HIV Stigmatization Harms Individuals and Public Health

There have been many successful stories about HIV treatment and prevention during the past three decades of the AIDS epidemic. Among the successful stories, HIV chemotherapy has been a major medical accomplishment in the past two decades and has dramatically reduced the morbidity and mortality of those with access to care [1]. Since a controlled trial demonstrated the efficacy and safety of combination antiretroviral therapy (cART) to treat HIV infection, virologic suppression, immune reconstitution, and long-term survival of HIV infected persons have been achievable goals.

Even though HIV infection is currently a controllable disease for patients on successful cART, people living with HIV/AIDS (PLWHA) are still suffering from social stigmatization in many countries, including South Korea [2, 3, 4]. Kittner et al. [3] reported 36.1% of German HIV subjects rated to feel guilty in relation to their infection, and they concluded HIV infected patients in Germany still suffer from an elevated level of anxiety and depression that was related with internal stigmatization. Stigma has been characterized as self, or internalized, stigma, which can limit self-efficacy and empowerment; perceived stigma, the sense of what others think or how they might treat persons thought or known to have HIV; and experienced stigma, the actual experience of discrimination, exclusion, or other social sanctions based on perceived HIV status. As Kittner et al. [3] pointed out, patients from the Asia-Pacific region including Korea tend to be more anxious to lose family and friends after disclosure than other regions [2]. One study assessed the prevalence of stigmatizing attitudes in Korean adolescents from 2006 to 2011 [4]. The responders discriminated significantly against those with HIV/AIDS, reporting attitudes such as being disgusted by PLWHA, contact avoidance of PLWHA, and blaming those with HIV for their infection. A global cross-sectional survey of perceived HIV-related stigma among 2,035 PLWHA from North America, Europe, Latin America, Africa, and the Asia-Pacific region including South Korea has been performed [5]. The survey showed 37% of responders reported loneliness as a result of their HIV status. Depression was reported by 27%. While 96% reported disclosing their HIV status to at least one person, 17% of patients who reported being in long-term sexual relationships had not disclosed their status to their partner. The authors concluded that perceived HIV stigma, isolation, and discrimination were persistent even 30 years into the HIV pandemic.

Stigmatization is harmful for individuals with HIV/AIDS because it results it social isolation and various mental illnesses such as depression and anxiety [2, 6]. Depression is the most common mental illness among HIV-infected persons, affecting up to 50% of PLWHA. The higher prevalence of depression in HIV infected persons (20-40% versus 7% in general population) is due to stigma, sexual dysfunction, side effects of cART, co-morbidities, and so on. In addition, depression can cause non-adherence to cART [7]. Song et al. [6] found that depressed Korean patients were more likely to miss clinical appointments. Poor adherence to cART is associated with virological failure, HIV resistance, and decreased survival.

From the perspective of public health, HIV-related stigma is a major barrier for people to access HIV testing, care, and treatment services [8]. Late presentation into care and delay in cART initiation likely generates more secondary HIV infections, increases morbidity and mortality, diminishes responses to cART, and causes higher health care expenditures. As a result, enhancing early diagnosis, access to care, and treatment are very important tasks for public health. Interventions to reduce HIV-related stigma are associated with improvements in access to HIV prevention and care services [9, 10].

Multidisciplinary HIV/AIDS experts developed recommendations for addressing stigma in the HIV/AIDS epidemic [8]. They offered recommendations to overcome the key challenges of defining, measuring, and reducing HIV/AIDS-related stigma and assessing the impact of stigma on HIV prevention and treatment program effectiveness. We need to develop a comprehensive framework for HIV/AIDS stigma and encourage the use of valid and reliable stigma measures by researchers and program implementers. Stigma-reduction strategies should be developed at the intrapersonal, interpersonal, community, institutional, and governmental levels.

Addressing HIV-related stigma will benefit individual and public health by improving the mental health and treatment adherence of individuals and encouraging early testing, access to care, and treatments. Multidisciplinary and multifaceted approaches to reduce HIV/AIDS-related stigma should be developed.