Associations between enacted stigma and risky sexual behavior among women in sub-Saharan Africa: A population-based multilevel analysis

Background: Many countries have now pledged to eradicate stigma and discrimination towards people living with HIV/AIDS as a strategy to effectively address the HIV epidemic. The present study examined the association between enacted stigma towards people living with HIV/AIDS and risky sexual behavior among women of childbearing age in sub-Saharan Africa.

Methods: A cross-sectional design was utilized to examine responses from 260,986 women who participated in the Demographic and Health Survey and AIDS Indicator Survey between 2006 and 2012 from 25 countries in sub-Saharan Africa. Multilevel modeling techniques were used to identify the association between enacted stigma and risky sexual behavior adjusting for other individual and community-level demographic, socio-economic and behavioral characteristics.

Results: Approximately 65% of women reported having stigmatizing feelings towards people with HIV/AIDS. In the multivariable-adjusted model, women with moderate and low level enacted stigma towards people with HIV/AIDS were less likely to be involved in risky sexual behavior compared to women with high level of enacted stigma (Adjusted Odds Ratio; aOR = 0.90; 95% CI 0.90 to 0.91; p < 0.0001 and aOR=0.84; 95% CI 0.83 to 0.85; p < 0.0001, respectively). The results of the final model showed that approximately 85% of the variance in the odds of risky sexual behavior could be attributed to the community-level factors (τ= 18.03, p < 0.0001).

Conclusion: Findings emphasize the importance of addressing stigma with nuance by developing contextually relevant strategies and policies that emphasize HIV risk as general community issue and not only for those deemed high-risk populations.