摘要：Objectives. We estimated the association between antiretroviral therapy (ART) uptake and HIV-related stigma at the population level in sub-Saharan Africa. Methods. We examined trends in HIV-related stigma and ART coverage in sub-Saharan Africa during 2003 to 2013 using longitudinal, population-based data on ART coverage from the Joint United Nations Program on HIV/AIDS and on HIV-related stigma from the Demographic and Health Surveys and AIDS Indicator Surveys. We fitted 2 linear regression models with country fixed effects, with the percentage of men or women reporting HIV-related stigma as the dependent variable and the percentage of people living with HIV on ART as the explanatory variable. Results. Eighteen countries in sub-Saharan Africa were included in our analysis. For each 1% increase in ART coverage, we observed a statistically significant decrease in the percentage of women (b = −0.226; P = .007; 95% confidence interval [CI] = −0.383, −0.070) and men (b = −0.281; P = .009; 95% CI = −0.480, −0.082) in the general population reporting HIV-related stigma. Conclusions. An important benefit of ART scale-up may be the diminution of HIV-related stigma in the general population. Recent evidence supporting the use of antiretroviral therapy (ART) for prevention of HIV transmission in low- and middle-income countries has raised hopes that the end of the HIV/AIDS epidemic is within reach. 1 The success of this strategy hinges on early diagnosis and linkage to care for people living with HIV (PLHIV). 2 However, people continue to present for treatment at late stages of disease 3 , and the stigma of HIV remains a major challenge. In the general population, stigmatizing beliefs are associated with reduced uptake of voluntary counseling and testing 4,5 and increased sexual risk-taking behavior. 6,7 When PLHIV internalize these beliefs, they may experience psychological distress and depression 8,9 and are less likely to disclose their seropositivity to potential social supports. 10,11 Internalized stigma, which is widespread among PLHIV in sub-Saharan Africa, 12 is also an important public health issue because it compromises ART adherence. 13,14 Consequently, efforts to counter stigma have been recognized as essential to HIV prevention and treatment. 15,16 The extent to which ART scale-up itself is associated with reductions in HIV-related stigma has not been conclusively demonstrated. On one hand, it has been argued that ART does little to counter persistent blaming attitudes and feelings of moral outrage in the community; indeed, ART may be perceived as enabling PLHIV to appear healthy enough to engage in promiscuous behaviors and spread HIV. 17–19 On the other hand, program implementers have argued that the increasing availability of effective treatment of PLHIV reduces the fear and stigma surrounding HIV in the general population 20–22 ; these observations have been supported by studies in multiple African countries, including South Africa, 23 Uganda, 24,25 and Malawi. 26 For example, in a population-based study conducted in Botswana, perceived access to ART was associated with markedly decreased odds of holding stigmatizing attitudes and of anticipated stigma. 27 Although such findings may be explained in part by the community sensitization campaigns that generally accompany ART scale-up, improvements in physical health and HIV-related symptom burden may also reduce the extent to which PLHIV internalize stigmatizing beliefs 25 and enable their economic rehabilitation and social reintegration, 28,29 thereby weakening the symbolic and instrumental associations 30 between HIV/AIDS and economic incapacity, social exclusion, and imminent death. 24 Understanding the extent to which ART scale-up is associated with changes in stigma in the general population is important for policymakers given the relative absence of proven interventions that improve stigma on a national or regional scale. 31–33 If ART scale-up is associated with reduced stigma in the general population, then expanding the availability of ART may itself spur a virtuous cycle of further improvements in ART uptake. Such a relationship would add to the impetus for strengthening ART delivery programs while identifying another much-needed intervention against HIV-related stigma. To help answer this question, we examined trends in stigma during ART scale-up in sub-Saharan Africa over the past decade, using longitudinal, country-level data on ART coverage from the Joint United Nations Program on HIV/AIDS (UNAIDS) and on HIV-related stigma from the Demographic and Health Surveys (DHSs) and AIDS Indicator Surveys (AISs). Our primary aim was to understand the extent to which increased ART coverage in sub-Saharan Africa was associated with changes in HIV-related stigma in the general population.
