Table 2.
A social-ecological approach to understanding how stigma drivers, facilitators, and stigma ‘marking’ impact the uptake and delivery of HIV services and implications for implementation science research to address stigma
| Health stigma and discrimination framework domains | Cases theme within | Operating across social–ecological levels | Examples of the impact of stigma on the uptake and delivery of HIV services from selected cases | Considerations for addressing stigma as a contextual determinant of implementation and uptake of HIV prevention and treatment services |
|---|---|---|---|---|
| Stigma drivers | ||||
| Fear of infection | B, C, D | Individual, Interpersonal | Faith is reluctant to seek care and scared to know her status. This demonstrates how stigma may reduce the likelihood that adolescents will engage in HIV testing and counseling | When designing approaches to HIV testing and counseling and HIV prevention education, there is a need to consider the strength of fears and other emotional factors associated with stigma, which affect the individual and interpersonal relationships, and impact the uptake of HIV services |
| Fear of social ramifications | A, C, D, | Interpersonal, Community | Kiden fears the social ramifications of experiencing SGBV and HIV-positive status and being forced to marry the boy who raped her. For Kiden, this led her to hide what had occurred from her parents and demonstrates how stigma drivers may impact the uptake of follow-up care and reduce disclosure | These cases demonstrate the crucial importance of addressing contextual social-cultural drivers outside of the health facility, including the family, that impact the uptake of and access to services |
| Fear of economic ramifications | A, B, C | Interpersonal, structural | Ruth fears the economic ramifications of HIV disclosure and being outcast by her in-laws and chased from home, without the economic resources for her maternal family to care for her and her child, she is unsure how she would survive. For Ruth, this fear impacts her uptake of ANC services | These cases demonstrate the need to address how factors such as the fear of economic ramifications operate across levels of the social-ecological model when implementing interventions to improve the uptake and delivery of HIV services to adolescents |
| Social judgment | A, C, D, E | Interpersonal, Community, Organizational | When Abu arrives at the clinic with Sali, the receptionist expresses social judgment about Sali’s gender identity, driving stigmatizing practices when they are told to wait in a separate area. Social judgment within the health facility impacts the delivery of HIV prevention services for Abu and his partner | These cases demonstrate the importance of ensuring health care providers and facility staff are trained and sensitized to work with adolescent key populations, as social judgment within the facility is a barrier to effectively implementing HIV services |
| Blame | A, C, D | Individual, Interpersonal, community | Kiden knows that the ‘community blamed girls’ who have experienced SGBV. Blame can reduce the likelihood that adolescents will engage in HIV testing and counseling or disclose their status, as friends, family, and community members will assign them responsibility and fault for acquiring HIV | These cases demonstrate the importance of considering how assigning fault and responsibility to an individual is internalized and may act as a barrier to care and the uptake of HIV services. Interventions need to consider the interpersonal and community-level aspects of blame as a contextual barrier to the uptake and delivery of HIV services |
| Prejudice | A, B, C, D, E | Individual, interpersonal, community, organizational | Faith engages in sex work due to prejudice expressed in the patriarchal street subculture that girls/women ‘can’t work’. Because of her engagement in sex work on the street she is not considered to be a ‘good girl’ by the counselor. The preconceived notion by healthcare providers can impact patient-provider interactions and the delivery of HIV services to adolescents | These cases demonstrate how prejudice operates across levels of the social-ecological framework and can impact the uptake and delivery of HIV services in several ways. At the health facility level, training facility staff and ensuring the facility is inclusive and provides equitable services to all regardless of their social identities is a vital consideration when implementing programmes, services, and policies |
| Stereotypes | A, B, C, D, E | Individual, interpersonal, community | The clinician stereotypes Sali believing that he will be unable to adhere to PrEP due to his appearance, thus impacting Sali’s ability to receive PrEP and the delivery of effective HIV services from the clinician | Widely held beliefs about groups of individuals are often difficult to shift and can have a major impact on the uptake and delivery of HIV services across multiple levels of the social-ecological model, thereby likely requiring multi-component interventions to improve implementation outcomes |
| Stigma facilitators | ||||
| Social support | A, B, D, E | Interpersonal, Community | Ruth receives social support from a neighbour about HIV testing and disclosure for couples. As well, she receives an understanding and helpful response from her sister that encourages her that her family will be there for her, and she is not a burden. Social support from friends, peers, family, and within the community can mitigate the stigma process, and improve the uptake of HIV services, such as medication adherence and retention in care for Ruth | These cases have shown how the presence of strong positive social support from family, friends, peers, and social networks is an important component to improve the uptake of HIV services. Social support, peers, and social networks may play an important role in bridging contextual barriers that influence the implementation and uptake of HIV services |
| Gender norms and equality | A, B, C, D, E | Individual, interpersonal, community, structural | The clinician seeing Abu and Sali becomes disgusted with them around their sexual identities and decision-making around receptive versus insertive sex practices, referring to their masculinity and femininity. The clinician treats them with disrespect resulting in a stigma facilitator impacting the delivery of HIV care and prevention to Abu and his partner | The impact of gender norms and equality is seen across cases and occurs across multiple levels of the social-ecological model. The expectations of women, men, and gender-diverse individuals act in society are an important contextual aspect that can affect the implementation of interventions, approaches, and policies to improve the uptake and delivery of HIV prevention and treatment. Stigma toward same-sex sexual practices needs to be addressed in healthcare provider training |
| Cultural norms | A, B, C, D, E | Individual, interpersonal, community, structural | Jemutai is lectured by the clinician about being a ‘good Christian’. Stigma enacted by clinicians reinforces social-cultural stigma around adolescent sexuality and health, instead of creating healthy and positive norms around adolescent SRH and sexual education. Reinforcing shame around sexual activity can lead to high-risk practices to hide engagement in sex and reduce likelihood of re-engaging in care for HIV testing and counseling | Cultural norms are another contextual barrier that operate across multiple levels of the social-ecological model. Deeply held cultural beliefs by health facility staff and healthcare providers can impact the delivery of evidence-based HIV services |
| Legal environment | C | Structural | Jemutai has difficulty accessing services on her own given her limited financial resources and status as a minor coming for testing without an adult guardian | This case demonstrates the importance of identifying legal and policy level issues that affect the implementation of HIV services |
| Stigma ‘marking’ | ||||
| Homelessness | B | Community, organizational, individual | As a result of stigma marking, stigma is applied to Faith targeting her street identity, and has an impact on health systems responsiveness, and her interactions with individuals in the health facility, and therefore the uptake of delivery of HIV services | This case shows the importance of addressing deeply held beliefs and attitudes healthcare providers and facility staff have about groups of individuals who have been ‘marked’ or labeled by society when implementing evidence-based interventions to improve uptake and delivery of HIV services |
| Sexual stigma | C, D, E | Community, individual | As a result of stigma marking, stigma is applied to both Abu and Sali due to HIV status and sexual orientation, impacting the patient-provider interaction, and the delivery of HIV services | This case demonstrates the importance of addressing deeply held beliefs and attitudes healthcare providers and facility staff have about groups of individuals who have been ‘marked’ or labeled by society when implementing evidence-based interventions to improve uptake and delivery of HIV services |
| HIV stigma | A, D | Community, interpersonal | As a result of stigma marking, stigma is applied to Kiden by her peers at school and she is marked as ‘spoilt’ and HIV-positive. This may facilitate internalized stigma, shame, and act as a barrier to the uptake of HIV services for Kiden | Stigma marking impacts the uptake and delivery of HIV services outside and within the health facility, and contextual barriers to implementation operate at multiple levels of the social-ecological model that are vital to consider |
SGBV sexual and gender-based violence; ANC antenatal care; PrEP pre-exposure prophylaxis