Table 3.

A social-ecological approach to understanding how stigma practices and stigma experiences impact the uptake and delivery of HIV services, operate across levels of the social–ecological model, 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 practices
Stigmatizing behaviours	A, B, C, D, E	Individual, interpersonal, community, organizational	Faith is told to sit alone to wait (exclusion) and is treated differently from others within the clinic when attempting to access HIV testing. Faith recognizes she is experiencing discrimination in the clinic due to her identity as a street youth. As a result, Faith will not return for follow-up HIV testing and counseling, thus influencing the access to and acceptability of services	Stigmatizing behaviours can occur outside or within the health facility, and across multiple levels of the social-ecological model to impact the uptake and implementation of HIV prevention and treatment services. Multi-component, targeted, and tailored interventions need to consider how to address stigmatizing behaviours affecting HIV services
Discriminatory attitudes	A, B, C, D, E	Individual, interpersonal, community, organizational	The clinical team chide Abu telling him he is too young to know what he wants and that he should ‘keep quiet’ about his sexual identity. The intersecting stigmas of Abu’s age and sexual orientation underpin the manifestation of discriminatory attitudes by clinical staff. By invalidating Abu’s identities and healthcare needs, the health system lacks responsiveness and HIV services are not delivered appropriately to meet his needs	Discriminatory attitudes within the organization as well as those held by individual providers and facility staff can act as barriers to the implementation and delivery of evidence-based HIV services, intervention, and policies and need to be addressed to improve the adoption and implementation of programmes and policies
Stigma experiences
Experienced stigma and discrimination	A, B, C, D, E	Individual, interpersonal, community, organizational, structural	Sali experiences discrimination when they are refused PrEP on the basis of their gender and sexual orientation leaving their health needs unmet and increasing HIV risk behaviours for Sali	Experiences of stigma and discrimination operate at all levels of the social-ecological model to impact the uptake and delivery of HIV services. There are opportunities for implementation science to understand and address how stigma is affecting HIV services
Anticipated stigma	A, B, C, D	Individual	Ruth anticipates stigma from the community if she gives birth at the local hospital as women who give birth in-hospital are assumed to be HIV-positive by the community. The anticipation of stigma in this case impacts the uptake PMTCT and having an in-hospital birth which would reduce the likelihood of mother-to-child transmission and improve childbirth outcomes for mother and child	The anticipation of stigma by adolescents may hinder their uptake of HIV services. Implementation science research should consider how to reduce and mitigate the effects of anticipated stigma on the uptake of HIV services
Internalised stigma	D	Individual	Kiden feels ashamed and suicidal when it became apparent her peers knew about her rape and made assumptions about her HIV status. Internalised stigma can reduce the likelihood of remaining engaged and retained in HIV care	Internalised stigma can act as a barrier to the uptake of HIV prevention and treatment services for individuals. Implementation science research should consider how to reduce and mitigate the effects of internalised stigma on HIV care

PMTCT Prevention of mother-to-child transmission