**1. Introduction**

Although the overall growth of the global AIDS epidemic appears to have stabilized, still, Sub-Saharan Africa has the majority of new infections with 1.8 million (1.6 million- 2.0 million) people becoming infected in 2009 (UNAIDS, 2010). Sub-Saharan Africa remains the region most heavily affected by HIV/AIDS, accounting for 68% of all people living with HIV/AIDS (PLWHA) and for 72% of AIDS related deaths in 2009 (UNAIDS, 2010). In West Africa, Nigeria has the largest epidemic in absolute numbers (UNAIDS, 2008) with 2.98 million people living with HIV and 192,000 adults and child deaths from AIDS in 2009 (UNAIDS, 2010). The HIV/AIDS prevalence rate in Nigeria remains uneven across different states (Utulu & Lawoyin, 2007; UNAIDS, 2010). A retrospective study carried out between 2000 and 2004 among 10,032 pregnant women attending the antenatal clinic at the Braithwaite Memorial Hospital, Port Harcourt Nigeria showed that 5.93% of the women were HIV- positive patients (Obi et al., 2007). Another study carried out in the university teaching hospital at Port Harcourt Nigeria between 1999 and 2004 showed a paediatric prevalence rate of 25.8% (Alikor & Erhabor, 2005). More recently, HIV prevalence among pregnant women attending antenatal clinic in Rivers State is 7.3% in 2008 (UNAIDS, 2010) making Rivers state one of the states with high HIVprevalence among pregnant women in Nigeria.

One of the many challenges associated with HIV/AIDS is stigma. Stigma is generally recognized as an 'attribute that is deeply discrediting' that reduces the bearer 'from a whole and usual person to a tainted, discounted one' (Goffman, 1974). Herek (2002) describes stigma as an enduring condition, status, or attribute that is negatively valued by a society and whose possession consequently discredits and disadvantages an individual (Herek, 2002). Steward and colleagues noted further that stigma is very much about the socially constructed meanings associated with the attribute or characteristic (Steward et al., 2008). Because AIDS or HIV infection is an enduring condition or characteristic that is negatively valued (Herek, 2002), AIDS-related stigma continues to be a barrier to caring for, and supporting, people whose HIV status is known in society (Campbell et al., 2007).

Stigma arises and stigmatization takes shape in specific contexts of culture and power (Parker & Aggleton, 2003). Stigma is especially significant in many developing countries, such as those in Africa, where social networks and, therefore, societal values, are relatively

Societal Beliefs and Reactions About People Living with HIV/AIDS 209

A convenience sample was used in this study. Interviewees were approached at the recruitment venues and interviews were held in workplaces, offices, restaurants, shops or on the street. An introductory sentence informed participants that the interviews were covering stigma towards PLWHA. Verbal consent was obtained from participants and total anonymity was guaranteed. Forty-one persons were approached, of whom 40 agreed to participate in the interviews (See Table 1). The one person who refused was too busy to grant an interview. No compensation was offered to participants. Interviews were conducted throughout the week. Interviews were conducted in the English language and were face to face. The interviews lasted between an hour and one and half hour. Basic demographic data about participants were gathered before the interviews. Interviews continued until no new information emerged. All interviews were audio-taped and

Nvivo (QRS release 2.0), a computer-assisted qualitative data analysis system, was used to aid analysis and reporting. The analysis of the interviews enabled us to identify causal relationships and, therefore, come up with a causal structure. Field notes and information from the literature review were also used during the analysis. Emerging issues were examined to identify related concepts. Different factors were formed from the emerging themes. A model was built to explore important relationships between concepts. Attributes were formed to include important characteristics such as gender and work category, which

An independent researcher coded a random selection of data to look for new concepts. The independent researcher compared emerging themes with the coding by the authors. New meanings and discrepancies were checked by re-reading the transcripts and fine-tuning interpretations until unambiguous categories and themes were agreed. No important

Demographic characteristics are presented in Table 1. Twenty four persons were female and 21 persons were married. An explanatory model was organized in a causal structure based on the combined responses of the interviewees (Figure 1). The model shows stigma by society as being affected by 10 different determining factors, all of which relate to processes and conditions that allow a manifestation of the stigma. These determining factors are degree of knowledge, association with promiscuity, blame, societal reaction to care givers, media, poverty, fear, religion, gender, and government role. Blame functions both as a determining factor that creates stigma, as well as manifestations of stigma. Other

The views of both men and women are combined. The described findings and interpretations offer a general insight, illustrated with verbatim excerpts. In the following sections, the various determining factors are presented. Subsequently, we describe different manifestations of stigma. Thirdly, the conditions of care will be described, and finally, we

manifestations of stigma are abandonment, isolation, and harassment.

discuss how these processes and condition interrelate in the explanatory model.

**2.1 Recruitment and consent of participants** 

transcribed verbatim.

were subsequently imported into Nvivo.

**2.2 Data analysis** 

**2.3 Validity** 

**3. Results** 

discrepancies were found.

strong (Greeff et al., 2008). The family and the community constitute vital aspects of the social structure that normally offers strength and support during times of need and crisis (Ajuwon et al., 1998; Hilhorst et al., 2006; Kipp et al., 2007). In this communal and social network, contact with someone afflicted with a disease regarded as a mysterious threat, inevitably, feels like trespassing or, worse, as violation of a taboo (Sontag, 1989).

Stigma influences all phases in prevention, detection and care for PLWHA. It decreases turn-up for facilities for voluntary counselling and testing in hospitals (Weiser et al., 2006). Anticipated stigmatizing societal reactions may also decrease the tendency to disclose serostatus to the immediate social environment and, more importantly, to sexual partners. Specifically, a study carried out in Port Harcourt, Nigeria, showed that 77% of PLWHA had disclosed their HIV sero-status to one or more others, of which 22.3% disclosed their condition to their parents, 9.7% to their siblings, 27.8% to pastors, 6.3% to friends, 10.4% to their family members and 23.6% to their sexual partners (Akani & Erhabor, 2006). Other studies has also documented selective disclosure patterns among PLWHA. (Gari et al., 2010; Anglewicz, et al., 2011; Stutterheim et al., 2011).

In a previous study, we reviewed behavioral problems of PLWHA in Sub-Saharan Africa in seeking care, and argued that this is partly due to stigmatizing responses to PLWHA from health care professionals and society at large (Mbonu, Van den Borne, & De Vries, 2009). Given the negative impact of stigma on care seeking and the selective disclosure of a positive HIV-sero-status to close and trusted people, it is important to understand why HIV/AIDS attracts such a degree of negative reaction in society. In the present study, we focus further on a description and analysis of public beliefs and reactions towards PLWHA in a multi-street study located in Port Harcourt Nigeria, to understand why and what makes society stigmatize PLWHA. The paper concludes with recommendations that may help reduce the negative reaction towards PLWHA.

### **2. Methodology**

A descriptive qualitative research design, using a convenient multi-venue street-intercept interview technique was used to explore public beliefs and reactions towards PLWHA. The street-intercept methodology provides access to segments of the urban population that are hard to reach and has a high degree of validity and reliability (Green, 1995; Miller et al., 1997; Baseman et al., 1999; Rotheram-Borus et al., 2001; Fortenberry et al., 2007). It is also used frequently in studies of sensitive topics, such as drug use and sexual behavior (Hidaka et al., 2008). In our study, due to the sensitivity of the topic, and in order to get remarks about PLWHA, we talked not only about individual processes but also at a meta-level about social processes. Furthermore, participants sometimes gave examples of processes or perceptions based on hearsay while in other parts they talked about themselves and their own experiences, perceptions and thoughts.

Participants were recruited between January and April 2006. Eligibility requirements included being an adult older than 18 years and residence or employment in Port Harcourt. Streets were selected from the Obio Akpor local government area of Port Harcourt. We recruited 40 participants for the interviews. Self- reported PLWHA were excluded. Port-Harcourt city is located in the Southern part of Nigeria specifically in the Eastern Niger Delta. The area is particularly rich in crude oil. Families have a median of 5 persons per household (Akpogomeh & Atemie, 2002).

## **2.1 Recruitment and consent of participants**

A convenience sample was used in this study. Interviewees were approached at the recruitment venues and interviews were held in workplaces, offices, restaurants, shops or on the street. An introductory sentence informed participants that the interviews were covering stigma towards PLWHA. Verbal consent was obtained from participants and total anonymity was guaranteed. Forty-one persons were approached, of whom 40 agreed to participate in the interviews (See Table 1). The one person who refused was too busy to grant an interview. No compensation was offered to participants. Interviews were conducted throughout the week. Interviews were conducted in the English language and were face to face. The interviews lasted between an hour and one and half hour. Basic demographic data about participants were gathered before the interviews. Interviews continued until no new information emerged. All interviews were audio-taped and transcribed verbatim.

## **2.2 Data analysis**

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

strong (Greeff et al., 2008). The family and the community constitute vital aspects of the social structure that normally offers strength and support during times of need and crisis (Ajuwon et al., 1998; Hilhorst et al., 2006; Kipp et al., 2007). In this communal and social network, contact with someone afflicted with a disease regarded as a mysterious threat,

Stigma influences all phases in prevention, detection and care for PLWHA. It decreases turn-up for facilities for voluntary counselling and testing in hospitals (Weiser et al., 2006). Anticipated stigmatizing societal reactions may also decrease the tendency to disclose serostatus to the immediate social environment and, more importantly, to sexual partners. Specifically, a study carried out in Port Harcourt, Nigeria, showed that 77% of PLWHA had disclosed their HIV sero-status to one or more others, of which 22.3% disclosed their condition to their parents, 9.7% to their siblings, 27.8% to pastors, 6.3% to friends, 10.4% to their family members and 23.6% to their sexual partners (Akani & Erhabor, 2006). Other studies has also documented selective disclosure patterns among PLWHA. (Gari et al., 2010;

In a previous study, we reviewed behavioral problems of PLWHA in Sub-Saharan Africa in seeking care, and argued that this is partly due to stigmatizing responses to PLWHA from health care professionals and society at large (Mbonu, Van den Borne, & De Vries, 2009). Given the negative impact of stigma on care seeking and the selective disclosure of a positive HIV-sero-status to close and trusted people, it is important to understand why HIV/AIDS attracts such a degree of negative reaction in society. In the present study, we focus further on a description and analysis of public beliefs and reactions towards PLWHA in a multi-street study located in Port Harcourt Nigeria, to understand why and what makes society stigmatize PLWHA. The paper concludes with recommendations that may help

A descriptive qualitative research design, using a convenient multi-venue street-intercept interview technique was used to explore public beliefs and reactions towards PLWHA. The street-intercept methodology provides access to segments of the urban population that are hard to reach and has a high degree of validity and reliability (Green, 1995; Miller et al., 1997; Baseman et al., 1999; Rotheram-Borus et al., 2001; Fortenberry et al., 2007). It is also used frequently in studies of sensitive topics, such as drug use and sexual behavior (Hidaka et al., 2008). In our study, due to the sensitivity of the topic, and in order to get remarks about PLWHA, we talked not only about individual processes but also at a meta-level about social processes. Furthermore, participants sometimes gave examples of processes or perceptions based on hearsay while in other parts they talked about themselves and their

Participants were recruited between January and April 2006. Eligibility requirements included being an adult older than 18 years and residence or employment in Port Harcourt. Streets were selected from the Obio Akpor local government area of Port Harcourt. We recruited 40 participants for the interviews. Self- reported PLWHA were excluded. Port-Harcourt city is located in the Southern part of Nigeria specifically in the Eastern Niger Delta. The area is particularly rich in crude oil. Families have a median of 5 persons per

inevitably, feels like trespassing or, worse, as violation of a taboo (Sontag, 1989).

Anglewicz, et al., 2011; Stutterheim et al., 2011).

reduce the negative reaction towards PLWHA.

own experiences, perceptions and thoughts.

household (Akpogomeh & Atemie, 2002).

**2. Methodology** 

Nvivo (QRS release 2.0), a computer-assisted qualitative data analysis system, was used to aid analysis and reporting. The analysis of the interviews enabled us to identify causal relationships and, therefore, come up with a causal structure. Field notes and information from the literature review were also used during the analysis. Emerging issues were examined to identify related concepts. Different factors were formed from the emerging themes. A model was built to explore important relationships between concepts. Attributes were formed to include important characteristics such as gender and work category, which were subsequently imported into Nvivo.

### **2.3 Validity**

An independent researcher coded a random selection of data to look for new concepts. The independent researcher compared emerging themes with the coding by the authors. New meanings and discrepancies were checked by re-reading the transcripts and fine-tuning interpretations until unambiguous categories and themes were agreed. No important discrepancies were found.
