Author: Sam Singer
Position: No occupation was given
Institution: UC Berkeley/UC San Francisco Joint Medical Program
E-mail: ssinger@berkeley.edu
Submitted Date: November 27, 2006
Published Date: November 29, 2006
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

In their essay in last month's PLoS Medicine, Daniel Reidpath and Kit Yee Chan challenge the widely cited link between HIV-related stigma and the spread of the epidemic. This is an important question, given the heavy emphasis on stigma in WHO, UNAIDS, and other public health policies, but in making their argument Reidpath and Chan misrepresent the connections that other authors have made between stigma and viral transmission, ignore evidence that does suggest an association, and propose a model of their own for which they offer no evidence.

HIV infection establishes itself first in certain high-risk groups--men who have sex with men, intravenous drug users, sex workers, mobile populations--and only later moves into the general population. In the early stages of the epidemic, stigma facilitates transmission within high-risk groups, because these already marginalized groups receive little attention from policy makers and the health care community and are further discriminated when they are identified with HIV and AIDS[1]. Stigma also prevents or makes it more difficult for members of high-risk groups to access preventive services, including HIV antibody testing[2]. Reidpath and Chan distort this dynamic by describing a model in which stigma leads to fear which leads to unsafe behavior. We know of no one who suggests that stigma causes homosexual intercourse or intravenous drug use. Instead, there is evidence that HIV-related stigma makes it difficult for people to take actions to reduce their risks; for example, by accessing HIV-education[3], exchanging needles[4], and negotiating condom use[5]. Stigma may even lead women who know they are HIV positive to breast-feed their infants rather than arouse suspicion of their serostatus status through formula feeding[6]. This undoubtedly increases the risk of vertical viral transmission.

Reidpath and Chan go on to propose that stigma may actually "slow the spread of infection from those [high-risk] groups to the general population". Although there is a plausible logic to this suggestion, there is no evidence for it. Even if stigma does reduce the opportunities that marginalized groups have to transmit HIV to the broader population, this would have little effect on the dynamics of a generalized epidemic.

While they recognize that stigma presents a barrier to the treatment and care of people living with HIV, Reidpath and Chan fail to recognize the association this may have with increased transmission. HIV-related stigma discourages people from disclosing their status, entering care, and adhering to ARV regimens, all of which represent missed opportunities for prevention.

Around the world HIV capitalizes on and reinforces social stigma and discrimination, especially the low status of women. Defeating the epidemic requires an honest examination of all these phenomena and interventions that target both the virus itself and its widespread social impacts.

References

1. Herek GM, Capitanio JP (1999) AIDS Stigma and Sexual Prejudice. American Behavioral Scientist 42: 1126-1143.

2. Nyblade L, Pande R, Mathur S, MacQuarrie K, Kidd R, et al. (2003) Disentangling HIV and AIDS Stigma in Ethiopia, Tanzania and Zambia. Washington, D.C.: International Center for Research on Women. 53 p.

3. (2002) AIDS stigma forms an insidious barrier to prevention/care. HIV experts describe problem in India. AIDS Alert 17: 111-113.

4. Ford K, Wirawan DN, Sumantera GM, Sawitri AA, Stahre M (2004) Voluntary HIV testing, disclosure, and stigma among injection drug users in Bali, Indonesia. AIDS Educ Prev 16: 487-498.

5. Roth J, Krishnan SP, Bunch E (2001) Barriers to condom use: results from a study in Mumbai (Bombay), India. AIDS Educ Prev 13: 65-77.

6. Doherty T, Chopra M, Nkonki L, Jackson D, Greiner T (2006) Effect of the HIV epidemic on infant feeding in South Africa: "When they see me coming with the tins they laugh at me". Bull World Health Organ 84: 90-96.