Exploring the relationship between anticipated stigma and community shared concerns about HIV on defaulting from HIV care in rural South Africa

Abstract

Although stigma has been associated with people living with HIV defaulting from care, there is a gap in understanding the specific impact of individual stigma and community-level concern about HIV on defaulting. This is a secondary analysis of a unique data set that links health facility–based medical records to a population-representative community survey conducted in 2018 in rural Mpumalanga province, South Africa. We used the parametric g-formula to estimate associations among individual anticipated stigma, low perceived community and local leader concern about HIV, and defaulting from care in the prior year. In addition, we estimated the population-level effects of intervening to reduce stigma and increase concern on defaulting. Among 319 participants on treatment, 42 (13.2%) defaulted from care during the prior year. Anticipated stigma (risk ratio [RR] 1.22, 95% confidence interval, CI [0.72, 2.74]), low perceived concern about HIV/AIDS from community leadership (RR 1.12, 95% CI [0.76, 3.38]), and low shared concerns about HIV/AIDS in the community (RR 1.37, 95% CI [0.79, 3.07]) were not significantly associated with default. Hypothetical population intervention effects to remove the individual anticipated stigma and low community concerns yielded small reductions in default (∼1% reduction). In this sample, we found a limited impact of reducing anticipated stigma and increasing shared concern about HIV on retention in care. Future studies should consider the limitations of this study by examining the influence of other sources of stigma in more detail and assessing how perceptions of stigma and concern impact the full HIV testing and care cascade.