**Trends and Levels of HIV/AIDS-Related Stigma and Discriminatory Attitudes: Insights from Botswana AIDS Impact Surveys**

Gobopamang Letamo *University of Botswana Botswana* 

### **1. Introduction**

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

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For a very long time now, people living HIV and AIDS have been stigmatized and discriminated against and these negative attitudes have been observed to deter people from seeking health care services such as participating in voluntary counselling and testing and prevention of mother-to-child transmission (Nyblade and Field, 2002). UNAIDS (2007) argued that in many countries and communities, the stigma associated with HIV and the resulting discrimination can be as devastating as the illness itself: abandonment by spouse and/or family, social ostracism, job and property loss, school expulsion, denial of medical services, lack of care and support, and violence. It found that these consequences, or fear of them, mean that people are less likely to come in for HIV testing, disclose their HIV status to others, adopt HIV preventive behaviour, or access treatment, care and support. If they do, they could lose everything. Previous research (for example, Alonzo and Reynolds, 1995) has found that HIV-related stigma originates from several sources. First, HIV and AIDS are associated with the deviant behaviour that is suspected to have caused the HIV-positive status. Second, that the individual was irresponsible to have contracted HIV. Third, that it is the individual's immoral behaviour that caused HIV and AIDS. Finally, that HIV and AIDS are contagious and threatening to the community.

One of the major challenges for studying HIV/AIDS-related stigma discrimination is how to best measure the concept of "stigma". At the moment, as USAID (2006) rightly stated: "...measures that can both describe an existing environment, and evaluate and compare interventions, are lacking" (p.2). A wide range of questions are used to measure stigma. There is a need to correctly measure stigma for a variety of reasons. USAID (2006) has summarized why there is a need to measure stigma and the reasons are summarized below. One such reason is the fact that anti-stigma interventions that have been designed and implemented need to be evaluated to determine if the intervention is effective or not. Another equally important reason for measuring stigma is to identify effective models and take them to scale. Measurement of stigma allows researchers to test the hypothesis that stigma would decline if antiretroviral drugs were more widely available. These are some of the reasons for developing a tested and validated measure of stigma.

Trends and Levels of HIV/AIDS-Related Stigma and

surveys in the same way that makes them comparable.

**2.2 Measurement of variables 2.2.1 Response variables** 

HIV/AIDS:

**2.2.2 Control variables** 

**2.2.3 Statistical analysis** 

Discriminatory Attitudes: Insights from Botswana AIDS Impact Surveys 227

three questions were used to assess HIV/AIDS-related stigma and discrimination: i) If a member of your family became sick with HIV/AIDS, would you be willing to care for him or her in your household? ii) If a teacher has HIV/AIDS but is not sick, should s/he be allowed to continue teaching in school? iii) If you knew that shopkeeper or food seller had HIV/AIDS, would you buy vegetables from them? These questions were asked in the three

Respondents who did not complete the individual questionnaire were excluded from the

Stigma is often rooted in social attitudes and it is in this context that trends and levels of HIV-related stigma and discrimination are investigated using variables assumed to measure social attitudes. Participants who did not respond in the affirmative to any of the below three questions were considered to harbor discriminatory attitudes towards people living with HIV/AIDS. The following three response variables were used in this study as measures of stigma and discriminatory attitudes towards people with

Respondents were asked: "If a member of your family became sick with HIV/AIDS, would you be willing to care for him or her in your household?" This indicator is a dummy

Respondents were asked: "If a teacher has HIV/AIDS but is not sick, should s/he be allowed to continue teaching in school?" This binary variable was coded in such a manner

Respondents were asked: "If you knew that a shopkeeper or a food-seller had HIV/AIDS, would you buy vegetables from them?" This variable was a dummy variable that equals one

Control variables used for this study included age (10-19, 20-29, 30-39, 40-49, 50-59 and 60-64 years), current marital status (married (married plus living together), once married (divorced, separated, widowed) and never married), and the highest level of education

The proportions of the people expressing discriminatory attitudes toward people living with HIV/AIDS were calculated using percentages. Cross tabulations were used to present the proportions of males and females with discriminatory attitudes toward people living with HIV/AIDS. Graphs were used to examine levels and trends in the proportions of people with discriminatory attitudes. Because comparison of percentages between the three surveys

attained (no education, primary (non-formal plus primary), secondary and higher).

present analysis. The analysis was also restricted to those aged 10-64 years.

**2.2.1.1 Unwillingness to care for a family member with HIV/AIDS**

**2.2.1.2 Should not allow a teacher with HIV/AIDS to teach** 

that the response "no" equals one or zero if it was "yes".

for respondents who stated "no" or zero if it was "yes".

variable that equals one for respondents who said "no" or zero if it was "yes".

**2.2.1.3. Would not buy vegetables from a shopkeeper with HIV/AIDS** 

In responding to the HIV/AIDS epidemic, the Government of Botswana embarked on various strategies to fight the disease, including HIV/AIDS-related stigma and discrimination. The National Strategic Framework (NSF) for HIV/AIDS 2003-2009 had as some of its key goals psycho-social and economic impact mitigation and the provision of a strengthened legal and ethical environment. It also had as one of its objectives the minimization of the impact of the epidemic on those infected and/or affected and creation of a supportive, ethical, legal and human rights-based environment conforming to international standards for the implementation of the national response (Republic of Botswana, 2002b). The NSF also identified stigma and denial as creating an environment maintaining the potential for increased infection as well as limiting the ability of people to live positively and responsibly with HIV and AIDS. The provision of voluntary counselling and testing was expected to enable people living with HIV and AIDS to go public with their serostatus.

In reviewing previous efforts before the NSF to address HIV and AIDS in the country, Government observed that important gaps existed. One such gap was that support groups for people living with HIV/AIDS (PLWHA) needed to be expanded in order to increase coverage and further assist in the breakdown of stigma and denial around HIV/AIDS. Another important gap identified was that the legal, ethical and human rights environment required strengthening to enable and support an effective national response (Republic of Botswana, 2002b).

The Government of Botswana has assumed that as voluntary counselling and testing becomes easily accessible and people know their status, it will bring down stigma and discrimination. It is argued that in countries such as Uganda, Cuba and others where HIV status is openly discussed, stigma surrounding HIV and AIDS has been dramatically reduced, if not completely eliminated (Republic of Botswana, 2002b:31)

On the basis of the foregoing, the key objective of this paper is to assess progress made in reducing the prevalence of HIV-related stigma and discriminatory attitudes in Botswana which was and continues to be a key objective in the national response. The purpose of the paper therefore is to estimate the levels and trends of HIV-related stigma in the country using three Botswana AIDS Impact Surveys (BAIS) I, II and III. It is assumed that any reduction in HIV/AIDS-related stigma and discrimination is a result of the anti-stigma interventions that the Government of Botswana has embarked on.
