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. S tigma 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 e t 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:
Community members received:
| 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). P sychological 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:
| 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). |
| 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 research89 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.