Quantification and factors associated with HIV-related stigma among persons living with HIV/AIDS on antiretroviral therapy at the HIV-day care unit of the Bamenda Regional Hospital, North West Region of Cameroon

Quantification and factors associated with HIV-related stigma among persons living with HIV/AIDS... Background: The Human Immunodeficiency Virus /Acquired Immune Deficiency Syndrome (HIV/AIDS) is not just a medical problem but its social impact is increasingly affecting its effective management. The fear of HIV-stigma constitutes a major barrier to HIV testing, prevention, uptake and adherence to antiretroviral therapy (ART). We aimed to quantify HIV-related stigma, and identify the factors associated with high HIV-related stigma among persons living with HIV and AIDS (PLHIVA) and on ART. Methods: A hospital-based cross sectional analytic survey targeting PLHIVA on ART at the HIV-day care unit of the Bamenda Regional Hospital of Cameroon was conducted from February to April 2016. A total of 308 eligible and willing participants were consecutively included in the survey. Data were collected using a pretested questionnaire designed from the Berger HIV stigma scale and analyzed using Epi info 3.5.4. Results: The mean age of the 308 participants was 40.1±10.2 years. The mean overall HIV/AIDS related stigma score was 88.3 ± 18.80 which corresponds to a moderate level of stigma according to the Berger stigma scale. Further analysis revealed that most participants suffered from moderate forms of the different subtypes of stigma including: personalized (49.8%), disclosure (66.4%), negative self-image (50.0%) and public attitude (52.1%) stigmatization. It was estimated that 62.7% (95% confidence interval [CI] = 57.8–68.9%) of the participants lived with high levels of HIV-related stigma. After controlling for gender, religion, age and occupation, level of education below tertiary (Adjusted Odds Ratio [AOR] = 0.70 [95% CI = 0.44–0.91]; p = 0.036) and a duration from diagnosis below 5 years (AOR = 1.74 [95% CI = 1.01–3.00]; p = 0.046) were significantly associated with high HIV-related stigma. Conclusion: About three out of every five PLHIVA receiving ART in Bamenda Regional Hospital still experience high levels of HIV-related stigma. This occurs more frequently in participants with low educational status, and who may have known their HIV status for less than 5 years. Anti-HIV-stigma programs in the North West Region need strengthening with intensified psychosocial follow-up of newly diagnosed cases. Keywords: Human immunodeficiency virus, Acquired immunodeficiency syndrome, Antiretroviral therapy, Stigma, Cameroon * Correspondence: christrah@yahoo.fr Kekem District Hospital, Kekem town, West Region, Cameroon Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Ajong et al. Globalization and Health (2018) 14:56 Page 2 of 7 Background related counseling [5]. To the best of our knowledge, no The Human Immunodeficiency Virus /Acquired Im- study has been done to quantify HIV-related stigma and mune Deficiency Syndrome (HIV/AIDS) remains one of identify its associated factors in Cameroon. A quantification the most stigmatizing pandemics worldwide [1]. The of HIV-related stigma will not only serve as a baseline for fight against HIV/AIDS remains one of the major points future comparison, but will help to evaluate the anti-stigma in the sustainable development agenda [2]. Though great strategies integrated in the management guidelines. Identi- efforts have been implemented at different levels to limit fying factors associated with HIV-related stigma might help the spread of HIV/AIDS, the incidence of HIV in the redesign or reinforce these interventions. Therefore, we developing world and more precisely Sub-Saharan Africa sought to measure HIV-related stigma, and identify factors (SSA) is still relatively high [3]. associated with high HIV-related stigma among PLHIVA By the end of 2015, an estimated 36.7 million people on antiretroviral therapy (ART) at the HIV-day care unit of were living with HIV/AIDS worldwide, with over the Bamenda Regional Hospital. two-thirds residing in sub-Saharan Africa, which in- cludes Cameroon [4]. Despite the recently reported drop Methods in the prevalence of HIV in Cameroon from 5.5 to 4.3% A hospital-based cross sectional analytic survey was con- over the last decade [5], it still remains amongst the ducted from February to April 2016. All eligible and highest in West and Central Africa [6]. consenting persons living with HIV/AIDS (PLHIVA) on Tackling AIDS-related stigma and discrimination is cru- ART at the HIV-day care unit of the Bamenda Regional cial in the effective prevention of HIV/AIDS, the care of hospital were targeted and recruited. The HIV-day care PLHIVA (People Living with HIV and AIDS) and goes a unit of the Bamenda Regional Hospital is a reference long way to significantly help in containing and managing HIV treatment unit in the North-west Region of this pandemic [1, 7–10]. HIV-related discrimination is not Cameroon, and receives patients from both the rural only a human right violation according to the United and urban areas of the Region. We excluded PLHIVA Nations General Assembly Special Session on HIV/AIDS, who were mentally incapacitated, below 15 years of age but problems of HIV-related stigmatization and discrimin- and patients who arrived critically ill and unable to ation need to be properly addressed to successfully meet respond to the questionnaire. ART-naïve patients were public health goals [11, 12]. not included because according to the Test and Treat The prevalence of HIV-related stigma varies with the recommendation, any patient not yet on treatment setting and method of evaluation. Even though it has no should just have been awaiting confirmation of his or standardized method of evaluation, HIV-related stigma is her status. All eligible and consenting participants who reported to be highly prevalent among PLHIVA [11–15]. visited the treatment unit during the study period were At every level of the HIV/AIDS management ladder (the consecutively included in the survey (n = 308 PLHIVA). prevention, care and treatment), stigma and discrimin- With the aim of limiting surveyor induced stigmatization ation has seriously impeded its success [12]. Unlike other and discrimination, the principal investigator undertook a chronic conditions such as diabetes, hypertension and two-months internship at the HIV-day care unit of the chronic liver disease, HIV testing and status disclosure are Bamenda Regional Hospital, and recruited colleagues as in- seriously limited by stigma and discrimination [13–19]. terviewers. Training sessions were organized during which Negative predictors of HIV-related stigma include, but are interviewers were trained on the consent process and data not limited to: a good knowledge on HIV/AIDS, past collection procedures. When the protocol, the question- participation in HIV anti-stigma campaigns, low level of naire and informed consent form were completed, the data education, and religion [19]. HIV-related stigma and collection tools were pretested on a sample 15 PLHIVA in discrimination is a major barrier limiting participation in a treatment centre in Yaoundé (Centre region of prevention of mother to child transmission programs, Cameroon) and validated after analysis by a team of HIV treatment, and adherence to ART [19]. HIV-related experts. Berger HIV Stigma Scale validated by Feyissa et al. stigma is therefore a serious barrier towards the successful in a resource-limited setting (Ethiopia) [21] and Jeyaseelan attainment of the ambitious triple 90 goal (90% diagnosed, et al. in India [22], contains four subscales (domains): 90% on treatment and 90% with suppressed viral load) of Enacted Stigma, Disclosure Concerns (a form of anticipated the Joint United Nations programme on HIV/AIDS stigma), Negative Self-Image (e.g. internalized stigma), and (UNAIDS) by the year 2020 [20]. Concern with Public Attitudes towards HIV (e.g., antici- In Cameroon, despite diverse efforts put in place by pated stigma) [21]. the Cameroon health system to combat HIV-related This culturally validated, HIV-Stigma scale has been stigma and discrimination, HIV-related stigma and dis- used with good results particularly in clinical settings to crimination remains a significant obstacle to the fight identify patients in need of psycho-emotional support against HIV/AIDS and the adherence to HIV/AIDS and assess post-intervention changes in stigma in many Ajong et al. Globalization and Health (2018) 14:56 Page 3 of 7 settings [23, 24]. It should be noted that onto the ele- estimated monthly revenue of less than 50000FCFA ments of the Berger scale was added sociodemographic (80.75 United States dollars). data and some information that allowed the identifica- Table 1 presents the ranges and means of the different tion of factors associated with HIV-related stigma. The domains of stigma experienced by the participants. The questionnaire was paper-based and is attached as overall mean HIV-related stigma score was 88.3 ± 18.80 (Additional file 1). Interviewers were of both sexes and (with a possible range of 40–160) which corresponds to were allowed to interview willing participants irrespective a moderate level of stigma according to the Berger of gender. During data collection, the interviewer identi- stigma scale. The mean HIV-related stigma score was fied eligible participants, and after thorough explanation 87.65 ± 18.62 and 88.64 ± 18.89 in men and women of the information notice form of the study, obtained in- respectively (p-value = 0.6608). formed consent from the participant or legal guardian. Table 2 shows the frequency distribution of respon- The data were collected face to face by interviewers in pri- dents according to HIV-stigma score level. Overall, 37.3, vate rooms within the facility (one participant at a time) 58.4% (180/308) and 4.2% experienced mild, moderate who asked questions and took down the responses of each and severe HIV-related stigma respectively. Following a participant. Participants received no remunerations for subgroup analysis, irrespective of gender, it was noted taking part in the survey. that most patients suffered from moderate forms of per- sonalized (49.8%), disclosure (66.4%), negative self-image (50.0%) and public attitude (52.1%) stigmatization. The Data analysis proportion with high level of stigmatization among the Data from validated questionnaires were entered into a population was 62.7% (95% CI = 57.8–68.9%). predesigned data entry sheet. After cleaning, the data Table 3 presents the factors associated with high were analyzed using the statistical software Epi-Info HIV-related stigma following bivariable and multivari- version 3.5.4. Categorical variables are reported as pro- able logistic regression analysis. When controlled for portions with their corresponding 95% confidence inter- gender, religion, age, and occupation; level of education vals (CI), while means were calculated for continuous below tertiary (Adjusted Odd Ratio [AOR] = 0.70 [95% variables. HIV-related stigma level was categorized into CI 0.44–0.91]; p = 0.036) and duration from diagnosis “high” and “low”. Participants with “high” HIV-related below 5 years (AOR = 1.74[1.01–3.00]; p = 0.046) were stigma were those for which the Berger stigma scale independently associated with high HIV-related stigma. classified them into at least a moderate level of stigma There was no statistically significant association between (that is, participants with a mean score value greater high HIV-related stigma and place of residence (rural/ than or equal to 80). The strength of association urban), monthly revenue and marital status. between the selected covariates (level of education, esti- mated monthly income, marital status, number of years Discussion from detection of HIV status, place of residence) and the The mean overall HIV/AIDS related stigma score was stigma level (high or low) was determined by calculating 88.3 ± 18.80 which corresponds to moderate level of the Odds Ratio (OR) and their 95% CI. A multivariable stigma according the Berger stigma scale. In addition, logistic regression analysis was used to identify factors most participants suffered from moderate forms of the associated with high HIV-related stigma (with gender, different subtypes of stigma including: personalized religion, age, and occupation considered as potential (49.8%), disclosure (66.4%), negative self-image (50.0%) confounders; solely based on literature). The threshold of and public attitude (52.1%) stigmatization. Over 60% of statistical significance was set at a p-value less than 0.05. the participants lived with high levels of HIV-related stigma. A level of education below tertiary and duration Results from diagnosis below 5 years were significantly associ- A total of 331 PLHIVA were contacted for the study and ated with high HIV-related stigma. 23 refused to participate giving a final sample size of 308 The sex ratio reported in this study is similar to that PLHIVA and a non-response rate of 6.9%. The mean age reported among PLHIVA in Africa with a female pre- of the 308 participants was 40.1±10.2 years with a mean ponderance [6, 25]. In addition, national demographic age of 43.9 ± 8.4 years and 38.1 ± 10.6 years among men and health survey report in 2011 shows that in and women respectively (p < 0.001). The population was Cameroon, the ratio is about two women infected with dominated by women (65.3%). About 2/5th (40.9%) of HIV for every one man [5]. This is in correlation with the participants were married, 35.1% single and 54.9% data on the prevalence of HIV/AIDS in Cameroon and had acquired at least secondary education. Christians more precisely in the North West Region of Cameroon were most represented (95.8%) with the rest Muslims. where surveys have shown that more women are in- More than 2/3th (69.9%) of the participants reported fected with HIV/AIDS than men [5]. The higher Ajong et al. Globalization and Health (2018) 14:56 Page 4 of 7 Table 1 Ranges and means of the different domains of stigma experienced by the participants Stigma domain Minimum score Maximum score Mean score ± SD Mean score ± SD p-value Mean± SD (lowest to highest score) recorded recorded in males in females (male and female) Personalized (18–72) 18 65 40.06 ± 10.51 39.93 ± 9.75 0.9195 39.98±10.00 Disclosure (10–40) 12 34 22.87 ± 4.65 23.67 ± 4.80 0.1596 23.39±4.76 Negative self- image (13–52) 14 48 26.96 ± 6.15 27.58 ± 6.85 0.4235 27.38±6.61 Public attitude (20–80) 20 73 45.09 ± 11.44 44.99 ± 11.05 0.9382 45.03±11.17 HIV stigma overall (40–160) 44 138 87.65 ± 18.62 88.64 ± 18.89 0.6608 88.3±18.80 Standard Deviation prevalence in women simply brings to light vulnerability Bamenda Regional Hospital. A study carried out in of women to the HIV/AIDS infection, mainly due to Ethiopia reported similarly high levels of perceived biological factors, which are usually favoured by HIV-related stigma mean score values [29]. socio-behavioural practices and socioeconomic differ- Following a subgroup analysis, irrespective of gender, it ences [26]. The overall mean HIV-related stigma score was noted that most patients suffered from moderate forms was 88.3 ± 18.80 (with a possible range of 40–160) which of personalized (49.8%), disclosure (66.4%), negative corresponds to a moderate level of stigma according the self-image (50.0%) and public attitude (52.1%) stigmatization. Berger stigma scale. Even though women seem more The proportion with “high” level of stigmatization among likely to be infected by the virus (sex ratio of about 2:1), the population was 62.7% (95% CI = 57.8–68.9%).Thisisin- the mean HIV-related stigma score was 87.65 ± 18.62 dicative of the high rate of HIV-related stigma perceived by and 88.64 ± 18.89 in men and women respectively (with these participants. Multiple studies in the African context no statistically significant difference. p-value = 0.6608). have reported similarly high rates of HIV-related stigma This means that on average, most clients in the among HIV positive patients [29–31]. These high rates of HIV-treatment unit experienced moderate HIV-related stigma could be associated with multiple pitfalls in the effect- stigma and that both genders were similarly affected. ive management of HIV/AIDS in Africa. According to inves- This is true as each of the estimated means of the stigma tigators of the 2011 national DHS in Cameroon, 46 and 58% sub-types was found to fall at least into the moderate of women and men respectively had never been screened for stigma category. HIV-related stigma has been reported HIV [5]. High rates of HIV-related stigma have been high and highlighted as a barrier to HIV/AIDS manage- associated with decreasing level of HIV voluntary ment by a series of African surveys [5, 25, 27, 28]. This testing [14, 32–34], status disclosure [25, 32], adherence to study indicates that HIV-related stigma is still very com- ART [32, 35], educative programs on HIV transmission mon among PLHIVA taking treatment from the and increased probabilities of maintaining the transmission Table 2 Frequency distribution of respondents on the HIV stigma score level Stigma type Score level Score value Frequency (percentage) in males Frequency (percentage) In females Frequency (percentage) Personalized Mild 18–36 45(42.5%) 82(41.2%) 127(41.6%) Moderate 37–54 49(46.2%) 103(51.8%) 152(49.8%) Severe 55–72 12(11.3%) 14(7.0%) 26(8.5%) Disclosure Mild 10–20 29(27.4%) 53(26.4%) 82(26.7%) Moderate 21–30 75(70.8%) 129(64.2%) 204(66.4%) Severe 31–40 2(1.9%) 19 (9.5%) 21(6.8%) Negative self- image Mild 13–26 51(47.7%) 90(44.8%) 141(45.8%) Moderate 27–39 54(50.5%) 100(49.8%) 154(50.0%) Severe 39–40 2(1.9%) 11(5.5%) 13(4.2%) Public attitude Mild 20–40 42(39.6%) 74(37.2%) 116(38.0%) Moderate 41–60 53(50.0%) 106(53.3%) 159(52.1%) Severe 61–80 11(10.4%) 19(9.5%) 30(9.8%) HIV stigma overall Mild 40–80 38(36.2%) 77(36.7%) 115 (37.3%) Moderate 81–120 63(60.0%) 117(58.8%) 180(58.4%) Severe 121–160 4(3.8%) 9(4.5%) 13(4.2%) Ajong et al. Globalization and Health (2018) 14:56 Page 5 of 7 Table 3 Factors associated with high HIV/AIDS related stigma Factors Univariable analysis Multivariable analysis OR 95% CI p-value AOR 95%ACI p-value Level of education above secondary (Y/ N) 0.69* 0.43–0.89 0.032 0.70 0.44–0.91 0.036* Number of year since diagnosis of HIV(+) Less than 5 years(Y/N) 1.74* 1.02–2.98 0.042 1.74 1.01–3.00 0.046* Urban residence(Y/N) 1.41 0.82–2.42 0.210 1.35 0.78–2.35 0.287 Monthly revenue less than 50.000FCFA(Y/N) 0.97 0.60–1.62 0.956 0.84 0.47–1.51 0.567 In union (Y/N) 0.84 0.53–1.35 0.479 0.84 0.51–7.53 0.489 Where Y/N=Yes/No, OR odds ratio CI confidence interval, AOR adjusted odds ratio, ACI adjusted confidence interval, *statistically significant (p ≤ 0.05) multivariable analysis was done with with gender, religion, age, and occupation considered possible confounders chain [32]. If patients received at the treatment centres are associated with high HIV-related stigma. The findings in this stigmatized, it gives us an idea of the level of stigma- this study suggest that PLHIVA with at least a tertiary tisation and the effect the effect that this can have among education are less likely to be victims of high patients lost to follow-up and others in the community. HIV-related stigma compared to their counterparts with Indeed, up to 66.4% of the participants had moderate lower level of education. A high level of education is problems with disclosure. This form of HIV-related associated with a better understanding of HIV/AIDS [5] stigma could be associated with very low rates of HIV and consequently, reduced disease-related stigma sero-status disclosure and consequently maintenance of [14, 16, 36, 37]. A facility-based cross-sectional the transmission chain [7]. This high level of Ethiopian study in 2015 reported a high level of edu- HIV-related stigma can seriously impede on the attain- cation to be significantly associated with reduced ment of the ambitious triple 90 HIV management goals HIV-related stigma among PLHIVA [29]. It is clear by the UNAIDS, set for 2020 [20]. that a high level of education and awareness among In Cameroon, anti-HIV-stigma interventions have the population on HIV/AIDS could limit the amount been adopted at the national, local (Health units and the of stigma and discrimination associated with the community) and individual level. Interventions at the AIDS pandemic [28]. Research findings suggest that national level include, but are not limited to: legislative improvingliteracy rates and a focus on correcting in- protection of the rights of PLHIVA, facilitation of access correct conceptions on HIV/AIDS might go a long to family planning services, emergency obstetric care way in fighting HIV-related stigma [14, 31]. and ART, and organisation of trainings to reduce stigma Clients who had been diagnosed within the last 5 years and discrimination in schools and among health care were more likely to be victims of high levels of stigma providers. Interventions at the community level include compared to those who had lived with their diagnosis among others: improving the knowledge of community for more than 5 years. Some level of “normalization” of dwellers on the transmission of HIV/AIDS, correcting the HIV status and stigma reduction has been reported perceptions through educative talks, and encouraging in surveys by provision of ART to PLHIVA [32, 38]. This leaders to create a climate of tolerance with no preju- finding is coherent with that of Fido et al., where a de- dice. The health care provider can reduce HIV-related creasing trend of HIV-related stigma was associated with stigma by avoiding stigmatizing statements, adoption of increasing number of years on ART [29]. Similarly, Tze- attitudes void of judgement, preserving and respecting mis et al. reported a decreasing trend of HIV-related patient-provider confidentiality, and adopting universal stigma with the years of living with HIV/AIDS and years standard precautions for all patients regardless of their on antiretroviral therapy [37]. Intensified psychological HIV-status. counselling and emotional support in the early days The fight against this pandemic in Africa and more following HIV diagnosis can help PLHIVA to gradually precisely in Cameroon requires much more focus in accept and live with their status. redesigning educative programs for both HIV positive Our study found no significant associations between and negative individuals in order to break this under- place of residence (urban/rural), estimated monthly rev- ground barrier. HIV-related stigma maintains the epi- enue, and marital status and high level of HIV-related demic underground and remains one of the major stigma. Contrasting findings were reported by Tzemis explanations why people do not wish to know their HIV et al. concerning these variables [39]. This could be status [7, 36]. explained by a relatively lower number of patients per After controlling for gender, religion, age and occupa- variable modality in the current study (compared to the tion, a level of education below tertiary and a duration study of Tzemis et al.), with consequential lower statis- from diagnosis below 5 years were significantly tical power. In addition, the sociocultural and financial Ajong et al. Globalization and Health (2018) 14:56 Page 6 of 7 status of the participants in the current study and that Acknowledgements Our sincere gratitude goes to: of Tzemis et al. are different. The findings herein should however be interpreted with The entire Ngholapeh’s family for their moral and financial support, care. The cross-sectional design of this study only allows The Director of the Bamenda Regional Hospital, the staff of the HIV treatment center for their support during our survey, development of hypotheses and cannot establish any All HIV positive patients of this treatment center who accepted to cause-effect relationships. In addition, no randomization or participate in this survey. power calculation was conducted. Also, recruitment of par- Funding ticipants was essentially convenient as data collection was The researchers received no funding from any research body. Everything dependent on the study duration. Even though our inter- required was provided by the research team. viewers were well trained, the responses of some partici- Availability of data and materials pants could be made socially desirable rather than The datasets used and/or analysed during the current study are available expressing their actual feelings, thereby underestimating from the corresponding author on reasonable request. the true burden of stigmatization in PLHIVA. Although the Authors’ contributions Berger HIV stigma scale has a few limitations, it has been ABA and PNN and NEN conceived the study and guided field data reported as an effective measure of stigma levels especially collection; ABA and MNY analyzed data; ABA drafted the manuscript; MJE, for future comparisons. In addition, the findings from a VNA, and KB contributed in supervising data collection and revising the manuscript; all authors read and approved the final manuscript. single treatment unit in Cameroon cannot fully paint the picture of the reality in Cameroon and sub-Saharan Africa. Authors’ information Also, our study enrolled only patients on ART and system- ABA: Doctor in Medicine, Kekem District Hospital, West Region, Cameroon. PNN: Associate professor of Obstetrics and Gynecology, Head of service of atically excluded those who are not taking treatment. This the Principal Maternity of the Yaoundé Central Hospital, Cameroon. Senior can possibly lead to an underestimation of the level of HIV/ lecturer of Obstetrics/Gynecology, department of Obstetrics/Gynecology, AIDS-related stigma in the whole population since we Faculty of Medicine and Biomedical Sciences of the University of Yaoundé I, Cameroon. think that patients who are loss to follow-up would be pos- NEN: Doctor in Medicine, Bamenda Regional Hospital, North-west Region, sibly more stigmatized than the study participants. How- Cameroon. ever our findings were consistent with results of studies MJE: Senior Lecturer of Medical Anthropology and Public Health in the Faculty of Medicine and Biomedical Sciences of the University of Yaoundé I, carried out in Africa and SSA and can be used as a baseline Cameroon, In charge of the Library of the University of Yaoundé I. for future estimates and comparison. MNY: Masters of Epidemiology and Public Health working as the M&E officer at M.A.SANTE (Meilleur Accès aux Soins de Santé), Yaoundé-Cameroon. VNA: Doctor in Medicine, Ibal sub-divisional Hospital, Oku, North-west Region, Cameroon. Conclusion KB: Lecturer of Obstetrics and Gynecology, Department of Biomedical About 3 out of every 5 PLHIV receiving ART in the Sciences, Faculty of Science, University of Dschang, Cameroon. Obstetrician/ HIV-daycareunitof the BamendaRegionalHospitalstill Gynecologist in the Dschang District Hospital, Cameroon. experience high levels of HIV-related stigma. This occurs Ethics approval and consent to participate more frequently in participants with low educational status, Ethical clearance for this study was obtained from the ethical review board and who may have known their HIV status for less than of the Faculty of Medicine and Biomedical Sciences of the University of Yaoundé I, and administrative authorization obtained from the Director of 5 years. The overall mean HIV-related stigma score among the Bamenda Regional Hospital. Only consenting participants were included these patients remains high. Anti-HIV-stigma programs in in the study and for participants who were aged less than 18 years, consent the North West Region need strengthening with intensified was obtained from their legal representatives. The interviewers were well trained on the consenting and data collection procedure and participants who psychosocial follow-up of newly diagnosed cases. Improving were mentally incapacitated and critically ill were not included in the survey. literacy rates may also help in reducing HIV-related stigma. Large scale studies that quantitatively measure HIV-related Competing interests The authors declare that they have no competing interest. stigma in more treatment centers are required; so as to es- tablish a clearer picture of HIV-related stigma in Cameroon. Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Additional file Author details Additional file 1: Questionnaire for the evaluation of HIV-related stigma 1 2 Kekem District Hospital, Kekem town, West Region, Cameroon. Department among PLHIVA and associated factors. (DOCX 32 kb) of Obstetrics and Gynaecology, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon. Obstetrics and Gynaecology unit, Higher Institute of Health Technologies, Yaoundé Central Hospital, Abbreviations Yaoundé, Cameroon. Bamenda Regional Hospital, Bamenda, North West AIDS: Acquired immune deficiency syndrome; AOR: Adjusted odds ratio; region, Cameroon. Department of Public Health, Faculty of Medicine and ART: Antiretroviral therapy; CI: Confidence interval; DHS: Demographic and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon. Meilleur health survey; HIV: The human immunodeficiency virus; PLHIVA: People living Accès aux Soins de Santé, Yaoundé, Cameroon. 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Quantification and factors associated with HIV-related stigma among persons living with HIV/AIDS on antiretroviral therapy at the HIV-day care unit of the Bamenda Regional Hospital, North West Region of Cameroon

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Medicine & Public Health; Public Health; Development Economics; Social Policy; Quality of Life Research; Epidemiology
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Abstract

Background: The Human Immunodeficiency Virus /Acquired Immune Deficiency Syndrome (HIV/AIDS) is not just a medical problem but its social impact is increasingly affecting its effective management. The fear of HIV-stigma constitutes a major barrier to HIV testing, prevention, uptake and adherence to antiretroviral therapy (ART). We aimed to quantify HIV-related stigma, and identify the factors associated with high HIV-related stigma among persons living with HIV and AIDS (PLHIVA) and on ART. Methods: A hospital-based cross sectional analytic survey targeting PLHIVA on ART at the HIV-day care unit of the Bamenda Regional Hospital of Cameroon was conducted from February to April 2016. A total of 308 eligible and willing participants were consecutively included in the survey. Data were collected using a pretested questionnaire designed from the Berger HIV stigma scale and analyzed using Epi info 3.5.4. Results: The mean age of the 308 participants was 40.1±10.2 years. The mean overall HIV/AIDS related stigma score was 88.3 ± 18.80 which corresponds to a moderate level of stigma according to the Berger stigma scale. Further analysis revealed that most participants suffered from moderate forms of the different subtypes of stigma including: personalized (49.8%), disclosure (66.4%), negative self-image (50.0%) and public attitude (52.1%) stigmatization. It was estimated that 62.7% (95% confidence interval [CI] = 57.8–68.9%) of the participants lived with high levels of HIV-related stigma. After controlling for gender, religion, age and occupation, level of education below tertiary (Adjusted Odds Ratio [AOR] = 0.70 [95% CI = 0.44–0.91]; p = 0.036) and a duration from diagnosis below 5 years (AOR = 1.74 [95% CI = 1.01–3.00]; p = 0.046) were significantly associated with high HIV-related stigma. Conclusion: About three out of every five PLHIVA receiving ART in Bamenda Regional Hospital still experience high levels of HIV-related stigma. This occurs more frequently in participants with low educational status, and who may have known their HIV status for less than 5 years. Anti-HIV-stigma programs in the North West Region need strengthening with intensified psychosocial follow-up of newly diagnosed cases. Keywords: Human immunodeficiency virus, Acquired immunodeficiency syndrome, Antiretroviral therapy, Stigma, Cameroon * Correspondence: christrah@yahoo.fr Kekem District Hospital, Kekem town, West Region, Cameroon Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Ajong et al. Globalization and Health (2018) 14:56 Page 2 of 7 Background related counseling [5]. To the best of our knowledge, no The Human Immunodeficiency Virus /Acquired Im- study has been done to quantify HIV-related stigma and mune Deficiency Syndrome (HIV/AIDS) remains one of identify its associated factors in Cameroon. A quantification the most stigmatizing pandemics worldwide [1]. The of HIV-related stigma will not only serve as a baseline for fight against HIV/AIDS remains one of the major points future comparison, but will help to evaluate the anti-stigma in the sustainable development agenda [2]. Though great strategies integrated in the management guidelines. Identi- efforts have been implemented at different levels to limit fying factors associated with HIV-related stigma might help the spread of HIV/AIDS, the incidence of HIV in the redesign or reinforce these interventions. Therefore, we developing world and more precisely Sub-Saharan Africa sought to measure HIV-related stigma, and identify factors (SSA) is still relatively high [3]. associated with high HIV-related stigma among PLHIVA By the end of 2015, an estimated 36.7 million people on antiretroviral therapy (ART) at the HIV-day care unit of were living with HIV/AIDS worldwide, with over the Bamenda Regional Hospital. two-thirds residing in sub-Saharan Africa, which in- cludes Cameroon [4]. Despite the recently reported drop Methods in the prevalence of HIV in Cameroon from 5.5 to 4.3% A hospital-based cross sectional analytic survey was con- over the last decade [5], it still remains amongst the ducted from February to April 2016. All eligible and highest in West and Central Africa [6]. consenting persons living with HIV/AIDS (PLHIVA) on Tackling AIDS-related stigma and discrimination is cru- ART at the HIV-day care unit of the Bamenda Regional cial in the effective prevention of HIV/AIDS, the care of hospital were targeted and recruited. The HIV-day care PLHIVA (People Living with HIV and AIDS) and goes a unit of the Bamenda Regional Hospital is a reference long way to significantly help in containing and managing HIV treatment unit in the North-west Region of this pandemic [1, 7–10]. HIV-related discrimination is not Cameroon, and receives patients from both the rural only a human right violation according to the United and urban areas of the Region. We excluded PLHIVA Nations General Assembly Special Session on HIV/AIDS, who were mentally incapacitated, below 15 years of age but problems of HIV-related stigmatization and discrimin- and patients who arrived critically ill and unable to ation need to be properly addressed to successfully meet respond to the questionnaire. ART-naïve patients were public health goals [11, 12]. not included because according to the Test and Treat The prevalence of HIV-related stigma varies with the recommendation, any patient not yet on treatment setting and method of evaluation. Even though it has no should just have been awaiting confirmation of his or standardized method of evaluation, HIV-related stigma is her status. All eligible and consenting participants who reported to be highly prevalent among PLHIVA [11–15]. visited the treatment unit during the study period were At every level of the HIV/AIDS management ladder (the consecutively included in the survey (n = 308 PLHIVA). prevention, care and treatment), stigma and discrimin- With the aim of limiting surveyor induced stigmatization ation has seriously impeded its success [12]. Unlike other and discrimination, the principal investigator undertook a chronic conditions such as diabetes, hypertension and two-months internship at the HIV-day care unit of the chronic liver disease, HIV testing and status disclosure are Bamenda Regional Hospital, and recruited colleagues as in- seriously limited by stigma and discrimination [13–19]. terviewers. Training sessions were organized during which Negative predictors of HIV-related stigma include, but are interviewers were trained on the consent process and data not limited to: a good knowledge on HIV/AIDS, past collection procedures. When the protocol, the question- participation in HIV anti-stigma campaigns, low level of naire and informed consent form were completed, the data education, and religion [19]. HIV-related stigma and collection tools were pretested on a sample 15 PLHIVA in discrimination is a major barrier limiting participation in a treatment centre in Yaoundé (Centre region of prevention of mother to child transmission programs, Cameroon) and validated after analysis by a team of HIV treatment, and adherence to ART [19]. HIV-related experts. Berger HIV Stigma Scale validated by Feyissa et al. stigma is therefore a serious barrier towards the successful in a resource-limited setting (Ethiopia) [21] and Jeyaseelan attainment of the ambitious triple 90 goal (90% diagnosed, et al. in India [22], contains four subscales (domains): 90% on treatment and 90% with suppressed viral load) of Enacted Stigma, Disclosure Concerns (a form of anticipated the Joint United Nations programme on HIV/AIDS stigma), Negative Self-Image (e.g. internalized stigma), and (UNAIDS) by the year 2020 [20]. Concern with Public Attitudes towards HIV (e.g., antici- In Cameroon, despite diverse efforts put in place by pated stigma) [21]. the Cameroon health system to combat HIV-related This culturally validated, HIV-Stigma scale has been stigma and discrimination, HIV-related stigma and dis- used with good results particularly in clinical settings to crimination remains a significant obstacle to the fight identify patients in need of psycho-emotional support against HIV/AIDS and the adherence to HIV/AIDS and assess post-intervention changes in stigma in many Ajong et al. Globalization and Health (2018) 14:56 Page 3 of 7 settings [23, 24]. It should be noted that onto the ele- estimated monthly revenue of less than 50000FCFA ments of the Berger scale was added sociodemographic (80.75 United States dollars). data and some information that allowed the identifica- Table 1 presents the ranges and means of the different tion of factors associated with HIV-related stigma. The domains of stigma experienced by the participants. The questionnaire was paper-based and is attached as overall mean HIV-related stigma score was 88.3 ± 18.80 (Additional file 1). Interviewers were of both sexes and (with a possible range of 40–160) which corresponds to were allowed to interview willing participants irrespective a moderate level of stigma according to the Berger of gender. During data collection, the interviewer identi- stigma scale. The mean HIV-related stigma score was fied eligible participants, and after thorough explanation 87.65 ± 18.62 and 88.64 ± 18.89 in men and women of the information notice form of the study, obtained in- respectively (p-value = 0.6608). formed consent from the participant or legal guardian. Table 2 shows the frequency distribution of respon- The data were collected face to face by interviewers in pri- dents according to HIV-stigma score level. Overall, 37.3, vate rooms within the facility (one participant at a time) 58.4% (180/308) and 4.2% experienced mild, moderate who asked questions and took down the responses of each and severe HIV-related stigma respectively. Following a participant. Participants received no remunerations for subgroup analysis, irrespective of gender, it was noted taking part in the survey. that most patients suffered from moderate forms of per- sonalized (49.8%), disclosure (66.4%), negative self-image (50.0%) and public attitude (52.1%) stigmatization. The Data analysis proportion with high level of stigmatization among the Data from validated questionnaires were entered into a population was 62.7% (95% CI = 57.8–68.9%). predesigned data entry sheet. After cleaning, the data Table 3 presents the factors associated with high were analyzed using the statistical software Epi-Info HIV-related stigma following bivariable and multivari- version 3.5.4. Categorical variables are reported as pro- able logistic regression analysis. When controlled for portions with their corresponding 95% confidence inter- gender, religion, age, and occupation; level of education vals (CI), while means were calculated for continuous below tertiary (Adjusted Odd Ratio [AOR] = 0.70 [95% variables. HIV-related stigma level was categorized into CI 0.44–0.91]; p = 0.036) and duration from diagnosis “high” and “low”. Participants with “high” HIV-related below 5 years (AOR = 1.74[1.01–3.00]; p = 0.046) were stigma were those for which the Berger stigma scale independently associated with high HIV-related stigma. classified them into at least a moderate level of stigma There was no statistically significant association between (that is, participants with a mean score value greater high HIV-related stigma and place of residence (rural/ than or equal to 80). The strength of association urban), monthly revenue and marital status. between the selected covariates (level of education, esti- mated monthly income, marital status, number of years Discussion from detection of HIV status, place of residence) and the The mean overall HIV/AIDS related stigma score was stigma level (high or low) was determined by calculating 88.3 ± 18.80 which corresponds to moderate level of the Odds Ratio (OR) and their 95% CI. A multivariable stigma according the Berger stigma scale. In addition, logistic regression analysis was used to identify factors most participants suffered from moderate forms of the associated with high HIV-related stigma (with gender, different subtypes of stigma including: personalized religion, age, and occupation considered as potential (49.8%), disclosure (66.4%), negative self-image (50.0%) confounders; solely based on literature). The threshold of and public attitude (52.1%) stigmatization. Over 60% of statistical significance was set at a p-value less than 0.05. the participants lived with high levels of HIV-related stigma. A level of education below tertiary and duration Results from diagnosis below 5 years were significantly associ- A total of 331 PLHIVA were contacted for the study and ated with high HIV-related stigma. 23 refused to participate giving a final sample size of 308 The sex ratio reported in this study is similar to that PLHIVA and a non-response rate of 6.9%. The mean age reported among PLHIVA in Africa with a female pre- of the 308 participants was 40.1±10.2 years with a mean ponderance [6, 25]. In addition, national demographic age of 43.9 ± 8.4 years and 38.1 ± 10.6 years among men and health survey report in 2011 shows that in and women respectively (p < 0.001). The population was Cameroon, the ratio is about two women infected with dominated by women (65.3%). About 2/5th (40.9%) of HIV for every one man [5]. This is in correlation with the participants were married, 35.1% single and 54.9% data on the prevalence of HIV/AIDS in Cameroon and had acquired at least secondary education. Christians more precisely in the North West Region of Cameroon were most represented (95.8%) with the rest Muslims. where surveys have shown that more women are in- More than 2/3th (69.9%) of the participants reported fected with HIV/AIDS than men [5]. The higher Ajong et al. Globalization and Health (2018) 14:56 Page 4 of 7 Table 1 Ranges and means of the different domains of stigma experienced by the participants Stigma domain Minimum score Maximum score Mean score ± SD Mean score ± SD p-value Mean± SD (lowest to highest score) recorded recorded in males in females (male and female) Personalized (18–72) 18 65 40.06 ± 10.51 39.93 ± 9.75 0.9195 39.98±10.00 Disclosure (10–40) 12 34 22.87 ± 4.65 23.67 ± 4.80 0.1596 23.39±4.76 Negative self- image (13–52) 14 48 26.96 ± 6.15 27.58 ± 6.85 0.4235 27.38±6.61 Public attitude (20–80) 20 73 45.09 ± 11.44 44.99 ± 11.05 0.9382 45.03±11.17 HIV stigma overall (40–160) 44 138 87.65 ± 18.62 88.64 ± 18.89 0.6608 88.3±18.80 Standard Deviation prevalence in women simply brings to light vulnerability Bamenda Regional Hospital. A study carried out in of women to the HIV/AIDS infection, mainly due to Ethiopia reported similarly high levels of perceived biological factors, which are usually favoured by HIV-related stigma mean score values [29]. socio-behavioural practices and socioeconomic differ- Following a subgroup analysis, irrespective of gender, it ences [26]. The overall mean HIV-related stigma score was noted that most patients suffered from moderate forms was 88.3 ± 18.80 (with a possible range of 40–160) which of personalized (49.8%), disclosure (66.4%), negative corresponds to a moderate level of stigma according the self-image (50.0%) and public attitude (52.1%) stigmatization. Berger stigma scale. Even though women seem more The proportion with “high” level of stigmatization among likely to be infected by the virus (sex ratio of about 2:1), the population was 62.7% (95% CI = 57.8–68.9%).Thisisin- the mean HIV-related stigma score was 87.65 ± 18.62 dicative of the high rate of HIV-related stigma perceived by and 88.64 ± 18.89 in men and women respectively (with these participants. Multiple studies in the African context no statistically significant difference. p-value = 0.6608). have reported similarly high rates of HIV-related stigma This means that on average, most clients in the among HIV positive patients [29–31]. These high rates of HIV-treatment unit experienced moderate HIV-related stigma could be associated with multiple pitfalls in the effect- stigma and that both genders were similarly affected. ive management of HIV/AIDS in Africa. According to inves- This is true as each of the estimated means of the stigma tigators of the 2011 national DHS in Cameroon, 46 and 58% sub-types was found to fall at least into the moderate of women and men respectively had never been screened for stigma category. HIV-related stigma has been reported HIV [5]. High rates of HIV-related stigma have been high and highlighted as a barrier to HIV/AIDS manage- associated with decreasing level of HIV voluntary ment by a series of African surveys [5, 25, 27, 28]. This testing [14, 32–34], status disclosure [25, 32], adherence to study indicates that HIV-related stigma is still very com- ART [32, 35], educative programs on HIV transmission mon among PLHIVA taking treatment from the and increased probabilities of maintaining the transmission Table 2 Frequency distribution of respondents on the HIV stigma score level Stigma type Score level Score value Frequency (percentage) in males Frequency (percentage) In females Frequency (percentage) Personalized Mild 18–36 45(42.5%) 82(41.2%) 127(41.6%) Moderate 37–54 49(46.2%) 103(51.8%) 152(49.8%) Severe 55–72 12(11.3%) 14(7.0%) 26(8.5%) Disclosure Mild 10–20 29(27.4%) 53(26.4%) 82(26.7%) Moderate 21–30 75(70.8%) 129(64.2%) 204(66.4%) Severe 31–40 2(1.9%) 19 (9.5%) 21(6.8%) Negative self- image Mild 13–26 51(47.7%) 90(44.8%) 141(45.8%) Moderate 27–39 54(50.5%) 100(49.8%) 154(50.0%) Severe 39–40 2(1.9%) 11(5.5%) 13(4.2%) Public attitude Mild 20–40 42(39.6%) 74(37.2%) 116(38.0%) Moderate 41–60 53(50.0%) 106(53.3%) 159(52.1%) Severe 61–80 11(10.4%) 19(9.5%) 30(9.8%) HIV stigma overall Mild 40–80 38(36.2%) 77(36.7%) 115 (37.3%) Moderate 81–120 63(60.0%) 117(58.8%) 180(58.4%) Severe 121–160 4(3.8%) 9(4.5%) 13(4.2%) Ajong et al. Globalization and Health (2018) 14:56 Page 5 of 7 Table 3 Factors associated with high HIV/AIDS related stigma Factors Univariable analysis Multivariable analysis OR 95% CI p-value AOR 95%ACI p-value Level of education above secondary (Y/ N) 0.69* 0.43–0.89 0.032 0.70 0.44–0.91 0.036* Number of year since diagnosis of HIV(+) Less than 5 years(Y/N) 1.74* 1.02–2.98 0.042 1.74 1.01–3.00 0.046* Urban residence(Y/N) 1.41 0.82–2.42 0.210 1.35 0.78–2.35 0.287 Monthly revenue less than 50.000FCFA(Y/N) 0.97 0.60–1.62 0.956 0.84 0.47–1.51 0.567 In union (Y/N) 0.84 0.53–1.35 0.479 0.84 0.51–7.53 0.489 Where Y/N=Yes/No, OR odds ratio CI confidence interval, AOR adjusted odds ratio, ACI adjusted confidence interval, *statistically significant (p ≤ 0.05) multivariable analysis was done with with gender, religion, age, and occupation considered possible confounders chain [32]. If patients received at the treatment centres are associated with high HIV-related stigma. The findings in this stigmatized, it gives us an idea of the level of stigma- this study suggest that PLHIVA with at least a tertiary tisation and the effect the effect that this can have among education are less likely to be victims of high patients lost to follow-up and others in the community. HIV-related stigma compared to their counterparts with Indeed, up to 66.4% of the participants had moderate lower level of education. A high level of education is problems with disclosure. This form of HIV-related associated with a better understanding of HIV/AIDS [5] stigma could be associated with very low rates of HIV and consequently, reduced disease-related stigma sero-status disclosure and consequently maintenance of [14, 16, 36, 37]. A facility-based cross-sectional the transmission chain [7]. This high level of Ethiopian study in 2015 reported a high level of edu- HIV-related stigma can seriously impede on the attain- cation to be significantly associated with reduced ment of the ambitious triple 90 HIV management goals HIV-related stigma among PLHIVA [29]. It is clear by the UNAIDS, set for 2020 [20]. that a high level of education and awareness among In Cameroon, anti-HIV-stigma interventions have the population on HIV/AIDS could limit the amount been adopted at the national, local (Health units and the of stigma and discrimination associated with the community) and individual level. Interventions at the AIDS pandemic [28]. Research findings suggest that national level include, but are not limited to: legislative improvingliteracy rates and a focus on correcting in- protection of the rights of PLHIVA, facilitation of access correct conceptions on HIV/AIDS might go a long to family planning services, emergency obstetric care way in fighting HIV-related stigma [14, 31]. and ART, and organisation of trainings to reduce stigma Clients who had been diagnosed within the last 5 years and discrimination in schools and among health care were more likely to be victims of high levels of stigma providers. Interventions at the community level include compared to those who had lived with their diagnosis among others: improving the knowledge of community for more than 5 years. Some level of “normalization” of dwellers on the transmission of HIV/AIDS, correcting the HIV status and stigma reduction has been reported perceptions through educative talks, and encouraging in surveys by provision of ART to PLHIVA [32, 38]. This leaders to create a climate of tolerance with no preju- finding is coherent with that of Fido et al., where a de- dice. The health care provider can reduce HIV-related creasing trend of HIV-related stigma was associated with stigma by avoiding stigmatizing statements, adoption of increasing number of years on ART [29]. Similarly, Tze- attitudes void of judgement, preserving and respecting mis et al. reported a decreasing trend of HIV-related patient-provider confidentiality, and adopting universal stigma with the years of living with HIV/AIDS and years standard precautions for all patients regardless of their on antiretroviral therapy [37]. Intensified psychological HIV-status. counselling and emotional support in the early days The fight against this pandemic in Africa and more following HIV diagnosis can help PLHIVA to gradually precisely in Cameroon requires much more focus in accept and live with their status. redesigning educative programs for both HIV positive Our study found no significant associations between and negative individuals in order to break this under- place of residence (urban/rural), estimated monthly rev- ground barrier. HIV-related stigma maintains the epi- enue, and marital status and high level of HIV-related demic underground and remains one of the major stigma. Contrasting findings were reported by Tzemis explanations why people do not wish to know their HIV et al. concerning these variables [39]. This could be status [7, 36]. explained by a relatively lower number of patients per After controlling for gender, religion, age and occupa- variable modality in the current study (compared to the tion, a level of education below tertiary and a duration study of Tzemis et al.), with consequential lower statis- from diagnosis below 5 years were significantly tical power. In addition, the sociocultural and financial Ajong et al. Globalization and Health (2018) 14:56 Page 6 of 7 status of the participants in the current study and that Acknowledgements Our sincere gratitude goes to: of Tzemis et al. are different. The findings herein should however be interpreted with The entire Ngholapeh’s family for their moral and financial support, care. The cross-sectional design of this study only allows The Director of the Bamenda Regional Hospital, the staff of the HIV treatment center for their support during our survey, development of hypotheses and cannot establish any All HIV positive patients of this treatment center who accepted to cause-effect relationships. In addition, no randomization or participate in this survey. power calculation was conducted. Also, recruitment of par- Funding ticipants was essentially convenient as data collection was The researchers received no funding from any research body. Everything dependent on the study duration. Even though our inter- required was provided by the research team. viewers were well trained, the responses of some partici- Availability of data and materials pants could be made socially desirable rather than The datasets used and/or analysed during the current study are available expressing their actual feelings, thereby underestimating from the corresponding author on reasonable request. the true burden of stigmatization in PLHIVA. Although the Authors’ contributions Berger HIV stigma scale has a few limitations, it has been ABA and PNN and NEN conceived the study and guided field data reported as an effective measure of stigma levels especially collection; ABA and MNY analyzed data; ABA drafted the manuscript; MJE, for future comparisons. In addition, the findings from a VNA, and KB contributed in supervising data collection and revising the manuscript; all authors read and approved the final manuscript. single treatment unit in Cameroon cannot fully paint the picture of the reality in Cameroon and sub-Saharan Africa. Authors’ information Also, our study enrolled only patients on ART and system- ABA: Doctor in Medicine, Kekem District Hospital, West Region, Cameroon. PNN: Associate professor of Obstetrics and Gynecology, Head of service of atically excluded those who are not taking treatment. This the Principal Maternity of the Yaoundé Central Hospital, Cameroon. Senior can possibly lead to an underestimation of the level of HIV/ lecturer of Obstetrics/Gynecology, department of Obstetrics/Gynecology, AIDS-related stigma in the whole population since we Faculty of Medicine and Biomedical Sciences of the University of Yaoundé I, Cameroon. think that patients who are loss to follow-up would be pos- NEN: Doctor in Medicine, Bamenda Regional Hospital, North-west Region, sibly more stigmatized than the study participants. How- Cameroon. ever our findings were consistent with results of studies MJE: Senior Lecturer of Medical Anthropology and Public Health in the Faculty of Medicine and Biomedical Sciences of the University of Yaoundé I, carried out in Africa and SSA and can be used as a baseline Cameroon, In charge of the Library of the University of Yaoundé I. for future estimates and comparison. MNY: Masters of Epidemiology and Public Health working as the M&E officer at M.A.SANTE (Meilleur Accès aux Soins de Santé), Yaoundé-Cameroon. VNA: Doctor in Medicine, Ibal sub-divisional Hospital, Oku, North-west Region, Cameroon. Conclusion KB: Lecturer of Obstetrics and Gynecology, Department of Biomedical About 3 out of every 5 PLHIV receiving ART in the Sciences, Faculty of Science, University of Dschang, Cameroon. Obstetrician/ HIV-daycareunitof the BamendaRegionalHospitalstill Gynecologist in the Dschang District Hospital, Cameroon. experience high levels of HIV-related stigma. This occurs Ethics approval and consent to participate more frequently in participants with low educational status, Ethical clearance for this study was obtained from the ethical review board and who may have known their HIV status for less than of the Faculty of Medicine and Biomedical Sciences of the University of Yaoundé I, and administrative authorization obtained from the Director of 5 years. The overall mean HIV-related stigma score among the Bamenda Regional Hospital. Only consenting participants were included these patients remains high. Anti-HIV-stigma programs in in the study and for participants who were aged less than 18 years, consent the North West Region need strengthening with intensified was obtained from their legal representatives. The interviewers were well trained on the consenting and data collection procedure and participants who psychosocial follow-up of newly diagnosed cases. Improving were mentally incapacitated and critically ill were not included in the survey. literacy rates may also help in reducing HIV-related stigma. Large scale studies that quantitatively measure HIV-related Competing interests The authors declare that they have no competing interest. stigma in more treatment centers are required; so as to es- tablish a clearer picture of HIV-related stigma in Cameroon. Publisher’sNote Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Additional file Author details Additional file 1: Questionnaire for the evaluation of HIV-related stigma 1 2 Kekem District Hospital, Kekem town, West Region, Cameroon. Department among PLHIVA and associated factors. (DOCX 32 kb) of Obstetrics and Gynaecology, Faculty of Medicine and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon. Obstetrics and Gynaecology unit, Higher Institute of Health Technologies, Yaoundé Central Hospital, Abbreviations Yaoundé, Cameroon. Bamenda Regional Hospital, Bamenda, North West AIDS: Acquired immune deficiency syndrome; AOR: Adjusted odds ratio; region, Cameroon. Department of Public Health, Faculty of Medicine and ART: Antiretroviral therapy; CI: Confidence interval; DHS: Demographic and Biomedical Sciences, University of Yaoundé I, Yaoundé, Cameroon. Meilleur health survey; HIV: The human immunodeficiency virus; PLHIVA: People living Accès aux Soins de Santé, Yaoundé, Cameroon. 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Globalization and HealthSpringer Journals

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