The Blame Game: Stigma and HIV/AIDS in an African Metropolis.

BACKGROUND: The purpose of the present study was to explore further the cross-cultural validity, consistency, and replicability of FAIDSS among students when assessing HIV/AIDS-related stigma and fear of people living with HIV/AIDS (PLWHA) in Lagos metropolis.
METHODS: Using a purposive method, participants in Lagos Metropolis were surveyed using a questionnaire and conceptualization derived from the work of Ross and Hunter (1992) to measure a variety of HIV-related attitudinal and behavioural items. Quantitative data analyzed employing factor analysis using maximum-likelihood extraction followed by oblique rotation (direct oblimin, delta= 0).
RESULTS: On the factor scale measuring having fear of sex with a particular person, younger respondents especially females significantly more likely to report greater fear than for any other groups. Our findings further suggest that levels of fear of outsiders are high among males and need urgent action and intervention at both individual and societal levels.
CONCLUSION: It is argued that messages and interventions must be targeted to promote a positive social environment for those living with or affected by HIV/AIDS, and to be useful in understanding stigma, fear and prejudice more fully and in reducing them. A crosscurrent behavioral change that can transform AIDS from an inevitably fatal pandemic to a chronic and manageable disease is the answer.

Introduction

Within one generation HIV/AIDS has been the most far-reaching and devastating epidemic the world has ever seen (1, 2). ‘Fear of stigma’ fuels the HIV/AIDS pandemic by creating a culture of secrecy, silence, ignorance, blame, victimization and shame (3). Available evidence suggests that sub-Saharan Africa (SSA) has the worst scenario of AIDS epidemic and the devastation of its impact is increasing (4).

Nigeria, is a nation with less concentrated HIV/AIDS, but characterized by one of the most rapidly increasing rates of new HIV/AIDS cases. In fact in 2008, around 3.1% of adults between ages 15–49 are living with HIV/AIDS (5).

The word ‘stigma’ dates back to the 1300s and it is derived from the same Greek roots as the verb “to stick” (6, 7). In Africa, mental illness is believed to have genetic or biological cause, hence people with mental disease are dangerous and the disease is pervasive and serious. Likewise, AIDS is perceived as a disease of shame and people living with HIV/AIDS (PLWHA) were seen to be solely responsible for their “misfortune” and as such the societal people are more likely to keep their distance from them (8). Tables 1 and 2 showed the problem is inextricably linked to issues of human rights, health and law. As well as other problems such as homophobia, misogyny and racism/xenophobia and can be associated with behaviours often considered socially unacceptable such as drug use and prostitution. A growing body of researches (9–33) has suggested that attitudes (especially stigmatizing attitudes) are influenced by societal, cultural and psychological factors. In addition, inaccurate understanding about HIV transmission, misinformation, misperception and folk conceptualization about an illness can distort educating the public about the illness (e.g., HIV/AIDS) and thus leading to stigmatizing attitudes and behaviors

Table 1:

Issue in relation to human sex

Why humans have sex

Psyche: Feel good in human brain/sexual pleasure-swirl of hormones and Neurotransmitters (dopamine, norepinephrines, serotonin, oxytocin) - Gain pleasure Feel alert, awake, and perhaps somehow jumpy. Physical reasons: stress reduction, physical desirability, experience seeking. Goal attainment: Resources, social status, class, revenge and utilitarian. Emotional reasons: Love, Romance, Commitment and Expression. Insecurity: Self-esteem boost, ego trip, Mate guarding, Mundane pleasure. Individual differences: personality traits, sexual exploit, sexual motivation, trying to Improving or boasting of sexual prowess, reward to a nice partner or in exchange for a favour.punishing or retaliatory to partner’s infidelity, Procreate to have children Spiritual Spirit of lust Nurture a relationship/express affection, intensify an ongoing affair, Escalating the level of commitment to a new or old lover, Spin-offs-Emotional closeness, bonding, ultra-commitment, love, affection, acceptance, tolerance, closeness etc Sperm competition Satisfy a need for intimacy or physical contact Channel excess energy or get some exercise Overcome boredom, duty/pressure. Get to sleep Get rid of an erection Comply with a partner’s demands Provide or receive reward or preferred job or employment, Comply with social roles or expectations Affirm gender or sexuality Ego trip/Vanity Inferiority complex or insecurity Out of nothingness, fantasy Bottom power politics Promiscuity/Sexual habit Affirm one’s desirability Gain social currency Demonstrate power (e.g., rape or revenge) Entrap the other person Satisfy curiosity, racial complex Satisfy a compulsive behavioural disorder Make money, land lucrative tender/contract work etc.

Why do people have so much hate against people living with HIV/AIDS (PLWHA).'

Societal disdain Myths and Misinformation Concomitant Ignorance Societal values Fear of getting the disease and not knowing the pain it will cause People are not sure of the ways they can become HIV+ People see HIV to be additional yoke and terrible drama when peoples; bank accounts were already three times zeroed. Fears and stigma of being labeled Hatred and intolerance Fears of illness, contagion and death Risk situation construct Mistrust and distrust Xenophobic trends and prejudice Cultural beliefs that HIV is an awful punishment from gods and ancestors Stigma associated with never-do-wells (e.g., homosexuals, prostitutes, injection drug users) Disgust in relation to sex outside of marriage HIV seen as a shameful, disgraceful, unworthy condition Inflammatory and ill-informed media coverage or commentary/rhetorics by high-profile figures such as prosecutors, government officials, or legislators. Serious criminal charges have been laid against HIV-positive people for activities such as biting, spitting, or scratching, despite the evidence that the risk of HIV transmission in this fashion is extraordinarily small at most (and in some cases, completely non-existent). Criminalization of HIV Lack of belief that cocktail medication can give PLWHA excellent chance of having 20+ yr of a healthy & productive life, Women who get infected are too scared to tell their husbands because he might blame them; blame for infertility falls on women more than men

Table 2:

Misinformation and wrong conceptualization about HIV/AIDS

DOOne can get infected with HIV/AIDS By having sex with condom By wearing clothes used by an infected individual By being bitten by anophelis mosquito that already fed on an HIV patient By shaking hands with a person who has the HIV virus By hugging someone a person infected By having injections By receiving a blood transfusion By using the same clippers, cutlery, and toilet with someone who is infected You can get AIDS from: Toilets Hugging Kissing on the lips Cups, spoons, knives, plates, glasses, etc Holding hands Telephones, door handles Towels Sharing food Dancing Talking to someone with AIDS Crowded rooms Insects or mosquito nets AIDS is a genocidal conspiracy by the West and entrenched by the governments. AIDS was produced in a government laboratory. AIDS is a man-made virus that was made to kill and wipe out the black people. AIDS is armagedon and it is the ‘last punishment of man’ according to the BOOKS! HIV/AIDS is an agent of genocide entrenched by the former apartheid regime. AIDS is a highly contagious disease, and PLWA are scums, paschal lambs and evil. AIDS can be contracted when someone infected sneezes or coughs on others There is a cure or vaccine for HIV/AIDS AIDS/HIV is a product of South Africa’s apartheid government plot against blacks. AIDS can be transmitted when people eat or drink after one another in at a ceremony AIDS can only be caught by adults through sexual intercourse or through sharing needles. The AIDS virus can be caught through ordinary close social contract, such as sitting next to an infected person or through face-to-face conversation or sharing tools or equipment with AIDS victims or toilet seats. Although all blood is tested, there is still a danger of getting AIDS from blood transfusion. AIDS is transmitted by foreigners (especially African immigrants in South Africa, colloquially known as Ma-kwere-kwere), rodents, droppings, arena mystery virus and prostitutes AIDS is like a mental disease and mental people are dangerous, pervasive and serious. AIDS is a disease of shame and people living with HIV are responsible for their ‘misfortune’. PLWA are wailing corpse expected to die hence no need for good things of life.

The Fear of AIDS Scale (FAIDSS) was developed and tested in three western societies (The Netherlands, the United States, and Australia) (10, 13, 26). Ross and Hunter examined the structure of FAIDSS in a sample of 134 health care workers in Melbourne, Australia. Factor analysis yielded five discrete dimension of fear of AIDS, with low to moderate intercorrelations (26).

The purpose of the present study was to explore further the cross-cultural validity, consistency, and replicability of FAIDSS among students when assessing HIV/AIDS-related stigma and fear of people living with HIV/AIDS (PLWHA) in Lagos metropolis.

Material and Methods

Study design

The participants were all students in three major tertiary institutions in Lagos metropolis in Nigeria. Over 1450 students completed the questionnaire but only 1118 met the criteria for selection and only their data were analyzed. Only full-time students who had completed a minimum of one semester were enrolled. The participants were composed of 601 males and 508 females (data on gender were missing for the remainder). Mean age was 24.2, SD= 6.1, median 23 yr, and the mean education level was 13.86 yr, SD= 3.3. This study did receive approval by the relevant Institutional Review Boards.

Study Site

Lagos, with about 8.2 million inhabitants at the 2006 census, was formerly the capital of the nation. Lagos is a huge metropolis protected from the Atlantic Ocean by long sand spits such as Bar Beach (part of supposed ‘Alex Merit Systems’) which stretch up to 100 km east and west of the mouth. The city is the economic and financial capital of Nigeria.

Data Analysis

Factor analysis was carried out using maximum-likelihood extraction followed by oblique rotation (direct oblimin, delta= 0) (see Akande & Ross (10), for a full review).

Results

Results of the factor analysis are presented in Table 3. The first factor extracted was described as a Loss of control factor; the second as a fear of having sex with a particular person factor; the third as a contact with outsiders or stigmatized groups factor. The fourth factor described fear of infection and contact with those infected or perceived to be infected, and the final factor was a fear of death and dying factor. Factor intercorrelations are presented in Table 4, and illustrate that the factor solution was moderately correlated.

Table 3:

Factor structure in Lagos metropolis

Item	Loading
Factor I: Loss of control
Helplessness	0.86
Hopelessness	0.88
Loss of self-respect	0.84
Becoming dependent on others (not financially)	0.76
Infecting others with one’s illness	0.73
Becoming mentally ill	0.68
Display of physical suffering of others	0.66
Becoming physically unattractive	0.67
Inadequate (abnormal) behaviour	0.57
Infection through blood	0.43
Infection through someone’s illness	0.44
Infection through sexual contact	0.47
Having contact with blood of other human beings	0.39
Drugs or chemicals	0.33 (33.1% of variance)
Factor 2: Fear of having sex with a particular person
Sexual contact with different partners	0.86
Frequent anonymous sexual contacts	0.77
Having extra-marital sexual contacts	0.77
Sexual intercourse	0.59
Having sexual contact with a prostitute	0.54
Having sexual contact with bisexual men or women	0.31 (5.4% of variance)
Factor 3: Context with outsiders
Having non-intimate contact (e.g., talking to a prostitute)	0.61
Having non-intimate contact (e.g., talking with homosexual men or women	0.52
Intimate contact (e.g., kissing on the cheek) with Acquaintances, family members or friends	0.57
Having non-intimate contact (e.g., talking to) with bisexual Men or women	0.54
Having physical contact with sick patients (medically ill people)	0.54
Foreigners	−0.64
Taking medical tests	0.51
Having physical contact with people who you know are
Addicted to drugs	0.46
Getting an injection	0.39 (5.7% of variance)
Factor 4: Infection and contact with infected people
Contracting AIDS	−0.78
Contracting venereal disease	−0.76
Having physical contact with a person with AIDS	−0.68
Viruses	−058
Undergoing blood transfusions	−0.44
Having sexual contact with homosexual men or women	−0.43 (2.7% of variance)
Factor 5: Death
Death	−0.72
Dying	−0.73
Growing ill	−0.42 (1.3% of variance)

Table 4:

Intercorrelations between scale factors

	Factor 1	Factor 2	Factor 3	Factor 4
Factor 2	0.45
Factor 3	0.43	0.34
Factor 4	0.62	0.41	0.43
Factor 5	0.47	0.24	0.39	0.44
(All P< 0.001)

Factor scores on the five scales are presented in Table 5. There were significant differences on the factor scale measuring fear of having sex with a particular person, with females and younger respondents having significantly greater fear, and on the scale measuring fear of outsiders males scored significantly higher than females, (P≤ 0.001). Reliabilities of the five scales were Factor 1, 0.92; Factor 2, 0.83; Factor 3, 0.71; Factor 4, 0.82 and Factor 5, 0.71.

Table 5:

Factor scores by sex (gender) and age groups

	Male	Female	< 23	≥ 23
Factor 1.Loss of control	28.9±8.4	28.6±9.2	29.6±9.4	28.5±8.6
Factor 2.Fear of sex	10.7±4.1	12.8±4.7 **	12.5±4.5	11.2±4.4**
Factor 3:Contact with outsiders	10.3±3.8	9.9±3.8*	10.4±4.1	10.3±3.8
Factor 4:Infection and contact with infected people	11.3±4.2	11.2±4.2	11.4±4.3	11.2 ±4.3
Factor 5:Death	5.2±2.5	5.2±2.5	5.3±2.6	5.2 ±2.5

P≤ 0.01

≤ 0.001

Results of comparison of the rotated matrix of the Lagos sample with the three sample matrices of Ross and Hunter (26) are presented in Table 6. There are accurate and significant matches for factors with the first Australian sample of health workers and, with the exception of one split match for each of the respective samples, also accurate and significant matches. The fact that with these two exceptions out of a possible 15 accurate matches, if the criterion of only one factor of the sample is being compared with, illustrates the high level of comparability between the factor structures between the Lagos and the three Australian Melbourne samples.

Table 6:

S indices between Lagos metropolis factors and Melbourne factors

Australian sample factors	Lagos metropolis factors
	1	2	3	4	5
Health workers (1) (n=134)
Factor 1	0.73*	0.00	0.00	0.00	−0.18
Factor 2	0.18	0.56*	0.00	0.00	0.00
Factor 3	0.33	0.00	0.36	−0.57*	0.00
Factor 4	0.34	0.00	0.14	0.00	−0.51*
Factor 5	0.12	0.17	0.56*	0.00	0.00
Social work students (n=220)
Factor 1	0.35	0.44*	0.00	−0.34	0.00
Factor 2	0.74*	0.00	0.00	0.00	− 0.17
Factor 3	0.16	0.16	0.67*	0.00	0.00
Factor 4	0.34	0.00	0.14	0.67*	−0.41*
Factor 5	0.00	0.00	0.46	−0.51*	0.00
Health workers (2) (n = 66)
Factor 1	0.53*	0.20	0.24	0.25	−0.18
Factor 2	0.58*	0.26	0.29	0.00	0.00
Factor 3	−0.03	0.00	0.26	0.00	−0.17
Factor 4	0.00	0.00	0.48*	−0.22	0.00
Factor 5	0.19	0.00	0.00	0.20	0.51*

P< 0.01

Discussion

First, the factor comparison analysis indicates that there is a significant and very accurate match between the factor solutions obtained with three previously reported Australian samples on the FAIDSS (26) and the Nigerian factor solution.

Second, the close association between fear of loss of control and fear of AIDS suggests that concern about the discriminating; stigmatizing, socially dislocating, and disabling aspects of HIV disease are a major concern. Of more immediate interest, however, is the association of the item measuring fear of infection with AIDS and venereal diseases with fear of blood transfusions and contact with homo- or bisexual people. These data suggest that heterosexual contact is not seen as such a risk and associated with a similar level of fear, which may increase the risk of heterosexual HIV transmission particularly given the reported prevalence of HIV-2 in Lagos.

The fear of HIV/AIDS or HIV-infection stigma in this sample should be interpreted in the context of attitudes toward deformity and disability in Nigeria, and with the implication that the level of fear and stigma may be higher given the lower level of support and acceptance in Nigerian society to the disabled.

The results of the current study, which largely are supportive of previous studies (10, 26) Ross and Hunter’s (26) findings indicate that the FAIDSS is a reliable index of fear of AIDS and stigma in this population and is readily scaleable, and the obtained factor structure was very close to that obtained in the Australian samples. This conclusion is buttressed by evidence that AIDS is conceptualized as being associated with homosexual persons and blood transfusions, and that preventive education will need to emphasize the risk of heterosexual HIV transmission and deemphasize the perception that only particular classes of person are at risk.

Study Limitations

First, the investigation on stigma and fears of AIDS was limited to relative small participants, with small effect size. Secondly, the investigation was conducted on students only, and not on other populations, to check if there might be a link between emotions and cognitive complexity or emotions and increased knowledge. Perhaps additional studies can consider locus attributions for specific, individual intention, belief and emotions instead of for fear/stigma as a set with two different typology scales. Thirdly, the present study was cross-sectional, rather than longitudinal, whilst the latter could have substantiated the findings of the study along certain structural changes. Future studies may contribute finer grained understanding of other forms of analyses and exploring ways of grouping countries and geopolitical locations in terms of intention, affect and cultures. Despite the limitations of the present study, the FAIDSS model has potential as an explanatory tool for studying the effect of AIDS Stigma. Additional cross-cultural studies using FAIDSS combined with other instruments on beliefs, attitudes, and intentions would therefore appear important. Such in-depth studies should allow exploration of indigenous notions.

In conclusion, responding to HIV/AIDS on a scale commensurate with the pandemic is more than a local imperative. As the end of the beginning appear in sight, the imperative must change gear to include religio-compassionate attitudes towards PLWHA, didactic social-clinical education and recognition of basic human rights to combat the impact of the climate of fear and stigma on the spread of this dreadful illness. Fighting a fatal illness will need more than medications and doctors, but requires self-renewal with “oneself” and understanding the extent to which morality, sexuality, religion and health intersect in day-to-day life activities of people (18). The burden of care for people living with AIDS should be shared between men and women, young and old amid social, medical and economic support (1). AIDS prevention, care and treatment should continue to be the leitmotiv of international AIDS campaigns and work, to slow the spread of AIDS and to improve the quality of life of those living with HIV/AIDS (34). The Lagos experience suggests an effective humane response to this disease should be based on a concern for equality, human rights and the tenets of social justice. A behavioral change that can transform AIDS from an inevitably fatal pandemic to a chronic and manageable disease will go a long way in understanding and decreasing stigma or prejudice and fear dramatically in Nigeria or Africa. A tall order? Maybe.

Ethical Considerations

Ethical issues including plagiarism, informed consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc. have been completely observed by the authors.