Multilevel HIV Stigma As a Barrier to HIV Testing Uptake and Receipt of HIV Test Results: A Context Quantified

Background and Purpose: Central Asia is experiencing one of the fastest growing HIV epidemics in the world, with some areas seeing infection rates doubling yearly since 2000 (WHO, 2010). The literature indicates significant barriers to HIV testing and result receipt exists at the individual, family, and community level in other populations. Guided by the Ecosystems Perspective, this study aims to provide new data on multilevel HIV stigma by utilizing an innovative methodology that allows for contextual effects to be quantified. Specifically, the study answers the research question: what are the stigma related barriers to HIV testing uptake and receipt of HIV test results at the individual, family, and community levels.

Methods: The UNICEF sponsored Multiple Indicator Cluster Surveys (MICS) datasets for Central Asia were used for this secondary study of cross-sectional survey data. The MICS is a nationally representative survey of randomly selected respondents using a stratified multistage sampling strategy. The sample consists of Kazakhstan (2006: n=14,719); Kyrgyzstan (2006: n=7,043); Uzbekistan (2006: n=14,205); and Tajikistan (2005: n=10,626) for a regional total n=46,593. All participants are ever-married women of reproductive age (15-49 years old). HIV stigma was measured in four categories: social rejection, prejudiced attitudes, and disclosure concerns. Within multilevel modeling (MLM), HIV stigma variables were used to assess the significance of differences in HIV testing and receipt of HIV test results among participants, their families, and communities, and the interactions among these levels, adjusting for confounding factors, such as wealth, education, and knowledge of HIV testing resources.

Results: Multi-level HIV stigma is associated with HIV testing uptake and receipt of HIV test results: 1) the odds of getting tested and picking-up test results among women who report less HIV stigma is 1.019 (p< .001) and 2.589 (p< .001) times that of the odds among those who do report more stigma at the individual level; 2) the odds of getting tested and picking-up test results among women who experience less HIV stigma within their families is 1.516 (p< .05) and 2.561 (p< .05) times that of the odds among those women who experience more family level stigma; and 3) the odds of getting tested and picking-up test results among women who experience less HIV stigma within their communities is 0.618 (p< .05) and 1.876 (p< .05) times that of the odds among those women who experience more community level stigma.

Conclusions and Implications: HIV stigma operates on the individual, family, and community levels to hinder HIV testing uptake and the receipt of HIV testing results. These findings could inform interventions targeted to increase uptake of HIV testing and receipt of HIV test results, a cornerstone of HIV intervention prevention, as it is a gateway to treatment. Social workers could be the professionals of choice to implement multilevel stigma reduction interventions in Central Asia, as the multilevel approach is inherent to social work practice. Moreover, the study enhances understanding of contextual predictors by moving beyond individual risk factors to address the contextual factors that are central to the social work ecosystems perspective.