Introduction: Although HIV stigma has been identified as an important risk factor for HIV transmission risk behaviors, little is known about the contribution of community-level HIV stigma to HIV transmission risk behaviors and self-reported sexually transmitted diseases (STDs) or how gender may modify associations.
Methods: We pooled data from the 2008 and 2013 Sierra Leone Demographic and Health Surveys. For HIV stigma, we examined HIV stigmatizing attitudes and HIV disclosure concerns at both individual and community levels. Outcomes of HIV transmission risk behaviors were recent condom usage, consistent condom usage, and self-reported STDs. We assessed associations with multivariable logistic regressions. We also analyzed gender as an effect modifier of these associations.
Results: Of 34,574 respondents, 24,030 (69.5%) who had heard of HIV were included in this analysis. Community-level HIV stigmatizing attitudes and disclosure concerns were associated with higher odds of self-reported STDs (adjusted odds ratio = 2.07; 95% confidence interval: 1.55 to 2.77; adjusted odds ratio = 2.95; 95% confidence interval: 1.51 to 5.58). Compared with men, community-level HIV stigmatizing attitudes among women were a stronger driver of self-reported STDs (interaction P = 0.07). Gender modified the association between community-level HIV disclosure concerns and both recent and consistent condom usage (interaction P = 0.03 and P = 0.002, respectively). Community-level HIV disclosure concerns among women were observed to be a driver of risky sex and self-reported STDs.
Conclusions: This study shows that community-level HIV stigma may be a driver for risky sex and self-reported STDs, particularly among women. Our findings suggest that community-held stigmatizing beliefs and HIV disclosure concerns among women might be important targets for HIV stigma reduction interventions.
*Division of Infectious Diseases, Department of Medicine, University of California at San Francisco (UCSF), San Francisco, CA;
†Division of Biostatistics, School of Public Health, University of California at Berkeley, Berkeley, CA;
‡Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital, Boston, MA;
§Harvard Medical School, Boston, MA;
‖Mbarara University of Science and Technology, Mbarara, Uganda; and
¶Division of HIV, ID and Global Medicine, Department of Medicine, San Francisco General Hospital, UCSF, San Francisco, CA.
Correspondence to: John D. Kelly, MD, MPH, Division of Infectious Diseases, Department of Medicine, University of California at San Francisco (UCSF), 513 Parnassus Avenue, S-380, San Francisco, CA 94117 (e-mail: dan.kelly@ucsf.edu).
A.C.T. acknowledges salary support through the US National Institutes of Health K23MH096620. S.D.W. acknowledges salary support through R-01 MH095683 and Burke Family Foundation. The authors received no specific funding for this study.
The remaining authors have no funding or conflicts of interest to disclose.
Received October 12, 2016
Accepted March 30, 2017
