Perceived stigma and its associated factors among people living with HIV/AIDS in Bharatpur art center, Chitwan district, Nepal

Abstract

Background

Stigma due to Human Immunodeficiency Virus (HIV) is an attitude and belief that negatively affects people with HIV. This stigma and discrimination affect the emotional well-being and mental health of people living with HIV, acting as a significant barrier to HIV prevention, treatment, care, support, and social integration. The aim of this study was to identify the perceived stigma level of PLHIV and its associated factors in the Bharatpur ART center, Chitwan, Nepal.

Objectives

To determine the prevalence of perceived stigma and its associated factors among PLHIV of Bharatpur ART Center, Chitwan District, Nepal.

Methodology

A descriptive cross-sectional study was conducted among 348 people from the Bharatpur ART center, Chitwan District, Nepal, using a systematic sampling procedure. A face-to-face interview was taken by using semi-structured tools for independent variables, and the Bunn standard HIV Stigma Scale tool was used to measure the dependent variables. Stigma was measured in terms of felt stigma, Public Attitudes Concern (PAC), Disclosure Concern (DC), Negative Self-Image (NSI), and Enacted Stigma (ES), as well as overall stigma.

Result

Overall, 58.9% of participants reported high perceived stigma. Among the stigma domains, negative self-image was the most prevalent (65.2%), followed by disclosure concern (56.9%), public attitude concern (53.7%), and enacted stigma (49.7%). Bivariate analysis showed that age, place of residence, ethnicity, education level, reason for HIV testing, experiences of exclusion due to HIV, feelings of hopelessness, and depression were significantly associated with perceived stigma (p < 0.05).

Conclusion

A substantial proportion of PLHIV attending the Bharatpur ART Center experienced high levels of perceived stigma. Several socio-demographic, HIV-related, and psychological factors were significantly associated with stigma. These findings highlight the importance of stigma-reduction interventions and the integration of mental health support within HIV care services. However, as the study used a cross-sectional design and bivariate analysis, causal relationships cannot be inferred.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-026-27535-6.

Background

Human Immunodeficiency Virus (HIV) remains a major global public health concern despite substantial progress in prevention and treatment. With the expansion of antiretroviral therapy (ART), people living with HIV (PLHIV) are able to live longer and healthier lives. However, HIV-related stigma and discrimination continue to pose significant barriers to effective HIV prevention, testing, treatment, and care services [1].

Stigma refers to the prejudice, discrimination, stereotyping, and exclusion experienced by individuals with devalued physical, behavioral or medical characteristics [2]. HIV-related stigma encompasses unreasonable or negative attitudes, behaviors, and judgments aimed towards those living with or at risk of HIV. It includes prejudice and discriminatory acts that result from classifying somebody as belonging to a group that is socially unacceptable [3, 4].

According to Joint United Nations Program on HIV/AIDS (UNAIDS) Global HIV Statistics (2025), 40.8 million people living with HIV and 31.6 million people on ART which is less than 34 million target by 2025 [5]. Who has identified HIV related stigma and discrimination as one of the significant barriers affecting the key population’s ability to access and utilize health service throughout the HIV continuum [6]. Because of this, many people are unwilling to get tested for HIV, reveal a positive test result, utilize Pre Exposure Prophylaxis (PrEP) or other HIV prevention strategies or receive life-saving HIV treatment [7]. According to a recent global report by the People Living with HIV Stigma Index, 13.0% of PLHIV experienced stigmatization at least once in the previous 12 months, perpetrated by health facility staff while undergoing HIV treatment. This rate almost doubled to 24.9% when respondents sought care for non-HIV-related health conditions and 84.8% of PLHIV also suffered internalized stigma. Additionally, among PLHIV who had temporarily discontinued ART, 34.3% reported that they were reluctant on resuming the treatment because of the fear of being mistreated by health workers or having their status disclosed without their consent. A part from health facilities, around 23.6% of respondents experienced stigma and discrimination because of their HIV status within the last 12 months in community settings. The most frequently mentioned incidences were being aware of others making discriminatory remarks or gossiping about them, with 14.2% noting ‘other’ persons and 12.6% indicating family members [8].

Stigma is found to be associated with a variety of unfavorable consequences for PLHIV, including a lower quality of life, mental health issues and limited access to care [9]. Several studies have found that HIV-related stigma has a negative influence on mental health, including increased anxiety [10, 11], depression [12, 13], emotional discomfort [14] and reduced life satisfaction [15, 16]. Turan et al. found that stigma within communities often leads PLHIV to internalize negative perceptions, which raises their expectation of stigmatizing interactions, thereby harming their health and mental well-being [17]. Furthermore, a meta-analysis by Rueda et al. found that high levels of stigma are associated with risky sexual behaviors, lower medication adherence, depression and decreased utilization of health and social services [11]. These data indicate that HIV-related stigma has a considerable and widespread negative impact on the physical, mental, and social health of HIV patients.

As per national HIV factsheet 2022 Nepal, the estimated number of PLHIV were 30,000, while 25,336 (84.5%) PLHIV knew their HIV status, 22,735 (89.7%) PLHIV were on ART and 15,284 (67.2%) PLHIV had their viral load status suppressed [18] showcasing the major challenges in achieving the 95-95-95 goal of Nepal’s National HIV strategic plan by the end of 2026 [19]. Notable portion of this gap in case detection, access to ART and adherence to treatment is contributed by stigma and discrimination. Likewise, the different studies from Nepal reveals the significant prevalence of depression, suicidal ideation, anxiety, stress, substance use [20–22] among PLHIV. Notable portion of this gap in case detection, access to ART, adherence to treatment and mental health issues is contributed by stigma and discrimination. Thus, it is essential to urgently identify the prevalence of stigma and associated factors so as to generate evidence and facilitate the prompt action.

Conceptual framework

This study is based on the assumption that perceived stigma among PLHIV is shaped by the interaction of socio-demographic factors (such as age, education, and place of residence), HIV-related experiences (such as disclosure and discrimination), and psychological factors including depression and hopelessness. These factors may collectively influence how individuals perceive and experience stigma within healthcare and community settings.

Although several studies have examined HIV-related stigma in Nepal, limited evidence exists on how socio-demographic and psychological factors are associated with perceived stigma among PLHIV receiving ART services at the local service delivery level. In particular, there is a lack of research focusing on ART centers that serve diverse populations from multiple districts.

The Bharatpur ART Center in Chitwan District is one of the major HIV treatment facilities in the region and provides services to a large number of PLHIV from surrounding districts. Understanding stigma in this setting is particularly important because experiences within healthcare environments can influence treatment adherence, disclosure practices, and mental health outcomes. Therefore, this study aimed to assess the level of perceived stigma and identify its associated factors among PLHIV attending the Bharatpur ART Center, Chitwan, Nepal.

Materials and methods

Study design, area and participants

A facility-based descriptive cross-sectional study was conducted at the Bharatpur Antiretroviral Therapy (ART) Center in Chitwan District, Nepal, from June 2023 to December 2023. Bharatpur is considered a major healthcare hub in Nepal and provides specialized medical services to populations from several surrounding districts.

The Bharatpur ART Center is one of the major HIV treatment facilities in the region and operates under Bharatpur Hospital, one of the largest government hospitals in Nepal. The center provides comprehensive ART services to a substantial number of people living with HIV (PLHIV) from both urban and rural areas of Bagmati Province and neighboring districts. Because of its wide service coverage and diverse patient population, the center was considered an appropriate setting for assessing perceived stigma and its associated factors among PLHIV receiving ART services.

The study population included people living with HIV (PLHIV) who were enrolled in ART services at the center. Individuals aged 18 years and above, who were receiving ART during the study period, were eligible to participate. Those who were seriously ill, mentally unable to respond, or unwilling to provide consent were excluded from the study.

According to the fact sheet of HIV epidemic update of Nepal 2020, Bagmati Province had the highest number of people enrolled in ART program [23]. Meanwhile, Bharatpur being the medical city of Nepal and Bharatpur hospital being one of the largest hospitals in Nepal [24] where PLHIV from different districts find accessible in receiving ART services. Thus, this study aims to find out the stigma and its associated factors among PLHIV in Bharatpur ART center, Chitwan District, Nepal. The study participants were clients who were on ART at Bharatpur ART center, Chitwan, Nepal.

Sample size and sampling method

A facility-based descriptive cross-sectional study was conducted at the Bharatpur Antiretroviral Therapy (ART) Center. The total number of PLHIV ever enrolled in ART at the center was 1,810. The sample size was calculated using Cochran’s formula for a finite population [25], considering a prevalence of perceived stigma of 46.1% based on a previous study conducted in Pokhara, Nepal [26], a 95% confidence interval, 5% margin of error, and 10% non-response rate. The final sample size was 348.

A systematic sampling technique was used. The sampling interval (k) was calculated as 5 (1810/348). The first participant was selected randomly using the lottery method, followed by every 5th individual. Participants were approached during routine ART visits between [June-2023] and [Dec-2023], informed about the study objectives and procedures, and provided written informed consent.

Inclusion criteria

Participants aged ≥ 18 years, enrolled in ART at the center, and able to provide informed consent.

Exclusion criteria

Mentally ill or unable to respond, lost to follow-up, migrated, deceased, or declined consent. If selected participants were excluded, the next eligible participant was included. Although systematic sampling was used, participants who missed visits or were lost to follow-up may not be represented, potentially introducing selection bias. Nevertheless, the demographic characteristics of the sample were broadly similar to the overall center population. The sample represents PLHIV attending the Bharatpur ART Center, which serves a diverse catchment area in Chitwan district. While findings may be generalizable to similar ART centers in Nepal, caution is needed when extrapolating results to all PLHIV nationwide.

Data collection tool

The data collection instrument consisted of four sections. Independent variables were assessed using a semi-structured questionnaire developed by the researchers based on an extensive literature review and consultation with subject experts. The questionnaire included items related to socio-demographic characteristics (e.g., age, sex, education, marital status, occupation), HIV-related factors (e.g., duration since HIV diagnosis, duration on antiretroviral therapy, disclosure status), and psychological factors such as depression and hopelessness. Content validity of the questionnaire was ensured through expert review and supporting literature.

Prior to the main study, the questionnaire was pretested among 30 people living with HIV attending the ART clinic at Prithvi Chandra Hospital to assess clarity, relevance, and feasibility of the instrument. Based on feedback from the pretest, minor modifications were made to improve wording, clarity, and sequencing of questions. Data obtained from the pretest were not included in the final analysis.

Perceived stigma, the dependent variable, was measured using the HIV Stigma Scale (HSS), originally developed by Berger et al. [26], and later refined by Bunn et al. [26]. The scale has previously been used and validated in the Nepalese context, including a study conducted by Subedi et al. [26]. The HSS is a 32-item instrument measured on a four-point Likert scale ranging from “strongly disagree” to “strongly agree.” It comprises four domains: Negative Self-Image, Public Attitude Concern, Disclosure Concern, and Enacted Stigma. One item in the Negative Self-Image domain and one item in the Disclosure Concern domain were reverse-coded prior to analysis.

The total stigma score ranged from 32 to 128. Domain-specific score ranges were 7–28 for Negative Self-Image, 6–24 for Public Attitude Concern, 8–32 for Disclosure Concern, and 11–44 for Enacted Stigma. For analytical purposes, the total stigma score was dichotomized into “high” and “low” perceived stigma based on the sample mean score. Participants scoring above the mean were classified as having high perceived stigma, whereas those scoring at or below the mean were categorized as having low perceived stigma. This approach was adopted because there is no universally established cut-off point for the HIV Stigma Scale in the Nepalese context, and the use of the sample mean has been applied in previous studies to facilitate interpretation in regression analyses.

Depression, hopelessness, and perceived stigma are conceptually related psychosocial constructs, and some degree of overlap may occur. To minimize potential conceptual confounding, each construct was measured using validated instruments with distinct items capturing different psychological dimensions. Independent variables were coded and categorized based on established cut-offs from previous literature or sample distribution for analytical purposes.

The internal consistency of the HIV Stigma Scale was assessed in the current study sample. The scale demonstrated high reliability with a Cronbach’s alpha value greater than 0.9, indicating excellent internal consistency [27].

Data collection techniques

Participants were informed about the objectives of the study, and written informed consent was obtained prior to data collection. Confidentiality and privacy were strictly maintained. Data were collected through face-to-face interviews conducted in a private counseling room at the ART center.

Statistical methods

Data were entered and analyzed using the Statistical Package for Social Sciences (SPSS) version 16. Descriptive statistics, including frequencies and percentages, were used to summarize the socio-demographic characteristics, HIV-related variables, psychological factors, and levels of perceived stigma among the study participants.

The association between perceived stigma (categorized as high and low) and independent variables was assessed using the chi-square test. This test was used to examine the relationship between categorical variables and perceived stigma. A two-sided p-value of less than 0.05 was considered statistically significant (α = 0.05).

All completed questionnaires were reviewed for completeness during the data collection process, and no missing data were identified in the final dataset. Therefore, all 348 participants were included in the statistical analysis. Independent variables were coded and categorized based on relevant literature and study objectives prior to analysis to ensure consistency in statistical comparisons.

Results

The study showed that the majority of respondents were male representing 50.9% of total respondents while female and transgender are 44.8% and 4.3% respectively. Nearly half (47.4%) of the respondents reported that they were currently residing in Municipality followed by Metropolitan City (33.6%), Rural Municipality (13.5%) and Sub metropolitan city (5.5%). Majority of the participants were Brahmin/Chhetri (39.3%) followed by Janajati (38.2%) while the least belonging to Muslim (0.9%). Majority of the respondents were Hindu (81.6%) followed by Buddha (14.9%), Christian (2.6%) and Muslim (0.9%). More than half (66.1%) of the respondents were Married/living together while (16.1%) of the respondents were never married followed by widowed (14.9%) and divorced/separated (2.9%). In regard to the educational status, nearly half (49.4%) of the respondents can only read and write followed by secondary education (23%), basic education (19.3%) and 8.3% of respondents had more than secondary education. Major occupation of respondents was reported to be agriculture (28.2%) followed by house wife (18.7%) while least involved in social works (0.3%). More over half (67.5%) of respondents had less than NRs 25,000 as a monthly family income.

While exploring the HIV related variables, more than half of respondents (58%) were diagnosed HIV positive for > = 5 years, resulting in a long term diagnosis followed by (25.3%) mid-term diagnosis i.e. diagnosed HIV positive for 1–5 years and (16.7%) had a short-term diagnosis i.e. diagnosed for less than 1 year. A majority (88.8%) of respondents tested their HIV status because of unsafe sexual contact while minorities tested because of STI, TB, pregnancy, surgery, HIV/AIDS symptoms, unsafe sexual contact, medical checkup for abroad, needle sharing and medical checkup in jail. 84.8% of respondents had disclosed their HIV status to others among which a majority (45.1%) had disclosed their status with intimate partner followed by family members (29.3%). Regarding the mode of transmission of HIV, 93.1% of respondents reported that the HIV was transmitted to their bodies through unsafe sexual contact, whereas 4.6% experienced vertical transmission, 2% through shared needles and blades and 0.3% through donated organs and blood. Regarding the physical intimacy, 86.5% of the respondents had physical relation after HIV diagnosis. A majority of respondents (72.4%) had multiple sex partners where only 3.7% respondents reported that they had no sex partner. 8.4% of respondents forgot whether they used a condom or not during their most recent sexual encounter, compared to 63.6% of respondents who said they had worn one. More than half of the respondents’ partner (57.8%) had HIV status positive.

Likewise, delving into the psychological factors, 56% of respondent reported that have been excluded/discriminated due to HIV among which 93.3% of respondents had been excluded/discriminated in health service provide center followed by 17.9% and 14.35% in family and community settings respectively. 71.6% and 71.3% reported feeling hopeless and depressed due to HIV respectively.

“Table 1 shows the general overview of socio-demographic characteristics of PLHIV currently taking ART from Bharatpur ART Center, Chitwan, Nepal. The age of respondents ranges from 18 years to 68 years with mean age 41.19 and standard deviation of 10.57.

Table 1.

Socio-demographic Information of Respondents (n = 348)

Characteristics	Frequency(n)	Percentage (%)
Age of Respondents in Year
18–35	100	28.7
36–50	182	52.3
> 50	66	19.0
Mean age of Respondent	Mean ± SD = 41.19 ± 10.57	Min/Max = 18/68
Sex
Male	177	50.9
Female	156	44.8
Transgender	15	4.3
Place of Origin
Metropolitan city	117	33.6
Sub Metropolitan City	19	5.5
Municipality	165	47.4
Rural Municipality	47	13.5
Ethnicity
Brahmin/Chhetri	137	39.3
Janajati	133	38.2
Muslim	3	0.9
Madhesi	8	2.3
Dalit	67	19.3
Religion
Hindu	284	81.6
Buddha	52	14.9
Muslim	3	0.9
Christian	9	2.6
Marital Status
Married or living together	230	66.1
Never Married	56	16.1
Separated/Divorced	10	2.9
Widowed	52	14.9
Educational Status
Only read and write	172	49.4
Basic (1–8)	67	19.3
Secondary (9–12)	80	23
More than Secondary	29	8.3
Family Income
Less than 25 K	235	67.5
More than 25 K	113	32.5
Functional Status
Yes	348	100
No	0
Occupation Status
Agriculture	98	28.2
Housewife	65	18.7
Job	59	17
Labor	32	9.2
Business	13	3.7
Others	1	0.3
Unemployment	63	18.1
Student	10	2.9
Prison Inmates	6	1.7
Social Works	1	0.3

The study showed that the majority of respondents were male representing 50.9% of total respondents while female and transgender are 44.8% and 4.3%. Nearly of half of respondents were stayed in Municipality (47.4%) while (33.6%) of the respondents stayed in Metropolitan City followed by Sub metropolitan city (5.5%) and Rural Municipality (13.5%). Majority of the participants were Brahmin/Chhetri (39.3%) followed by Janajati (38.2%) while the least belonging to Muslim (0.9%). Majority of the respondents were from Hindu (81.6%) followed by Buddha (14.9%), Christian (2.6%), Muslim (0.9%). More than half (66.1%) of the respondents were Married/living together while (16.1%) of the respondents were Never married/Unmarried followed by widowed (14.9%) and divorced/separated (2.9%).

In regard to the respondents (49.4%) can only read and write, (23%) had secondary education, (19.3%) had Basic education, (8.3%) of respondents had more than secondary education. All of the respondents had good functional status. Major occupation of respondents to be agriculture (28.2%) followed by house wife (18.7%) while least involved in social works (0.3%). More over half (67.5%) of respondents had less than Rs25000 in family income, while 32.5% had more than Rs25000 in family income.”

“Table 2 shows the information on level of perceived stigma among the respondents with respect to different domains of stigma. The majority of respondents (65.2%) reported experiencing high level of negative self-image. A significant proportion of respondents (53.7%) expressed a high level of concern regarding public attitudes. Likewise, 56.9% of respondents reported having a high level of disclosure concern while 49.7% had high level of enacted stigma. Overall, a majority of respondents (58.9%) reported level of perceived stigma.”

Table 2.

Perceived stigma level of PLHIV (n = 348)

Stigma domains	Level of perceived stigma	Frequency	Percentage (%)
Negative self-image	Low	121	34.8
	High	227	65.2
Public Attitude Concern	Low	161	46.3
	High	187	53.7
Disclosure Concern	Low	150	43.1
	High	198	56.9
Enacted Stigma	Low	175	50.3
	High	173	49.7
Overall Stigma	Low	143	41.1
	High	205	58.9

On bivariate analysis, independent variables such as age, place of residents, ethnicity, education level, Reason for Testing, excluded due to HIV, Hopeless due to HIV and Depressed due to HIV were found to be significantly associated with dependent variable i.e., Perceived Stigma (Table 3).

Table 3.

Association of overall perceived stigma with independent variables (n = 348)

Variables	Level of perceived stigma		χ2	P-value
	Low	High
Age
18–40	71 (47)	80 (53)	3.872	0.049*
> 40	72 (36.5)	125 (63.5)
Place of origin
Metropolitan city	55 (47)	62 (53)	8.363	0.039*
Sub Metro	5 (26.3)	14 (73.7)
Municipality	71 (43)	94 (57)
Rural Municipality	12 (25.5)	35 (74.5)
Ethnicity
Brahmin/Chhetri	46 (34.1)	89 (65.9)	4.488	0.034*
Other than Brahmin/Chhetri	97 (45.5)	116 (54.5)
Education level
Only Read and write	75 (43.6)	97 (56.4)	8.182	0.042*
Basic	34 (50.7)	33 (49.3)
Secondary	23 (28.7)	57 (71.3)
More than Secondary	11 (37.9)	18 (62.1)
Reason for Testing
Unsafe sexual contact	133 (43)	176 (57)	4.332	0.037*
Other than unsafe sexual contact	10 (25.6)	29 (74.4)
Excluded due to HIV
Yes	62 (32.1)	131 (67.9)	15.202	0.001*
No	80 (53)	71 (47)
Hopeless due to HIV
Yes	88 (35.3)	161 (64.7)	11.957	0.001*
No	55 (55.6)	44 (44.4)
Depressed due to HIV
Yes	87 (35.1)	161 (64.9)	12.884	< 0.001*
No	56 (56)	44 (44)

* denotes significant association by applying Pearson chi-square test at 5% level of Significance

Discussions

Perceived stigma is one of the major barriers in accessing care by PLHIV. The current study found significant level (58.9%) of perceived stigma among PLHIV in Bharatpur ART Center, Chitwan District. This prevalence is comparable to findings from studies conducted in Pokhara Nepal [26], Central China [28], and Southern Ethiopia [29], suggesting that HIV-related stigma continues to be a persistent concern across diverse geographic and sociocultural contexts. The current study also identified significant associations between perceived stigma and several factors, including age, place of residence, ethnicity, education level, reason for HIV testing, experiences of exclusion due to HIV status, hopelessness, and depression.

A statistically significant association was observed between age and perceived stigma (χ² = 3.872, p = 0.049), with respondents aged over 40 years reporting a higher proportion of perceived stigma compared to younger participants. Similar associations have been reported in previous studies [30, 31]. However, this interpretation should be considered cautiously because the present study used a cross-sectional design and relied on bivariate analysis. In addition, age may be closely related to factors such as duration since HIV diagnosis or duration of treatment, which were not controlled for in the current analysis. Interestingly, some previous studies have reported contrasting findings, suggesting that older adults may experience lower levels of stigma due to greater psychological resilience or longer-term adaptation to living with HIV [32]. The PLHIV Stigma Index 2.0 in Nepal also highlights variation across age groups, with younger individuals reporting higher levels of internalized stigma [33]. These mixed findings indicate that the relationship between age and stigma may be complex and context dependent.

The study also found a significant association between place of residence and perceived stigma (χ² = 8.363, p = 0.039). Higher levels of stigma were reported among participants residing in sub-metropolitan areas and rural municipalities compared to those living in metropolitan cities. Similar patterns have been observed in previous studies, which suggest that individuals living in less urbanized settings may experience greater stigma due to limited access to HIV-related information and fewer supportive services [9]. Additionally, rural communities often have closer social networks, which may increase concerns about disclosure and fear of social judgment [11]. Evidence from the PLHIV Stigma Index 2.0 in Nepal also reports higher levels of external stigma in rural areas, including experiences of gossip, social exclusion, and discrimination in healthcare settings [33].

Ethnicity was another factor associated with perceived stigma (χ² = 4.488, p = 0.034), with Brahmin/Chhetri respondents reporting higher levels of stigma compared to other ethnic groups. A similar finding was reported in a previous study conducted in Pokhara, Nepal [26]. Cultural expectations, social norms, and perceptions related to morality and illness may influence how stigma is experienced across different ethnic groups [5]. Research conducted in low- and middle-income countries has also highlighted the role of structural and cultural factors in shaping stigma experiences [34]. These findings suggest that culturally sensitive approaches may be important when designing interventions aimed at reducing HIV-related stigma.

Education level also showed a significant association with stigma (χ² = 8.182, p = 0.042). Participants with secondary education reported higher levels of stigma compared with those with basic education. Although many studies suggest that education is associated with lower stigma due to improved awareness and knowledge, findings in this area are not always consistent. For example, research conducted in Uganda found that increased years of schooling were associated with lower HIV-related stigma [35]. Similarly, research among elderly men in China showed that higher HIV/AIDS knowledge scores, often associated with higher education, corresponded with lower stigma levels [36]. However, other studies have reported contradictory findings. Research among college students in the U.S. revealed low levels of HIV transmission knowledge, with only 4% responding correctly to related questions, suggesting that higher education does not always equate to accurate HIV knowledge [37].

The reason for HIV testing was significantly associated with stigma levels (χ² = 4.332, p = 0.037). Participants who reported being tested for reasons other than unsafe sexual contact experienced higher levels of stigma compared with those tested due to unsafe sexual contact. One possible explanation is that individuals tested due to illness or suspicion of infection may experience greater anxiety or concern about disclosure of their status to family members or partners. Previous research has suggested that contexts surrounding HIV testing and diagnosis may influence how individuals perceive and internalize stigma [38].

Experiences of social exclusion were strongly associated with perceived stigma in this study (χ² = 15.202, p < 0.001). Participants who reported experiencing exclusion also reported substantially higher levels of stigma. Social exclusion has been widely recognized as a key component of stigma and discrimination experienced by PLHIV [39]. The theoretical framework proposed by Link and Phelan also identifies social exclusion as a central mechanism through which stigma is enacted and reinforced within communities [40]. These findings highlight the importance of addressing social attitudes and discrimination as part of stigma reduction efforts.

Psychological factors were also significantly associated with perceived stigma. Participants who reported feelings of hopelessness related to HIV experienced higher levels of perceived stigma (χ² = 11.957, p = 0.001). Similarly, respondents who reported depressive symptoms had significantly higher levels of stigma (χ² = 12.884, p < 0.001). Previous research has demonstrated that stigma and mental health conditions such as depression are closely related among PLHIV [39]. Depression, often a neuropsychiatric complication of HIV, can exacerbate feelings of isolation and hopelessness, which in turn heightens perceptions of stigma [41]. Psychological distress may both influence and be influenced by stigma experiences, potentially contributing to feelings of isolation and reduced well-being HIV infection has also been associated with a range of psychological and neurological complications that may affect mental health outcomes among people living with HIV [42]. These findings underscore the importance of integrating mental health services into HIV care programs.

Overall, the findings of this study suggest that perceived stigma among PLHIV is influenced by a combination of socio-demographic characteristics, social experiences, and psychological factors. Addressing stigma therefore requires comprehensive interventions that include community education, psychosocial support, and efforts to reduce discrimination within healthcare and community settings. However, the findings of this study should be interpreted in light of several limitations. First, the study used a cross-sectional design, which limits the ability to establish temporal relationships between variables. Second, the analysis relied on bivariate statistical methods, and potential confounding factors were not controlled for in the analysis. Therefore, the observed associations should not be interpreted as causal relationships. Future studies employing multivariable analytical approaches and longitudinal designs may provide a more comprehensive understanding of the independent factors associated with perceived stigma among PLHIV.

Limitations and future directions

This study has some limitations that should be considered when interpreting the findings. The analysis was limited to bivariate associations using chi-square tests; therefore, potential confounding effects between variables could not be fully controlled. Future studies employing multivariable analytical approaches may provide a more comprehensive understanding of the independent factors associated with perceived stigma among people living with HIV.

Conclusion

This study found a high level of perceived stigma among people living with HIV attending the Bharatpur ART Center. Perceived stigma was significantly associated with several factors, including age, place of residence, ethnicity, education level, reason for HIV testing, experiences of exclusion, hopelessness, and depression. These findings suggest that HIV-related stigma remains an important challenge affecting PLHIV receiving ART services.

The results highlight the need for targeted interventions within ART programs that address both social and psychological aspects of stigma. Integrating mental health support, strengthening counseling services, and promoting community awareness may help reduce stigma and improve the overall well-being of PLHIV. Future research using more comprehensive analytical approaches is recommended to further explore the factors associated with HIV-related stigma.

Abbreviations

HIV

Human Immunodeficiency Virus

PLHIV

People Living with HIV

ART

Antiretroviral Therapy

HSS

HIV Stigma Scale

PAC

Public Attitude Concern

DC

Disclosure Concern

NSI

Negative Self Image

ES

Enacted Stigma

PrEP

Pre-Exposure Prophylaxis

SPSS

Statistical Package for Social Sciences

CD4

Cluster of Differentiation 4

AIDS

Acquired Immunodeficiency Syndrome

UNAIDS

Joint United Nations Programme on HIV/AIDS

STI

Sexually Transmitted Infections

TB

Tuberculosis

Authors’ contributions

AL, MG, MP, JKP, and LD conceptualized the study and were responsible for methodology and instrument development. AL was responsible for data collection. AL and MG contributed to data curation and data analysis. AL and MG were responsible for drafting the manuscript under the guidance and supervision of LD and JKP. All authors contributed to the reviewing, supervision, and final edition of this manuscript. All authors read and approved the final manuscript.

Funding

This study received no any funding.

Data availability

The corresponding author can provide access to the dataset upon request that supports the findings of the current study.

Declarations

Ethics approval and consent to participate

Ethical approval for this study was obtained from the Institutional Review Committee (IRC) of Shree Medical and Technical College, Nepal. Permission to conduct the study was also obtained from the Bharatpur Hospital. The study was conducted in accordance with the Declaration for Helsinki. Written informed consent was obtained from all participants prior to data collection, and confidentiality and privacy were strictly maintained throughout the study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.