Self-stigma among women living with human immunodeficiency virus in South India.

Sir,

Self-stigma is the acceptance of negative societal characterizations, labels, and perceptions about people living with human immunodeficiency virus (HIV), and applying them to self. It is often associated with self-deprecating emotions and cognitions such as shame, self-blame, embarrassment, and low self-worth.[1] Women face enhanced stigma and discrimination associated with HIV due to their percieved inferior status to men in society.[2] This study aimed to assess the self-stigma among women living with HIV.

The observational study was carried out in the Network for Positive people in Trichy, Tamil Nadu, from March 2017 to April 2017, recruiting a total of 32 women living with HIV with at least 18 years of age. A semi-structured questionnaire was used to collect the demographic and disease status. Self-stigma was measured using the Tamil version of the Internalized Stigma of Mental Illness (ISMI) scale.[34] It contains 28 questions in a 4-point Likert scale format subdivided into four subscales (alienation, stereotype endorsement, discrimination experience, and stigma resistance). A higher score reflects more internalized stigma, while lower scores reflect low internalized stigma.

Among the 32 respondents, the majority were older than 30 years (84%) and the overall age range spanned from 23 to 48 (mean of 37.4 ± 5.83) years. Twenty-seven women were literate (84%), 18 (56%) were widowed, 26 (81%) were working as labor, and 18 (56%) had a family income of below Rs.5000 in Indian currency. Among the respondents, 14 (44%) women had the disease more than 10 years. Ten women identified a co-morbidity of tuberculosis infection at the time of HIV diagnosis. Among these, three (30%) women were diagnosed as newly affected by tuberculosis.

Prior studies found that people living with HIV infection or acquired immune deficency syndrome have a high level of perceived, internalized, and enacted stigma.[5] This study showed that seven women living with HIV (22%) had minimal to no self-stigma, 23 (72%) had mild self-stigma, and 2 (6%) had moderate self-stigma. Among the respondents, 91% (29/32) of them disclosed their disease with their family and 93% (27/29) of them were accepted by their family. However, nearly half of them (53%) disclosed their disease with neighbors, possible due to HIV-related stigma and discrimination.

Among the respondents, 87% (28/32) of women were infected by their partners of these, 56% (15/28) had a partner that expired due to HIV. Among the rest of the four partners, three of them were not infected and one was not tested for unknown reasons.

All the women had children except one woman; of these, 42% (13/31) of their children were infected with HIV, possibly enhancing psychological stigma to these women although these statistical comparisons could not be made due to limited power.

The variables most significantly associated with ISMI total score - 112 were literacy and status of disclosure to neighbors [Table 1]. Illiterate women (ISMI 68.6) reported more internalized stigma than literate women (ISMI 61.7, P = 0.03). Women who did not disclose their disease with neighbors (ISMI 66.7) reported more internalized stigma than the women who disclosed their disease (ISMI 59.4, P<0.01). Pearson correlation test was done between disease duration and ISMI total score and a statistically significant negative correlation ( r = −0.423, P = 0.02) was obtained, revealing that increased disease duration results in increase risk of internalized stigma.

Table 1

Independent t-test for variables versus Internalized Stigma of Mental Illness scale total score

Status	n	Mean±SD	t	df	P
Age
Below 30	5	63.0±6.08	0.07	30	0.95
Above 30	27	62.8±6.62
Education
Illiterate	5	68.6±4.28	2.34	30	0.03*
Literate	27	61.7±6.25
Occupation
No work	6	65.3±4.97	1.07	30	0.30
Work	26	62.2±6.68
Marital status
Married	14	64.9±3.69	1.69	30	0.10
Widow	18	61.2±7.66
Family income
Below Rs.5000	18	64.2±5.34	1.43	30	0.16
Above Rs.5000	14	61.0±7.44
Disclosure of disease with family
Disclosed	27	62.3±6.49	−1.13	30	0.27
Not disclosed	5	65.8±5.89
Neighbor
Disclosed	17	59.4±5.77	−3.91	30	0.00**
Not disclosed	15	66.7±4.79

*P<0.05, **P<0.01. SD=Standard deviation, n=frequency, df=difference, t=independent ’t’ test value

The National Strategic Plan for HIV/AIDS and sexually transmitted infection 2017–2024 has aims to eliminate HIV/AIDS related stigma and discrimination by 2020.[6] In summary, this study demonstrates that women affected with HIV have a mild level of self-stigma, with illiteracy and no disclosure to neighbors enhancing risk for internalized stigma. Interventions to provide an enabling environment that reinforces positive attitudes, beliefs, and practices has potential to reduce the self-stigma among women living with HIV and improve their psychosocial wellbeing and quality of life. Future studies should evaluate the efficacy of such interventions on reduicng stigma among these women to help achieve the aims of The National Strategic Plan by 2020.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.