. 2019 Mar 19;4(2):e001285. doi: 10.1136/bmjgh-2018-001285

Table 3.

Characteristics of included studies and intervention effects

Study reference	Country/Setting	Population	Intervention components and description	Programme dose	Study design	Sample size	Self-stigma measure used	Additional outcomes reported	Time to follow-up	Impact on self-stigma and effect size
Interventions targeting only individual-level risks and resilience
Low et al ⁵³	Western Kenya	People living with HIV (mean age: 45)	Behavioural (door-to-door HIV testing aimed to increase testing uptake in the presence of stigma).	18 months.	Cluster randomised controlled trial	3295 (not clear how many are T and C, equal split assumed)	17 stigma items drawn from various sources,^{84 85} subscales: community stigma, personal stigma, community stigma actions, personal stigma actions, self-stigma. Focus on latter.	Community leader stigma towards PLH (reduced), community member stigma towards PLH (reduced).	18 months	No significant change in self-stigma, 0.05 (−0.02, 0.12).
Mundell⁵⁷	South Africa	HIV-positive pregnant women (mean age: 27)	Health education. Stigma coping.	10 weeks.	Prospective cohort study with treated and non-treated (non-experimental)	T: 72 C: 84	Personal stigma scale based on ref 86 composed of 12 items focused on own experience of stigma and internalised blame.	Positive coping (improved), self-esteem (improved), levels of positive support and HIV-related support (improved), disclosure (improved), depression (no significant change), HIV knowledge (no significant change).	3 months	Study reports no significant change in self-stigma, but did not provide sufficient information for calculating effect size.
Rongkavilit et al ⁵¹	Thailand, Bangkok	Young men who have sex with men, living with HIV (mean age: 23)	Behavioural (motivational interviewing focused on changing sexual risks and alcohol use).	4 sessions.	Randomised controlled trial	T: 37 C: 37	12 internalised stigma items drawn from Berger’s 40-item HIV Stigma Scale.⁷³	Sexual risk behaviour (reduced), adherence (no significant change), alcohol and drug use (no significant change), general mental health (no significant change).	1 and 6 months	No significant change in self-stigma, −0.43 (−0.90, 0.03).
Tshabalala and Visser⁵⁴	South Africa	Women living with HIV (age range 22–40)	Cognitive-behavioural therapy: Psychological support. Behavioural.	8 weekly sessions.	Randomised controlled trial	T: 10 C: 10	Serithi Internalised Stigma Scale,⁸⁷ 16 items denoting two factors of tendency towards self-blame and interpersonal distance.	Coping (improved), self-esteem (improved), depression (reduced), enacted stigma (no significant change).	2 months	Reduction in self-stigma, −1.22 (−2.17, −0.26).
Van Tam et al ⁵⁵	Vietnam, Quang Ninh (4 outpatient clinics)	Adults living with HIV (age range: 18–60)	Behavioural (peers aimed to increase participants’ ART adherence through check-ins following a checklist).	Biweekly visits for first 2 months, after this weekly.	Cluster randomised controlled trial	T: 119 C: 109	Internal AIDS-Related Stigma Scale.⁷¹	Quality of life (improved).	12 months	No significant change in self-stigma, −0.03 (−0.29, 0.23).
Interventions targeting relational-level and individual-level risks and resilience
Go et al ⁵²	Vietnam, Thai Nguyen Province	Men who inject drugs (mean age: 35)	Stigma awareness and coping. Health education. Community stigma reduction (through video screenings and home visits to raise awareness and debunking misconceptions).	Men living with HIV who inject drugs received: 2 individual post-test counselling sessions. 2 small group sessions consisting of 6–10 participants. Community members received: 2-part video. A series of 6 HIV education sessions delivered by a trained community mobiliser.	Four-arm factorial randomised controlled trial	Community T: 139 Individual T: 95 Both T: 132 C: 89	New scale developed for the purposes of this study, capturing both HIV-related as well as injecting drug use-related internalised stigma.	HIV seroconversions (no significant change), sexual and injection risks (initial reductions at 6 months’ follow-up observed but not sustained at 24 months).	Every 6 months, 24-month endpoint	No significant change in self-stigma, −0.07 (−0.39, 0.25).
Peltzer et al ⁶⁰	South Africa, Mpuma-langa	HIV-positive pregnant women (median age: 28)	’Protect your Family’ programme: Health education for both women and their male partners (delivered separately for women and their male partners, and focused on health-seeking behaviours, adherence, intimate partner violence, communication). Psychological support (individual counselling for women). Cognitive-behavioural intervention for both women and their male partners (to improve communication, health-seeking behaviours, anger management and reduce intimate partner violence).	Standard PMTCT care and three prenatal weekly 2-hour group sessions and one 1-hour individual counselling session (at 32 weeks’ gestation) and two 1-hour monthly individual or couples counselling sessions (6 and 12 weeks postnatally).	Cluster randomised controlled trial	T: 342 C: 357	12 items drawn from Berger’s 40-item HIV Scale⁷³ (contains four stigma subscales: personalised stigma, disclosure concerns, negative self-image and public attitude stigma).	HIV serostatus (no change) and ART adherence for mothers and infants (no change), HIV and PMTCT knowledge (no change). Additional outcomes listed in study protocol: intimate partner violence and communication and male HIV testing and engagement in PMTCT.	12 months	Reduction in self-stigma, −0.48 (−0.63, −0.33).
Prinsloo et al ⁶¹	Urban South Africa	People living with HIV (mean age: NA)	Stigma coping. Community stigma reduction intervention (through raising awareness, acting psychodramas and pamphlet distribution).	5 months in total: 27 3-hour workshops for both PLH and community. 5 workshops on ‘Coping with HIV Stigma’ for those interested in continuing. Weekly door-to-door teaching with a pamphlet. 6-session support group for community and PLH groups.	Mixed-methods prospective cohort study	62	HASI-P internalised stigma subscale.²⁴	Reported by people living with HIV: verbal abuse, healthcare neglect, social isolation, fear of contagion (no significant changes in any of the above outcomes). Reported by community members: behaviour towards PLH, symbolic and instrumental stigma (no significant changes in any of the above outcomes).	5 months	Study reports no significant change in self-stigma, but did not provide sufficient information for calculating effect size.
Interventions targeting structural-level and individual-level risks and resilience
Bhatta and Liabsuetrakul⁶²	Nepal	People living with HIV (mean age: 36)	Empowerment (focusing on autonomy and community activism, self-care, stress management and rights).	6 weekly, 90 min sessions	Randomised controlled trial	T: 66 C: 66	Stigma was measured using a 23-item scale drawn from Genberg et al (2008),⁸⁸ including three subscales, namely shame/blame, perceived discrimination and equity.	Empowerment (improved), social support (improved), quality of life (improved).	3, 6 months	Reduction in self-stigma, −1.37 (−1.74, −0.98).
Chidrawi et al ⁶³ and 2014 (reporting on same sample)	South Africa, North-West Province	People living with HIV (mean age: 37)	Empowerment (to implement a stigma reduction intervention in their communities).	2-day lecture and activity-based workshop. Six 3-day workshops. 4-week period of project implementation.	Prospective cohort study	18	HASI-P internalised stigma subscale.²⁴	HIV signs and symptoms (reduced), quality of Life (no significant change).	Every 4 months, 12 months endpoint	Reduction in self-stigma. Effect size calculated for longest follow-up (after 12 months): −0.51 (−1.17, −0.15).
Ghosal et al ⁸³	India, Kolkata	Female sex workers (mean age: 32)	‘Dream building’: Empowerment (dream-building workshops whereby participants set their own goals, are supported to reshape their self-image in positive direction and are provided skills to assert their rights). Economic strengthening (training session focused on saving that were also provided to control group).	8 weekly group sessions.	Cluster randomised controlled trial	T: 264 C: 203	Newly developed measures, shame related to sex work, captured by one item: ’Are you ashamed of your occupation?’ Self-worth, coded as 0 if the person referred to herself as a ’Bad woman’, ’Fallen woman’, ’Woman with no future’, ’Criminal’.	Happiness (improved), self-efficacy (improved), future-oriented behaviour captured by savings and healthcare choices (improved), decision-making power (no significant change), comfort in public interaction, aspirations (no significant change).	Immediate post-test	Reduction in self-stigma. Shame: −1.05 (−1.24, −0.85). Self-worth: 2.55 (2.31, 2.80).
Lifson et al ⁵⁹	Rural Ethiopia	People living with HIV (mean age: 34)	Community health support workers provided: Health education (including facilitated communication with the clinic about the client’s health and treatment regimens). Psychological support (counselling and social support). Economic strengthening (through referrals to community organisations for support with nutrition, clothing, housing or income-generating activities).	1–4 times per month over 12 months.	Prospective cohort study	142	HASI-P internalised stigma subscale.²⁴	HIV knowledge (improved), physical and mental quality of life (improved), perceived social support (improved).	12 months	Study reports a statistically significant reduction in self-stigma scores (from 1.6 to 0.05, p<0.001), but did not provide sufficient information for calculating the effect size.
Maluccio et al ⁶⁵	Uganda (Gulu and Soroti)	ART-naïve adults living with HIV (mean age: 39)	ART initiation (in healthcare facility). Economic strengthening (food assistance). Treatment support (monthly meeting with a support officer who provided treatment and disclosure counselling).	12 months.	Quasi- experimental difference-in-difference matching	T: 448 C: 456	HASI-P internalised stigma subscale.²⁴	External, enacted, received stigma (no significant change).	12 months	Reduction in self-stigma, −0.14 (−0.25, −0.02).
Nyamathi et al ⁵⁸	Rural India	Women living with HIV (mean age: 31)	Health education (living with HIV, ART, parenting and maintaining a healthy home environment). Stigma coping. Economic strengthening (monthly supply of grains, bus token and life skills training).	6 sessions—45 min, then weekly visits for 15–60 min.	Cluster randomised controlled trial	T: 34 C: 34	10-item scale which was one of four stigma scales based on previous research^{89 90} and adapted to India (eg, ’How much do you feel that you deserve to have HIV?’).	Disclosure avoidance/avoidance coping (improved).	6 months	Reduction in self-stigma, −4.60 (−5.51, −3.69).
Turan et al ⁶⁷	Rural Kenya (Nyanza)	Newly diagnosed pregnant women living with HIV (mean age: 24)	ART initiation (in healthcare facility). Health education (HIV care and treatment programme, which provided access to health education, adherence counselling services, patient support group).	6 weeks.	Prospective cohort study	135	HASI-P internalised stigma subscale.²⁴	Postpartum depression (reduced).	6 weeks	Study reports a reduction in self-stigma, but did not provide sufficient information for calculating effect size.
Uys et al ⁶⁴	Lesotho, Malawi, South Africa, Swaziland and Tanzania	Adults living with HIV (mean age: 38)	Empowerment (people living with HIV, together with healthcare workers, designed and implemented interventions).	Workshop: 21 hours, peer-organised meetings varied between 5 and 8 hours, total dose thus varied between 8 and 20 hours.	Cohort study	41	HASI-P internalised stigma subscale.²⁴	Self-esteem (improved), self-efficacy (no significant change).	1 month	Reduction in self-stigma, −0.50 (−0.93, −0.06).
Interventions operating only at the structural-level
Makoae et al ⁷⁰	Lesotho, Malawi, South Africa, Swaziland and Tanzania	People living with HIV (mean age: 36)	Clinical ART provision.	12 months.	Prospective cohort study with treated and non-treated (non-experimental)	T: 488 C: 443	HASI-P internalised stigma subscale.²⁴	None.	6, 12 months	Reduction in self-stigma, −0.18 (−0.05, −0.31).
Peltzer and Ramlagan⁶⁹	South Africa, KwaZulu-Natal	ART-naive adults living with HIV (mean age: 36)	ART initiation (in healthcare facility).	Not applicable.	Prospective cohort study	735	6-item Internalised AIDS-Related Stigma Scale capturing self-defacing beliefs.⁷¹	HIV-related health status (improved), quality of Life (improved), depression (significant increase, adverse effect).	6 and 12 months	Reduction in self-stigma, −0.59 (−0.69, −0.48).
Tsai et al ⁶⁸	Rural Uganda	ART-naïve adults living with HIV (median age: 34)	ART initiation (in healthcare facility).	2 counselling sessions preinitiation, then 2–5 times annually, more counselling sessions on request.	Prospective cohort study	262	Internal AIDS-Related Stigma Scale.⁷¹	HIV symptom burden (improved), physical and psychological well-being (improved), depression symptom severity (reduced).	Varies, but medium 3.4 years	Reduction in self-stigma, −0.25 (−0.42, −0.08).
Wagner et al ⁶⁶	Uganda, Kampala and Kakira	Adults living with HIV (mean age: 36)	ART initiation (in healthcare facility).	12 months; ART patients attend clinic on a monthly basis at first and then bimonthly; non-ART patients attend clinic between 2 and 6 months depending on their CD4 count.	Prospective cohort study with treated and non-treated (non-experimental)	T: 300 C: 302	Internal AIDS-Related Stigma Scale drawn from Kalichman et al.⁷¹	Depression (reduced), hopelessness (reduced).	6 and 12 months	Reduction in self-stigma, −0.47 (−0.64, −0.31).

ART, antiretroviral treatment; C, control arm; HASI-P, HIV/AIDS Stigma Instrument for People Living with HIV; NA, not applicable; PLH, people living with HIV; PMTCT, prevention of mother-to-child transmission; T, treatment arm.