Factors associated with stigma and discrimination towards people living with HIV/AIDS in Ethiopia.

Background: HIV is a major public health concern in many developing countries. HIV related discriminatory attitudes or stigmas considered as a key in the prevention and control of HIV prevalence. This work evaluated the overall attitude of the population towards people living with HIV (PLHIV) in Ethiopia, which helps in the prevention and control of HIV/AIDS. Methods: Secondary data was obtained from the 2016 Ethiopian Demographic and Health Survey. Data included 20,770 samples of women and men between the ages of 15 to 49 years, which is a nationally representative sample in Ethiopia. Analytical methods used in this paper include descriptive analysis and multivariate logistic regression to identify factors associated with discriminatory attitudes . Results: A total of 20,770 samples who have heard about HIV/AIDS were included in the analysis. Out of this, 41% of respondents said they would not buy fresh vegetables from vendor and 34.1% of them indicated HIV positive children should not attend school with HIV negative children. Multivariate Logistic regression results indicated having discriminatory attitudes were associated with the lack of knowledge of HIV/AIDS prevention methods, endorsement transmission misconceptions, and never have been tested for HIV. Furthermore, respondents reside in rural areas, lack of formal education, belonging to poor wealth quantile, and lack of media exposure shows a higher level of discriminatory attitudes. Conclusion: The ndings of this research showed a high magnitude of stigma towards people living with HIV/AIDS among reproductive age women and men in Ethiopia. For stigma and discriminatory attitudes to be decreased interventions should focused on improving HIV related knowledge’s through mass medias such as television and newspapers, especially through medias that can address the rural community.


Introduction
The HIV/ AIDS virus continues to be one of the biggest public health problems in Ethiopia, with around 718,500 people living with HIV and resulting in more than 19,999 deaths in 2016 [1,2]. In addition to the medical problems people living with HIV/AIDS face different social problems like a stigma. Even if, the country spends more than two decades into the HIV/AIDS epidemic, peoples who have HIV were highly likely to perceive and internalize a great deal of stigma enacted by their families and communities, along with society and its institutions [3].
According to the World Health Organization(WHO), HIV-related stigma is de ned as "a process of devaluation of people either living with or associated with HIV and AIDS. Discrimination follows stigma and is the unfair treatment of an individual based on his or her real or perceived HIV status" [4]. Stigma can be de ned as "an attribute that is deeply discrediting, reducing an individual from a whole and usual person, to a tainted discounted one" [5]. However, Stigma is not limited to negative attitudes or prejudicial views held against marginalized groups in this case, PLHIV [3].
In Ethiopia, despite the progress in scaling up HIV prevention and treatment efforts [6], negative attitudes against people who are affected by HIV continue persistent [3]. These negative attitudes have been observed to deter people from seeking health care services such as participating in Antiretroviral Drug Therapy [7,8], voluntary counselling and testing [8], and prevention of mother-to-child transmission [9]. Therefore, addressing stigma was considered as a key for overall management and control of the HIV/AIDS epidemic.
Previous studies done on HIV/AIDS-related stigma revealed that knowledge about transmission methods such as knowledge of local misconceptions about HIV, and testing for HIV can drastically alter the negative attitude towards PLHIV [10][11][12]. Further, the socioeconomic conditions, exposure to mass media, and the context in which the persons are embedded may also play a role in in uencing attitude towards PLHIV [11,[13][14][15]. Despite the analyses conducted in literature, there has been a limited attempt to analyze HIV/AIDS-related stigma in Ethiopia, especially from a national representative sample.
This study aimed to identify determinants of HIV-related discriminatory attitudes from a nationally representative sample of the study population in Ethiopia and examine the association between HIV/AIDS related knowledge's with expression of discriminatory attitudes..

Data source
The data were obtained from the 2016 Ethiopian Demographic and Health survey (EDHS), conducted by the central statistics agency of Ethiopia with the nancial and technical support of the United Nations Children's Fund [16]. The DHS(Demographic and Health survey) employed a representative sample of women and men from nine regions and two administrative cities of Ethiopia. The DHS utilized a multistage strati ed cluster sampling in which sample households are selected within clusters enumeration areas. The nal sample included 20,770 women and men aged 15-49 years.

Measurements of variables Dependent variable
To measure discriminatory attitudes towards people living with HIV/AIDS, the 2016 survey included two questions: (1) "Should children with AIDS virus be allowed to attend in school with children who do not have AIDS virus?"; and (2) "Would you buy food from a shopkeeper or vendor if you knew that this person had the AIDS virus?" [16].

Independent variables
In this study, key independent variables were knowledge about HIV/AIDS prevention methods, transmission misconceptions, and their HIV/AIDS testing status.
Based on the literature review, this study also included a number of socioeconomic and demographic variables known to affect discriminatory attitudes towards HIV-infected people [10,11,13,15]. Socioeconomic and Demographic variables were education, mass media exposure, household wealth status, age, sex, marital status, region, and residence.

Statistical analysis Descriptive analyses
After the extraction of data, STATA software Version 14 (StataCorp LP, College Station, Texas 77845 USA) was used to clean up, rename, recode, and further analyze. Sampling weights were used to adjust the probability of selection and non-response differences. Cross tabulations and summary statistics were conducted to describe the study population. Further, Pearson's Chi-squared test was used for analyzing contingency tables.

Multivariable logistic regression
Multivariate logistic regression models were used to examine factors associated with discriminatory attitudes towards people living with HIV/AIDS. Sociodemographic, soci-economic, and HIV/AIDS knowledge related tted into univariate logistic regression models and estimating odds ratios (OR). Those variables, having a P value of less than 0.05, were retained and a backward regression method was applied in order to re ne the model.

Background characteristics
A total of 20,770 individuals (59.5%, n= 12,358 women's and 40.5%, n=8,412 men's) who have heard about HIV/AIDS were included in the study. The background information of the sample population can be seen in Table 1. Overall, The highest proportion of respondents (59.3%) were between age 15-29, 63.3% of respondents were rural residents. In terms of educational level, forty-eight percent of them had primary education, whereas 36.6 % had no education. Nearly 32% were in the poor economic category, and 61.5% of respondents were Tigray, Amhara, Oromia, SNNP, and Dire-Dawa residents. The proportion of discriminatory attitudes among women and men As Figure 1 shows, 44.3% of women and 37.7% of men respondents said they would not buy vegetables from an HIV-infected vendor, and 38.8% of women and 29.7% of men would not be willing to allow an HIV infected child to attend school.
Association of discriminatory attitudes towards PLHIV with HIV related knowledge's among men and women In the analysis, discriminatory attitudes were signi cantly associated with Comprehensive knowledge about HIV, knowledge about mother-to-child transmission Ever tested for HIV (p<0.01). From knowledgeable respondents, A higher proportion of men than women had a more discriminatory attitude toward PLHIV. From respondents who had tested for HIV before the survey, above two-thirds of them had a favorable attitude ( Table 2).  Table 3 shows that the discriminatory attitude was signi cantly associated with age, residence, education, wealth, and region (p<0.001). The level of discriminatory attitudes was lower in urban areas and respondents in higher educational status. Factors associated with discriminatory attitudes towards PLHIV Table 4 shows the factor associated with respondent attitudes towards PLHIV. In multivariate analysis, women and men respondents who reside in a rural area were about 1.61 and 1.64 times greater odds of having discriminatory attitudes respectively compared with urban residents. Likewise, when uneducated women and men compared with educated respondents, respondents who had no formal education had Furthermore, respondents who have exposure to mass media shows favorable attitudes towards PLHIV, respondents who don't read newspapers before the survey were about 1.55 (women) among and 1.34 (men) times more likely to have discriminatory attitudes to PLHIV compared to the attitude of respondents who read newspapers once a week. Similarly, the discriminatory attitudes of women respondents towards PLHIV increased by 26% among women who never watched television before (AOR =1.26, 95% CI: 1.11-1.42) compared to women respondents who watch television at least once a week.

Discussion
This paper attempt to describes common discriminatory attitudes towards PLHIV, and assess the sociodemographic and HIV-related knowledge factors associated with the negative attitude of respondents about HIV. In this study, among men and women of reproductive age, urban areas, higher educational level, high-income indices, regions such as(Amhara, Benishangul, Gambella, and Dire Dawa), knowledge about HIV transmission, ever tested for HIV, and reading newspapers were positively associated with discriminatory attitudes towards PLHIV.
Regarding the age respondents, our analysis revealed there lack of association between age and discriminatory attitudes. This is in line with the ndings of a study conducted in a rural part of southern Ethiopia [10], Afghanistan [14], and Tajikistan [15]. However, this result contrast with a study done in Pakistan [12], which shows younger age groups had a more positive attitude towards PLHIV than older age groups. Similarly, this study indicated reproductive age women and men from urban residency had a favorable attitude towards PLHIV than residents in the rural area. This is in line with ndings of studies that shows urban residents were less likely to express discriminatory attitudes towards PLHIV than rural residents [12,15]. Further our analysis indicated that respondents from households of rich wealth indexes were less likely to express discriminatory attitudes towards PLHIV as compared to the respondent from the poorest household. This nding has also been consistent with previous studies conducted in Pakistan [12], and Tajikistan [15].
Furthermore, Women and men education were positively associated with attitudes towards PLHIV in Ethiopia, our multivariate analysis indicated respondents who had primary education and above were less likely to express discriminatory attitudes than reproductive age women and men with no formal education. This result is consistent with previous studies, which show respondents who had at least a primary educational level have a favorable attitude towards PLHIV [12,13,15]. This might be because educated individuals will have more access to information regarding HIV/AIDS than their counterparts.
In this study, HIV/AIDS-related knowledge was signi cantly associated with attitudes towards PLHIV among reproductive-age women and men. Women and men who had comprehensive knowledge about HIV/AIDS had higher odds of having a positive attitude about PLHIV compared to women and men who are not knowledgeable about HIV transmission methods. It is in line with studies reported in Ethiopia [10,11], china [13], and Tajikistan [15], this could be because knowledgeable persons In this study, media exposure was signi cantly associated with attitudes towards PLHIV among reproductive-age women and men. Women who watch televisions at least once a week had higher odds of having favorable attitudes towards PLHIV compared to women's who didn't watch televisions. Similarly, respondents who read newspapers had lower discriminatory attitudes towards PLHIV. This ndings are consistent with the previous studies, which shows that mass media exposure have a positive effect in reducing discriminatory attitudes [12,13,15]. This could be exposure to mass medias are the major source of information, and most powerful tool for addressing a large group of people to change the community awareness, attitude and practice towards HIV/AIDS.

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The ndings of this research showed a high magnitude of stigma towards people living with HIV/AIDS among reproductive age women and men in Ethiopia. Our analysis revealed that, key HIV related knowledge's such as lack of Comprehensive knowledge about HIV , lack of knowledge on mother-to-child transmission, endorsement of common community misconceptions, and never tested for HIV . Moreover, respondents reside in rural areas, lack of formal education, belonging to poor wealth quantile, and lack of media exposure shows a higher level of discriminatory attitudes.
For stigma and discriminatory attitudes to be decreased interventions should focused on improving HIV related knowledge's through mass medias such as television and newspapers, especially through medias that can address the rural community.