Determinants and effects or consequences of internal HIV-related stigma among people living with HIV in Morocco

Amal Ben Moussa,Daniela Rojas Castro,Virginie Villes,Lahoucine Ouarsas,Rosemary M Delabre,Mohammed Elkhammas,Aziza Bennani,Mehdi Karkouri,Kamal Alami,Hind Filali

doi:10.1186/s12889-021-10204-1

Abstract

BackgroundHIV-related stigma and discrimination constitute a barrier to different intervention programs. Unlike external stigma, internal stigma is not well explored in in the Middle East and North African countries, while grasping this particular form of stigma is essential to limit its effects. The present study aims to measure internal stigma effects and to identify factors associated with this kind of stigma not yet documented among people living with HIV (PLHIV) in Morocco.MethodsThe PLHIV Stigma Index questionnaire (adapted and translated into French and Moroccan Arabic dialect “darija”) was used to collect information regarding the stigma and discrimination experienced by PLHIV across 8 cities in Morocco (September–October 2016). A randomly drawn cluster of 10 PLHIV, consisting of 5 men and 5 women, was drawn at each participating medical care center to achieve a nationally representative sample of PLHIV. Fifteen interviewers living with HIV and five supervisors were selected and trained to administer the questionnaire. An internal stigma score (range: 0–7), was calculated based on seven negative feelings/ beliefs. Negative binomial regression was used to identify characteristics associated with the internal stigma score.ResultsAmong 626 PLHIV, internal stigma was reported by 88.2%. The median [IQR] internal stigma score was 4 [2–5]. Regarding internal stigma, 51% avoided going to the local clinic when needed and 44% chose not to attend social gatherings. Belonging to at least one key population (aIRR [95%CI] = 1.15 [1.03; 1.28]), experiencing discriminatory reactions from family following HIV status disclosure (1.28 [1.11; 1.49]), avoiding HIV services for fear of stigmatization by staff (1.16 [1.05; 1.28]) and being denied health services because of HIV status (1.16 [1.03;1.32]), are among the factors significantly associated with an increase of the internal stigma score.ConclusionsInternal stigma is high among Moroccan PLHIV and significantly impacting their life decisions and their healthcare access. Multi-level interventions are needed to address internal stigma experienced by PLHIV in Morocco.

Highlights

HIV-related stigma and discrimination constitute a barrier to different intervention programs
The Stigma Index is an international initiative launched in 2004 by various organizations (Global Network of People Living with HIV, International Community of Women living with HIV/ AIDS, UNAIDS) to document the various experiences of people living with HIV (PLHIV) related to stigma and discrimination
A total of 626 PLHIV were recruited to the study 2 trans individuals were excluded from the analysis due to the low number in comparison to male and female participants and the inability to analyze as a separate group

Summary

Introduction

HIV-related stigma and discrimination constitute a barrier to different intervention programs. HIV-related stigma and discrimination permeates at all levels of society to the point that it is widely acknowledged these factors must be addressed to have an effective and sustainable response to the HIV epidemic [1, 2] It becomes evident, and challenging, in certain parts of the world where individuals experience stigma and discrimination, criminalization and/or penalization for certain behaviors that may be considered both socially or culturally unacceptable and may increase exposure to HIV. In the Middle East and North African (MENA) region, for example, a 2011 report found that half of the countries had laws that acted as barriers to HIV-related prevention, treatment and care [3] These laws penalize, and/or criminalize key populations and their behaviours and practices such as homosexuality and sex work. Male circumcision, which is widely practiced in these countries, is a well-demonstrated biological mechanism to reduce HIV infections, adopting a strategy based on religious principles have shown its limits as the MENA region is the region that has seen the highest rise in number of new infections since 2001 [5]

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