The effect of universal testing and treatment on HIV stigma in 21 communities in Zambia and South Africa.

Anne L Stangl,Helen Ayles,Deborah Donnell,Lario Viljoen,Sian Floyd,Constance Mubekapi-Musadaidzwa,Sarah Fidler,Ab Schaap,Richard Hayes,Mara Steinhaus,Peter Bock,Graeme Hoddinott,Triantafyllos Pliakas,Rory Dunbar,Virginia Bond,Tila Mainga,James R Hargreaves,Nomtha Mandla

doi:10.1097/qad.0000000000002658

Abstract

Objectives:To assess the impact of a combination HIV prevention intervention including universal testing and treatment (UTT) on HIV stigma among people living with HIV, and among community members and health workers not living with HIV.Design:This HIV stigma study was nested in the HPTN 071 (PopART) trial, a three-arm cluster randomised trial conducted between 2013 and 2018 in 21 urban/peri-urban communities (12 in Zambia and nine in South Africa).Methods:Using an adjusted two-stage cluster-level analysis, controlling for baseline imbalances, we compared multiple domains of stigma between the trial arms at 36 months. Different domains of stigma were measured among three cohorts recruited across all study communities: 4178 randomly sampled adults aged 18–44 who were living with HIV, and 3487 randomly sampled adults and 1224 health workers who did not self-report living with HIV.Results:Prevalence of any stigma reported by people living with HIV at 36 months was 20.2% in arm A, 26.1% in arm B, and 19.1% in arm C (adjusted prevalence ratio, A vs. C 1.01 95% CI 0.49–2.08, B vs. C 1.34 95% CI 0.65–2.75). There were no significant differences between arms in any other measures of stigma across all three cohorts. All measures of stigma reduced over time (0.2--4.1% reduction between rounds) with most reductions statistically significant.Conclusion:We found little evidence that UTT either increased or decreased HIV stigma measured among people living with HIV, or among community members or health workers not living with HIV. Stigma reduced over time, but slowly.ClinicalTrials.gov number:NCT01900977.

Highlights

1.1 Background and Prior ResearchThe global health burden associated with human immunodeficiency virus (HIV) infection continues to grow, with an estimated 33 million people living with HIV, including 22.5 million adults and children in sub-Saharan Africa
While considerable progress has been made in expanding the coverage of antiretroviral treatment (ART) for patients living with advanced disease (CD4 count < 200 cells/μL), a large proportion of HIV-infected individuals who need treatment are not yet receiving it
Because of the uncertainties regarding the additional impact provided by offering immediate ART we propose to carry out a trial with three arms

Summary

Introduction

1.1 Background and Prior ResearchThe global health burden associated with human immunodeficiency virus (HIV) infection continues to grow, with an estimated 33 million people living with HIV, including 22.5 million adults and children in sub-Saharan Africa. There are 2.5 new HIV infections for every HIV-infected patient commencing ART, meaning that there is an ever-expanding pool of patients who will need treatment in the future [1]. Unless the number of new infections can be steeply reduced, it will be increasingly difficult and costly to provide ART for all those who need it [2, 3]. For these reasons, effective HIV prevention has become an even more pressing priority in the era of ART roll-out

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