Relationship Between Individual, Family, and Community Stigma and Male Circumcision in India: Implications for HIV Social Work Practice and Policy

Background and Purpose:  India is home to the world's third-largest population suffering from HIV/AIDS, with the number of people living with HIV estimated between 2,100,000 and 2,800,000 (UNAIDS, 2009).  The prevalence rate among 15-49 year olds is 0.3% [0.3% - 0.4%]. The literature indicates that male circumcision can reduce HIV transmission by 51-60%  ADDIN EN.CITE  ADDIN EN.CITE.DATA (Auvert et al., 2005; Bailey et al., 2007; Gray et al., 2007) ; however, only 13.6% of males in India are circumcised (DHS, 2006). Cultural and religious stigma may influence low rates of circumcision in this population, and thus guided by the Ecosystems Perspective, this study examined multilevel HIV stigma and its association with circumcision.  Specifically, the following hypothesis was tested: HIV stigma at the individual, family, and community levels is associated with males being uncircumcised. The presentation discusses the implications of the findings to HIV social work practice and policy.

Methods:The sample consists of 65,455 men aged 15 to 54 years. The sample was drawn from the USAIDS sponsored Demographic and Health Survey from India. The DHS is a cross-sectional survey that is nationally representative survey of randomly selected respondents using a stratified multistage sampling strategy. HIV stigma was measured in five variables. With six multilevel models (MLM), HIV stigma variables at the individual, family, and community levels were tested to assess the significance of differences in circumcision among participants, adjusting for confounding factors, such as wealth, education, region, and age. 

Results: HIV stigma is associated with circumcision on individual, family, and community levels.  Statistically significant findings include: 1) the odds of being circumcised among men who reported greater HIV stigma were 13% times lower (95% CI: 0.847, 0.890; p< 0.001) than among men who reported less stigma; 2) the odds of being circumcised among men whose families reported higher HIV stigma were 16% times greater (95% CI: 1.097,1.228; p< 0.001) than among families reporting less stigma; 3) the odds of being circumcised among men who reside in communities with greater HIV stigma were 134% times more (95% CI: 1.864, 2.937; p< 0.001) than among communities with less stigma.

Conclusions and Implications: Male circumcision, a key element of HIV prevention intervention, is affected by HIV stigma at the individual, family, and most significantly, community level. The findings exemplify the ecological fallacy and illustrate the complexity of HIV stigma; findings at the community level do not correlate to the individual level. Social workers could be the professionals of choice to address stigma in India, as the multilevel approach is inherent to social work practice, being liaisons between at risk individuals and their environments, which include families and communities. Moreover, the study enhances understanding of contextual predictors by moving beyond individual risk factors to address the contextual factors that are central to social work HIV practice and policy.