have a possibility of spreading

*'It is better to tell government to take away a person with HIV especially females because if one does not take care she can spread it to other male people. Some of them know they will die one day so they* 

Many of the participants felt that government has a major role in providing care for PLWHA and increasing the knowledge of people about HIV/AIDS. Take the following quote, for

*'Government should continue with public information. People are still not educated very well. Some* 

Participants also felt government should be involved in the care of persons with HIV, as

*'Government should make antiretroviral therapy within the limit of individuals. Some should be helped if they cannot afford it because I read in the newspapers that ART is very expensive.' (Female,* 

As a result of these factors, there are changes in the relationship between the general public and PLWHA. The various manifestations of external stigmas, such as abandonment,

Participants in this study reported knowing PLWHA that are abandoned or would advocate abandoning PLWHA. People are suspicious that people with HIV/AIDS can purposely share household sharp objects or start flirting because they know they will die. Because of that, some participants wanted the government to restrict the movement of PLWHA. Other people felt that persons with HIV/AIDS have to accept their fate and need to learn to live

*people think that if you share toilet with a HIV person you will get HIV.' (Female, married)* 

*say she deserves what happened to her…..but if it is a male it is different.' (Female, single)* 

HIV/AIDS more purposively than men, as the following illustrates:

**3.1.9 Gender** 

*single)* 

observed:

example:

*married)* 

gender difference in blame:

*start flirting about.' (Male, single)* 

shown by the following quotes:

**3.2 Manifestations of stigma** 

**3.2.1 Abandonment** 

isolation, harassment and blame will be discussed.

**3.1.10 Government role** 

contributes further to stigmatization of such people. Economic difficulties complicate the situation for persons with HIV or for people who may be willing to care for them. Sometimes, even when relatives provide PLWHA with money for drugs, people caring for the person with HIV/AIDS can divert the money for personal use or for burial because they feel the person is dying anyway, in addition to trying to avoid caring for the person. They regard it is a waste of scarce resources, as one interviewee noted:

*'…when the HIV person was sick, his elder brother was given money by people to take care of the person with HIV for drugs but he spent the money on him self. He believed his brother was going to die so there was no need of giving him that money for care.' (Female, single)* 

#### **3.1.7 Fear**

Many of the participants had a fear of HIV/AIDS infection, and felt they could make mistakes when caring for such a person. People feel that PLWHA are close to death and since people are afraid of death, they try to avoid anything that reminds them of their own mortality, for instance:

*'People who know someone with HIV, the relationship with the person will change somehow because people are scared. Nobody wants to die. When we see someone (HIV person) like that we need to know how to deal with them.' (Male, single)* 

#### **3.1.8 Religion**

Our data revealed that religion may play both a detrimental and a supportive role. It is an important factor in the stigma of PLWHA with some of the participants placing religion above the medical treatment, causing much conflict in caring for PLWHA. Some of the participants believed it was possible to heal HIV/AIDS because there is nothing God cannot do. This merely reflects the notion that, if they contract HIV/AIDS, they may likely seek care in faith healing houses. This affects care-seeking behavior and, especially may cause treatment delay. This participant was convinced that, in her church, HIV/AIDS can be cured:

*'Many people with HIV/AIDS will fear to tell their pastor that they have AIDS so it is a problem because I know in my church they heal HIV/AIDS.' (Female, married)* 

However, another participant felt that the way the church goes about HIV/AIDS is wrong. In the church, where people look up to pastors and hope to get comfort, clergy may misuse the power they have over people, as demonstrated by the following comment:

*'There is segregation in the church. The church counselors give a paper to new couples to go for compulsory HIV screening and when the results turn positive, they give them back seats in the church. The church committee gossip around and people who have heard are not comfortable with the persons with HIV so they feel segregated.' (Female, married)* 

Giving them back seats is possible because they are able to use their power to give them whichever seat position they wish. Information about who has HIV also travels very fast in the church, as one participant noted:

*'I heard about the HIV couple in the church I attend. I did not know until people found out and started telling others. It was the pastor who found out through spiritual means and called them out. He asked them whether they are HIV positive and they said yes.' (Female, single)* 

Openly asking for persons with HIV/AIDS to come out in public has added implications because the whole church will become aware of the HIV status of those involved.

#### **3.1.9 Gender**

214 Social and Psychological Aspects of HIV/AIDS and Their Ramifications

contributes further to stigmatization of such people. Economic difficulties complicate the situation for persons with HIV or for people who may be willing to care for them. Sometimes, even when relatives provide PLWHA with money for drugs, people caring for the person with HIV/AIDS can divert the money for personal use or for burial because they feel the person is dying anyway, in addition to trying to avoid caring for the person. They

*'…when the HIV person was sick, his elder brother was given money by people to take care of the person with HIV for drugs but he spent the money on him self. He believed his brother was going to* 

Many of the participants had a fear of HIV/AIDS infection, and felt they could make mistakes when caring for such a person. People feel that PLWHA are close to death and since people are afraid of death, they try to avoid anything that reminds them of their own

*'People who know someone with HIV, the relationship with the person will change somehow because people are scared. Nobody wants to die. When we see someone (HIV person) like that we need to know* 

Our data revealed that religion may play both a detrimental and a supportive role. It is an important factor in the stigma of PLWHA with some of the participants placing religion above the medical treatment, causing much conflict in caring for PLWHA. Some of the participants believed it was possible to heal HIV/AIDS because there is nothing God cannot do. This merely reflects the notion that, if they contract HIV/AIDS, they may likely seek care in faith healing houses. This affects care-seeking behavior and, especially may cause treatment delay. This participant was convinced that, in her church, HIV/AIDS can be

*'Many people with HIV/AIDS will fear to tell their pastor that they have AIDS so it is a problem* 

However, another participant felt that the way the church goes about HIV/AIDS is wrong. In the church, where people look up to pastors and hope to get comfort, clergy may misuse

*'There is segregation in the church. The church counselors give a paper to new couples to go for compulsory HIV screening and when the results turn positive, they give them back seats in the church. The church committee gossip around and people who have heard are not comfortable with the* 

Giving them back seats is possible because they are able to use their power to give them whichever seat position they wish. Information about who has HIV also travels very fast in

*'I heard about the HIV couple in the church I attend. I did not know until people found out and started telling others. It was the pastor who found out through spiritual means and called them out.* 

Openly asking for persons with HIV/AIDS to come out in public has added implications

the power they have over people, as demonstrated by the following comment:

*He asked them whether they are HIV positive and they said yes.' (Female, single)* 

because the whole church will become aware of the HIV status of those involved.

regard it is a waste of scarce resources, as one interviewee noted:

*because I know in my church they heal HIV/AIDS.' (Female, married)* 

*persons with HIV so they feel segregated.' (Female, married)* 

the church, as one participant noted:

**3.1.7 Fear** 

mortality, for instance:

**3.1.8 Religion** 

cured:

*how to deal with them.' (Male, single)* 

*die so there was no need of giving him that money for care.' (Female, single)* 

Our data show that women living with HIV experience more problems because their position is often marginal and inferior. Many of the participants expressed the concern that women encounter more problems because they are largely dependent on their husbands in almost every aspect: financially, emotionally, and in decision-making. Many of the participants said some women may be willing to care for a person with HIV/AIDS, but they need the approval of their husbands before they can go ahead. Chastity are also expected from women so when they contract HIV/AIDS, they are blamed to a larger extent, which may affect the willingness to care for them. The following illustrates a classic example of gender difference in blame:

*'The person I know living with HIV is a girl. It will be different for a man because people will not think immediately of sex as a cause of the HIV. They will think he got it from barbing salon.' (Female, single)* 

When a woman is infected with HIV, she is easily labeled a prostitute, as one participant observed:

*'Women seem to suffer in everything. You find out that when a lady is HIV positive, nobody wants to hear anything apart from the fact that she has been fornicating and moving from place to place. They say she deserves what happened to her…..but if it is a male it is different.' (Female, single)* 

This male participant showed concern that women have a possibility of spreading HIV/AIDS more purposively than men, as the following illustrates:

*'It is better to tell government to take away a person with HIV especially females because if one does not take care she can spread it to other male people. Some of them know they will die one day so they start flirting about.' (Male, single)* 

#### **3.1.10 Government role**

Many of the participants felt that government has a major role in providing care for PLWHA and increasing the knowledge of people about HIV/AIDS. Take the following quote, for example:

*'Government should continue with public information. People are still not educated very well. Some people think that if you share toilet with a HIV person you will get HIV.' (Female, married)* 

Participants also felt government should be involved in the care of persons with HIV, as shown by the following quotes:

*'Government should make antiretroviral therapy within the limit of individuals. Some should be helped if they cannot afford it because I read in the newspapers that ART is very expensive.' (Female, married)* 

#### **3.2 Manifestations of stigma**

As a result of these factors, there are changes in the relationship between the general public and PLWHA. The various manifestations of external stigmas, such as abandonment, isolation, harassment and blame will be discussed.

#### **3.2.1 Abandonment**

Participants in this study reported knowing PLWHA that are abandoned or would advocate abandoning PLWHA. People are suspicious that people with HIV/AIDS can purposely share household sharp objects or start flirting because they know they will die. Because of that, some participants wanted the government to restrict the movement of PLWHA. Other people felt that persons with HIV/AIDS have to accept their fate and need to learn to live

Societal Beliefs and Reactions About People Living with HIV/AIDS 217

The extent to which a person with HIV is discriminated against can, sometimes, depend on the closeness of the person who is rendering the care. Some of our participants felt that they

*'Caring for a HIV person depends on how close the person is. If it is my brother or sister I can manage* 

Due to sympathy on religious grounds, some participants felt some people will still care for

*'People will run away though it may not be everybody. Some people because of fear of God, will like to encourage that HIV person because there is no other way to do it. One cannot poison a person with HIV to die. One will prefer to take care of the person until God wants him or her.' (Male, single)*  The way people discriminate home caretakers of a person with HIV/AIDS can be different from the way they react to healthcare professionals. Many of the participants in our study mentioned that the public may not react to healthcare professionals in the way they react to home care givers, because they feel they may have a need for a healthcare professional themselves. They are generally expected to be doing their work and their duty, which includes caring for PLWHA in a protective way. One participant, when asked whether healthcare professionals caring for PLWHA will be stigmatized like home caregivers, responded by saying that their profession makes them different from home care givers: *'Look at the name you called them, professionals. Healthcare professionals know how to take care of* 

The various factors, conditions and processes that give rise to external stigma, and the way

This study offers a description and exploration of the various factors, conditions and processes that allows stigma to manifest in Port Harcourt Nigeria. Our study indicates that people are still not very knowledgeable about HIV/AIDS, its mode of transmission and treatment possibilities. People react negatively towards PLWHA because they know little about the disease. Hence, they cannot handle PLWHA even when it is a close relative (Hilhorst et al., 2006). Lear (1998) argued that the problem of behavioural change is compounded by the persistence of myths concerning HIV/AIDS. Furthermore, as long as diseases such as HIV/AIDS are not well understood in an era in which medicine's central premise is that all diseases can be cured (Sontag, 1989), it will continue to evoke reactions from the society. Apart from our present data which show that society has negative reactions towards PLWHA, other studies in Sub-Saharan Africa, (Hilhorst et al., 2006; Campbell et al., 2007; Greeff et al., 2008; Demmer, 2011; Singh et al., 2011) have also shown that those who care for PLWHA receive negative reactions, putting the entire family at risk, making HIV/AIDS a societal problem. Moreover, 2010 UNAIDS report also shows that PLWHA have experienced different stigmatization reactions ranging from verbal abuse,

Our data show that not only that people stigmatize people diagnosed with HIV/AIDS, they also preoccupy themselves with the health diagnosis of other people through creating ideas about special features and body structures associated with certain illnesses such as HIV/AIDS. People not only live in a society that is structured by communal interaction (Wood & Lambert, 2008) but is also intertwined with gossip and rumors. HIV/AIDS

will only care for a close person with HIV, as in the following instance:

*but if it is my house help I will be afraid.' (Female, single)* 

persons with HIV/AIDS when they have no other option:

physical harrassment to denial of health care (UNAIDS, 2010).

**3.3 Conditions for care** 

*themselves.' (Female, single)* 

**4. Discussion** 

they relate, will be discussed below.

with the fact that people will stigmatize them. Another participant preferred to shift the responsibility of care to health care professionals:

*'Why must a HIV person come to the house? They should stay back in the hospital.' (Female, married)* 

#### **3.2.2 Isolation**

Participants described how their relationship will change upon realizing that a person with HIV/AIDS, or a caregiver of such a person, is around. People avoid people with HIV/AIDS. This explains why PLWHA are reluctant and selective in disclosure as a way of coping with HIV/AIDS stigma. People also feared that, once they care for someone with HIV/AIDS, word will spread around and from there on, people will isolate them. This participant talks about her experience of how PLWHA are cared for:

*'Sometimes people with HIV/AIDS are locked up in the room and the care givers pass a hole through which they give them food so that the caregivers do not come in contact with the person. Sometimes the caregivers do not even give the person food so that the person can die.' (Female, single)* 

A participant shared what happened when a person with HIV/AIDS living close to her came back home from hospital:

*'They try to isolate the woman who is caring for her daughter. When she was discharged and came home to their house, people started peeping at them through the window. People will not want to go to the kitchen when she is cooking and they will not want to go near the bathroom until they finish using the bathroom. Everybody wants to keep away. People look at the care giver as someone who is not reasonable anymore.' (Female, single)* 

#### **3.2.3 Harassment**

We also found that harassment can be a manifestation of stigmatisation and can be shown in any form of unwelcome behavior. According to this participant, who tried to describe what will happen to someone caring for a person with HIV/AIDS:

*'The care givers of HIV persons will have a problem because it will be the talk of the area. People will say there is a person with HIV/AIDS in that area. Some will not be relating to them because they are afraid.' (Male, single)* 

In addition, people gossip in the community. This participant gave an account of a person she knows and has HIV/AIDS:

*'People were running away, they always say they don't want to be involved, wherever she passes people will point at her and say look at that person with HIV. Nobody wants to visit her. The ones that go just want to gossip.' (Female, single)* 

#### **3.2.4 Blame**

Our findings indicate that the society frequently assigns blame to PLWHA. Blame is another way used by the people to stigmatize persons with HIV, for example:

*'People blame them because they feel a responsible person is supposed to live a rightful life so they cannot contact the disease.' (Male, married)* 

Consider also the following point:

*'You know, here in Nigeria, if you have such sickness, people will start blaming the person with HIV. They will tell her all sorts of things. They do not care how she got it. They will say the person got it from sexual intercourse.' (Female, single)* 

Despite these various effect factors manifesting as stigma, some participants set conditions for care, which will be discussed in the next section.

#### **3.3 Conditions for care**

216 Social and Psychological Aspects of HIV/AIDS and Their Ramifications

with the fact that people will stigmatize them. Another participant preferred to shift the

*'Why must a HIV person come to the house? They should stay back in the hospital.' (Female,* 

Participants described how their relationship will change upon realizing that a person with HIV/AIDS, or a caregiver of such a person, is around. People avoid people with HIV/AIDS. This explains why PLWHA are reluctant and selective in disclosure as a way of coping with HIV/AIDS stigma. People also feared that, once they care for someone with HIV/AIDS, word will spread around and from there on, people will isolate them. This participant talks

*'Sometimes people with HIV/AIDS are locked up in the room and the care givers pass a hole through which they give them food so that the caregivers do not come in contact with the person. Sometimes* 

A participant shared what happened when a person with HIV/AIDS living close to her

*'They try to isolate the woman who is caring for her daughter. When she was discharged and came home to their house, people started peeping at them through the window. People will not want to go to the kitchen when she is cooking and they will not want to go near the bathroom until they finish using the bathroom. Everybody wants to keep away. People look at the care giver as someone who is* 

We also found that harassment can be a manifestation of stigmatisation and can be shown in any form of unwelcome behavior. According to this participant, who tried to describe what

*'The care givers of HIV persons will have a problem because it will be the talk of the area. People will say there is a person with HIV/AIDS in that area. Some will not be relating to them because they are* 

In addition, people gossip in the community. This participant gave an account of a person

*'People were running away, they always say they don't want to be involved, wherever she passes people will point at her and say look at that person with HIV. Nobody wants to visit her. The ones* 

Our findings indicate that the society frequently assigns blame to PLWHA. Blame is another

*'People blame them because they feel a responsible person is supposed to live a rightful life so they* 

*'You know, here in Nigeria, if you have such sickness, people will start blaming the person with HIV. They will tell her all sorts of things. They do not care how she got it. They will say the person got it* 

Despite these various effect factors manifesting as stigma, some participants set conditions

*the caregivers do not even give the person food so that the person can die.' (Female, single)* 

responsibility of care to health care professionals:

about her experience of how PLWHA are cared for:

will happen to someone caring for a person with HIV/AIDS:

way used by the people to stigmatize persons with HIV, for example:

came back home from hospital:

**3.2.3 Harassment** 

*afraid.' (Male, single)* 

**3.2.4 Blame** 

she knows and has HIV/AIDS:

*that go just want to gossip.' (Female, single)* 

*cannot contact the disease.' (Male, married)*  Consider also the following point:

*from sexual intercourse.' (Female, single)* 

for care, which will be discussed in the next section.

*not reasonable anymore.' (Female, single)* 

*married)* 

**3.2.2 Isolation** 

The extent to which a person with HIV is discriminated against can, sometimes, depend on the closeness of the person who is rendering the care. Some of our participants felt that they will only care for a close person with HIV, as in the following instance:

*'Caring for a HIV person depends on how close the person is. If it is my brother or sister I can manage but if it is my house help I will be afraid.' (Female, single)* 

Due to sympathy on religious grounds, some participants felt some people will still care for persons with HIV/AIDS when they have no other option:

*'People will run away though it may not be everybody. Some people because of fear of God, will like to encourage that HIV person because there is no other way to do it. One cannot poison a person with HIV to die. One will prefer to take care of the person until God wants him or her.' (Male, single)* 

The way people discriminate home caretakers of a person with HIV/AIDS can be different from the way they react to healthcare professionals. Many of the participants in our study mentioned that the public may not react to healthcare professionals in the way they react to home care givers, because they feel they may have a need for a healthcare professional themselves. They are generally expected to be doing their work and their duty, which includes caring for PLWHA in a protective way. One participant, when asked whether healthcare professionals caring for PLWHA will be stigmatized like home caregivers, responded by saying that their profession makes them different from home care givers:

*'Look at the name you called them, professionals. Healthcare professionals know how to take care of themselves.' (Female, single)* 

The various factors, conditions and processes that give rise to external stigma, and the way they relate, will be discussed below.

## **4. Discussion**

This study offers a description and exploration of the various factors, conditions and processes that allows stigma to manifest in Port Harcourt Nigeria. Our study indicates that people are still not very knowledgeable about HIV/AIDS, its mode of transmission and treatment possibilities. People react negatively towards PLWHA because they know little about the disease. Hence, they cannot handle PLWHA even when it is a close relative (Hilhorst et al., 2006). Lear (1998) argued that the problem of behavioural change is compounded by the persistence of myths concerning HIV/AIDS. Furthermore, as long as diseases such as HIV/AIDS are not well understood in an era in which medicine's central premise is that all diseases can be cured (Sontag, 1989), it will continue to evoke reactions from the society. Apart from our present data which show that society has negative reactions towards PLWHA, other studies in Sub-Saharan Africa, (Hilhorst et al., 2006; Campbell et al., 2007; Greeff et al., 2008; Demmer, 2011; Singh et al., 2011) have also shown that those who care for PLWHA receive negative reactions, putting the entire family at risk, making HIV/AIDS a societal problem. Moreover, 2010 UNAIDS report also shows that PLWHA have experienced different stigmatization reactions ranging from verbal abuse, physical harrassment to denial of health care (UNAIDS, 2010).

Our data show that not only that people stigmatize people diagnosed with HIV/AIDS, they also preoccupy themselves with the health diagnosis of other people through creating ideas about special features and body structures associated with certain illnesses such as HIV/AIDS. People not only live in a society that is structured by communal interaction (Wood & Lambert, 2008) but is also intertwined with gossip and rumors. HIV/AIDS

Societal Beliefs and Reactions About People Living with HIV/AIDS 219

church, and the pastors were very influential, making their actions very crucial. Aholou and colleagues further noted that the churches have strengths, credibility and are well grounded in communities (Aholou et al., 2009). Many PLWHA regard church as one of the places of protection from negative reaction from society, but they end up being stigmatized by their fellow worshippers. Our data show that a positive HIV test result from premarital HIV screening means that the information may leak to other members of the church and the continuity of the marriage maybe jeopardized since there is no standard guideline regarding the privacy and confidentiality of people. Premarital HIV screening is also quickly becoming a prerequisite for marriage to be contracted in many churches (Uneke, Alo & Ogbu, 2007) and since marriage is very important in society, many people end up knowing their status by necessity while ill prepared for the negative reactions from the society. Sontag (1989) argues that any disease that is considered a mystery and acutely enough to be feared will be felt to be morally, if not literally, contagious, in addition to the notion that cleanliness is next to godliness; thus, stigmatization is not unexpected for PLWHA even in the church. Lear (1998) shows that some Roman Catholic churches in Kenya and Uganda have used words such as "Love faithfully to avoid AIDS" to discourage usage of condoms. Other recent studies (e.g., Iwelunmor et al., 2006; Campbell et al., 2007; Neville & Rubin, 2007) also reported both supportive and detrimental roles. The belief in faith healing and miracles was also found in our study, which means that many who know of their status may choose faith

healing as a first choice of care, or combine it with care from a health institution.

medicine dealers (Ajuwon & Shokunbi).

period of actual illness (Hilhorst et al., 2006).

With all these negative reactions towards PLWHA in general, our study also shows that societal reactions can be different depending on the person's gender. Society is constructed in such a way that it is a man's world because decisions and actions are often dependent on men (Ajuwon & Shokunbi, 1998). Society exonerates men with multiple partners (Ankra, 1994; Ajuwon et al., 1998; Hartwig et al., 2006; Utulu & Lawoyin, 2007) as it reflect male virility. The sexual norm in Nigeria promotes sexual liberty for men and sexual purity for women (Ajuwon & Shokunbi, 1998). Yet, our study shows that, when a man contracts HIV/AIDS, he may be regarded a victim and attracts more sympathy. This is in keeping with studies carried out in Nigeria, which show that male PLWHA are more accepted than female ones (Hilhorst et al., 2006; Babalola et al., 2009). A man is also often able to hide his HIV-positive status if he chooses, and may end up spreading the infection because he is the breadwinner and may have money to care for himself. A woman, on the other hand, is mostly, financially dependent (Ajuwon et al., 1998; Hilhorst et al., 2006; Strebel et al., 2006), often finding it difficult to hide her status. Their maginal position also means they will not be able to seek appropriate care since they are mostly embarrassed if seen in a sexually transmitted infection (STI) clinic, making them resort to traditional healers or patent

Our data point out that, even when money is given for the care of PLWHA, family members may decide not to use it, since the person is regarded as dying and they may want to save it for the burial. This finding, taken together with other studies carried out in Sub-Saharan Africa (Plummer et al., 2006; Campbell et al., 2007; Amuri et al., 2011) shows that poverty creates an additional burden to PLWHA and their carers. Corpses are valued and cost money to be buried, with people more willing to offer help during funerals than during the

Our study also shows that the media contributed to stigmatization because of the way they portrayed information about HIV/AIDS earlier in the epidemic. For example, in a Nigerian

inspires much gossip, rumor and speculation. The images and the ideas associated with PLWHA are an expression of their concern for social order and of a sense of dissatisfaction from within society (Sontag, 1989). This has significant implications for PLWHA. It increases self-stigmatization, in addition to the stigmatization from society when they have body features that are widely believed to indicate HIV/AIDS. It is perhaps not surprising that our study shows that PLWHA who are heavy weighted may be exonerated because people do not believe they can be heavy weighted and at the same time have HIV/AIDS, especially when they are on antiretroviral therapy (ART) and have less need for frequent hospitalization. This aspect of body politics was also reported by Greeff and colleagues (Greeff et al., 2008).

Our data emphasize that people link HIV/AIDS to promiscuity, which makes people stigmatize PLWHA because they are regarded as people who have gone against the societal values by having indiscriminate sex. Society has strong morals and values that guide it (Campbell et al., 2007) and sex is considered a highly private issue not to be discussed in the open (Ajuwon et al., 1998; Stewart & Richter, 1998). HIV/AIDS is also seen as a disease that flushes out an identity of a certain "risk group", a community of pariahs that might have remained hidden from neighbours, colleagues, family and friends because HIV/AIDS is considered as a calamity brought about by oneself (Sontag, 1989). Our data shows that the association with promiscuity is what causes blame because of the assumed bad behavior. The linking of blame to immoral behaviour was also similarly reported in a multi-country study of Zimbabwe, South Africa, Tanzania and Thailand, in which participants from Tanzania and Zimbabwe felt that PLWHA deserved what they got in terms of being punished for their reckless behavior (Maman et al., 2009). In our study, participants often assigned blame to PLWHA without bothering to find out the cause of infection with HIV/AIDS of the person. It is noteworthy that our findings show that blame is both a cause of stigma and a manifestation of stigma. First, society acts as a social watchdog for people by linking moral judgments to people's assumed behavior. Secondly, the judgment meted to PLWHA affects the willingness to give care; society is not ready to help someone whose illness arose from wilful social misbehavior thereby stigmatizing PLWHA. Moreover, due to societal judgment, PLWHA and the family care givers may find it difficult to justify for any financial help since many people do not have health insurance. This finding, taken together with another study carried out in Nigeria, confirms the likelihood of people needing financial help in Nigeria (Hilhorst et al., 2006). The probability of being helped is worsened by the principle of reciprocity in society, which is of particular concern. Hilhorst and colleagues (2006) went on to say that social capital implies reciprocity that has to be built and maintained requiring investments and resources which PLWHA may not be able to meet with such obligations. Furthermore, society is a death-denying one, where the prospect of no future or the loss of independence is an abomination (Chateauvert, 1993). Our data show that, while some people may be willing to assist PLWHA because they feel they can end up in the same situation in the future, others stigmatize PLWHA by expecting government to take them away or keeping them back at the hospital. Those who choose to care for PLWHA often prefer to keep that a secret so that the stigma does not spread to the rest of the family. This is particularly significant in Nigeria, because when people find out someone close to them is HIV-positive, it can jeopardize the chance of marriage because of the high value of marriage and pregnancy (Ajuwon & Shokunbi, 1998).

Findings from our study have shown that the churches do help PLWHA, but sometimes they make their situation very difficult. People are often obedient to the pastors and in the

inspires much gossip, rumor and speculation. The images and the ideas associated with PLWHA are an expression of their concern for social order and of a sense of dissatisfaction from within society (Sontag, 1989). This has significant implications for PLWHA. It increases self-stigmatization, in addition to the stigmatization from society when they have body features that are widely believed to indicate HIV/AIDS. It is perhaps not surprising that our study shows that PLWHA who are heavy weighted may be exonerated because people do not believe they can be heavy weighted and at the same time have HIV/AIDS, especially when they are on antiretroviral therapy (ART) and have less need for frequent hospitalization. This aspect of body politics was also reported by Greeff and colleagues

Our data emphasize that people link HIV/AIDS to promiscuity, which makes people stigmatize PLWHA because they are regarded as people who have gone against the societal values by having indiscriminate sex. Society has strong morals and values that guide it (Campbell et al., 2007) and sex is considered a highly private issue not to be discussed in the open (Ajuwon et al., 1998; Stewart & Richter, 1998). HIV/AIDS is also seen as a disease that flushes out an identity of a certain "risk group", a community of pariahs that might have remained hidden from neighbours, colleagues, family and friends because HIV/AIDS is considered as a calamity brought about by oneself (Sontag, 1989). Our data shows that the association with promiscuity is what causes blame because of the assumed bad behavior. The linking of blame to immoral behaviour was also similarly reported in a multi-country study of Zimbabwe, South Africa, Tanzania and Thailand, in which participants from Tanzania and Zimbabwe felt that PLWHA deserved what they got in terms of being punished for their reckless behavior (Maman et al., 2009). In our study, participants often assigned blame to PLWHA without bothering to find out the cause of infection with HIV/AIDS of the person. It is noteworthy that our findings show that blame is both a cause of stigma and a manifestation of stigma. First, society acts as a social watchdog for people by linking moral judgments to people's assumed behavior. Secondly, the judgment meted to PLWHA affects the willingness to give care; society is not ready to help someone whose illness arose from wilful social misbehavior thereby stigmatizing PLWHA. Moreover, due to societal judgment, PLWHA and the family care givers may find it difficult to justify for any financial help since many people do not have health insurance. This finding, taken together with another study carried out in Nigeria, confirms the likelihood of people needing financial help in Nigeria (Hilhorst et al., 2006). The probability of being helped is worsened by the principle of reciprocity in society, which is of particular concern. Hilhorst and colleagues (2006) went on to say that social capital implies reciprocity that has to be built and maintained requiring investments and resources which PLWHA may not be able to meet with such obligations. Furthermore, society is a death-denying one, where the prospect of no future or the loss of independence is an abomination (Chateauvert, 1993). Our data show that, while some people may be willing to assist PLWHA because they feel they can end up in the same situation in the future, others stigmatize PLWHA by expecting government to take them away or keeping them back at the hospital. Those who choose to care for PLWHA often prefer to keep that a secret so that the stigma does not spread to the rest of the family. This is particularly significant in Nigeria, because when people find out someone close to them is HIV-positive, it can jeopardize the chance of marriage because of

the high value of marriage and pregnancy (Ajuwon & Shokunbi, 1998).

Findings from our study have shown that the churches do help PLWHA, but sometimes they make their situation very difficult. People are often obedient to the pastors and in the

(Greeff et al., 2008).

church, and the pastors were very influential, making their actions very crucial. Aholou and colleagues further noted that the churches have strengths, credibility and are well grounded in communities (Aholou et al., 2009). Many PLWHA regard church as one of the places of protection from negative reaction from society, but they end up being stigmatized by their fellow worshippers. Our data show that a positive HIV test result from premarital HIV screening means that the information may leak to other members of the church and the continuity of the marriage maybe jeopardized since there is no standard guideline regarding the privacy and confidentiality of people. Premarital HIV screening is also quickly becoming a prerequisite for marriage to be contracted in many churches (Uneke, Alo & Ogbu, 2007) and since marriage is very important in society, many people end up knowing their status by necessity while ill prepared for the negative reactions from the society. Sontag (1989) argues that any disease that is considered a mystery and acutely enough to be feared will be felt to be morally, if not literally, contagious, in addition to the notion that cleanliness is next to godliness; thus, stigmatization is not unexpected for PLWHA even in the church. Lear (1998) shows that some Roman Catholic churches in Kenya and Uganda have used words such as "Love faithfully to avoid AIDS" to discourage usage of condoms. Other recent studies (e.g., Iwelunmor et al., 2006; Campbell et al., 2007; Neville & Rubin, 2007) also reported both supportive and detrimental roles. The belief in faith healing and miracles was also found in our study, which means that many who know of their status may choose faith healing as a first choice of care, or combine it with care from a health institution.

With all these negative reactions towards PLWHA in general, our study also shows that societal reactions can be different depending on the person's gender. Society is constructed in such a way that it is a man's world because decisions and actions are often dependent on men (Ajuwon & Shokunbi, 1998). Society exonerates men with multiple partners (Ankra, 1994; Ajuwon et al., 1998; Hartwig et al., 2006; Utulu & Lawoyin, 2007) as it reflect male virility. The sexual norm in Nigeria promotes sexual liberty for men and sexual purity for women (Ajuwon & Shokunbi, 1998). Yet, our study shows that, when a man contracts HIV/AIDS, he may be regarded a victim and attracts more sympathy. This is in keeping with studies carried out in Nigeria, which show that male PLWHA are more accepted than female ones (Hilhorst et al., 2006; Babalola et al., 2009). A man is also often able to hide his HIV-positive status if he chooses, and may end up spreading the infection because he is the breadwinner and may have money to care for himself. A woman, on the other hand, is mostly, financially dependent (Ajuwon et al., 1998; Hilhorst et al., 2006; Strebel et al., 2006), often finding it difficult to hide her status. Their maginal position also means they will not be able to seek appropriate care since they are mostly embarrassed if seen in a sexually transmitted infection (STI) clinic, making them resort to traditional healers or patent medicine dealers (Ajuwon & Shokunbi).

Our data point out that, even when money is given for the care of PLWHA, family members may decide not to use it, since the person is regarded as dying and they may want to save it for the burial. This finding, taken together with other studies carried out in Sub-Saharan Africa (Plummer et al., 2006; Campbell et al., 2007; Amuri et al., 2011) shows that poverty creates an additional burden to PLWHA and their carers. Corpses are valued and cost money to be buried, with people more willing to offer help during funerals than during the period of actual illness (Hilhorst et al., 2006).

Our study also shows that the media contributed to stigmatization because of the way they portrayed information about HIV/AIDS earlier in the epidemic. For example, in a Nigerian

Societal Beliefs and Reactions About People Living with HIV/AIDS 221

done without necessarily running a risk of contracting HIV/AIDS. A significant proportion of people in society have heard about HIV/AIDS and the kind of aggression with which the media initially provided information on HIV/AIDS, which enhanced discrimination, should

The authors wish to thank Dr Anja Krumeich for her help in the design of the

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now be turned towards giving HIV/AIDS a human face.

**7. Acknowledgments** 

Company, Inc.

questionnaires.

**8. References** 

news paper in October 19, 1987, HIV/AIDS was typified as "a self-inflicted scourge caused by reckless sexual extravaganza, and the person must be prepared to bear the consequence of their lustful discretion" (Lear, 1998). Such images in the media flourish and take time to be reversed.
