In Botswana, individuals who perceive that antiretroviral therapy is readily available to members of their community have less negative attitudes toward people with HIV than those who say that treatment is not accessible, according to a population-based study.¹ Respondents who reported that antiretroviral therapy was available in or near their village had greatly reduced odds of having negative attitudes toward those with HIV (odds ratios, 0.4) and of expecting to be the target of such attitudes should they become infected (0.1). Moreover, nearly two-thirds (63%) believed that increased access to anti-HIV drugs had reduced the stigma of infection.

Few studies have explored the impact of universal access to HIV treatment on stigma in a developing country. The investigators note that Botswana, where 24% of adults are HIV-positive, is a particularly appropriate setting for such research, as prejudice toward individuals with HIV was common prior to the 2002 inception of a national antiretroviral treatment program. Furthermore, Botswana has the second-highest rate of HIV infection of any country.

In November–December 2004, investigators surveyed a population-based sample of adults aged 18–49 living in the five districts of Botswana that have the greatest number of HIV-positive residents. The researchers used a probability sampling design to choose households within these regions, and interviewed 1,268 randomly selected respondents, who provided information on demographic characteristics, emotional and physical health, and condom use and clinic visits in the last 12 months. They also answered 15 questions designed to test their knowledge of HIV, as well as seven items examining their attitudes toward people with HIV and nine items assessing whether they anticipated encountering negative attitudes if they were to become infected. The relationship between respondent characteristics and HIV-related attitudes were evaluated using multivariate logistic regression.

About half of the respondents were women (52%) and a similar proportion had more than a high school education (54%). Forty-four percent lived in urban areas, while the rest were split between somewhat less developed "urban villages" (30%) and rural areas (27%). The vast majority (88%) said that HIV treatment was available nearby, and one-third had visited a health clinic at least three times in the past year. About four in 10 (38%) reported that they had used a condom every time they had had sex in the past year. On average, respondents correctly answered half of the HIV knowledge questions.

Thirty-eight percent of respondents had at least one negative attitude toward HIV-positive individuals. Two items were endorsed by about one-quarter of respondents: Twenty-seven percent said they would not share a meal with someone who had HIV, and 23% would not buy food from an infected shopkeeper. In contrast, only 3–5% said they would not care for an HIV-infected relative, or believed that people with HIV should be expelled from school or denied certain rights.

Seven in 10 respondents reported that they would expect to encounter negative reactions if they were to become HIV-positive. More than half (54%) thought their community would ostracize them, 31% thought they would be treated badly at work or school and 30% said their spouse or partner would break up with them. Smaller proportions feared physical abuse (12%), job loss (12%), ill treatment from health professionals (12%) or not receiving care from their family (8%).

In a multivariate analysis adjusting for demographic and health variables, respondents had reduced odds of reporting at least one negative attitude if they reported having access to HIV treatment (odds ratio, 0.4). In addition, the odds of having negative attitudes were lower among residents of urban villages and rural regions (0.6 for each) than among those who lived in urban areas, and respondents with more than a high school education (0.7) and those who had visited a health clinic three or more times in the past year (0.7) had lower odds than those with less education or fewer clinic visits, respectively. Negative attitudes were more common among inconsistent condom users (1.6) than among those who always used condoms.

Most of these factors were also associated with respondents anticipating some type of negative reaction if they were to become HIV-positive: Odds were reduced among respondents who had access to HIV treatment (odds ratio, 0.1), lived in rural areas (0.7) or had visited a clinic at least three times in the past 12 months (0.7), and were elevated among inconsistent condom users (1.8). In addition, anticipating adverse reactions was negatively associated with HIV knowledge (0.8 for each additional correct response), and women were less likely than men to expect such reactions (0.7).

Overall, 63% of respondents agreed that universal access to antiretroviral therapy has helped reduce prejudice toward HIV-positive individuals. Furthermore, larger proportions of respondents had tolerant attitudes toward those with HIV in this survey than in a similar 2001 study. For example, 97% of respondents in the current study agreed that an HIV-positive teacher who is not sick should be allowed to teach, compared with just 59% in the earlier survey.

However, because of the study's cross- sectional design, the researchers caution that the causality of the link between access to HIV therapy and negative attitudes cannot be determined; in addition, these results, which may not apply to all Botswanans, could be influenced by social desirability bias and by recent initiatives designed to reduce stigma, such as "opt-out" HIV testing. They add that these findings reflect only attitudes, not behaviors, and should not be seen as "grounds for complacency," especially since women and other vulnerable groups continue to feel the effects of stigma. Rather, the researchers suggest, universal treatment access should be considered one piece of a "multimodal strategy" that "empowers people living with HIV/AIDS to take an active role in combating stigma and discrimination."—S. Ramashwar

1. Wolfe WR et al., The impact of universal access to antiretroviral therapy on HIV stigma in Botswana, American Journal of Public Health, 2008, 98(10):1865– 1871.