The impact of HIV stigma on time to art initiation in four African countries

BACKGROUND: HIV-related stigma poses a major barrier to antiretroviral therapy (ART) access and adherence, but little is known about the quantitative impact of stigma on time to ART initiation. To assess this relationship, we analyzed data from the nationally representative Population-based Impact Assessment (PHIA) surveys conducted in Eswatini, Malawi, Tanzania, and Zambia between 2015-2017.
METHODS: This retrospective cohort analysis included adults > 18 years who self-reported as HIV+ in one of the four surveys, had a reactive HIV test, provided dates of their first HIV+ test result and ART initiation, and completed the survey stigma module. The stigma module asked about:
(1) feeling the need to hide one's HIV+ status when seeking health care and
(2) having been denied health services because of HIV status in the last 12 months.
Time to ART initiation stratified by demographics and stigma status was analyzed via inverted Kaplan-Meier curves. The association between stigma and the probability of ART initiation was assessed via proportional hazards regression accounting for survey design.
RESULTS: Among 9,376 HIV+ adults, 5,384 reported an ART initiation date with complete data. Just over half (55%) reported initiating ART within one month of HIV diagnosis, 72% within one year, and 78% within two years, cumulatively. 9.3% of all HIV+ adults reported feeling the need to hide their HIV status at a health care facility and 2% reported being denied health services.
Individuals who reported experiencing stigma were significantly less likely to initiate ART at all time points compared to those who did not (p < 0.001). After adjustment for demographics and year of diagnosis, compared to those who reported experiencing stigma ('Yes' to each questions), those who did not report needing to hide their status (HR: 1.19 [1.03-1.38]) and those who did not report being denied healthcare (HR: 1.46 [1.02-2.07]) were significantly more likely to report a shorter rime interval between HIV diagnosis and ART initiation.
CONCLUSIONS: These representative findings from Eswatini, Malawi, Tanzania, and Zambia quantify the impact of HIV-related stigma on timely initiation of ART. Strengthening stigma reduction policies and programs has the potential to accelerate progress toward the UNAIDS 95-95-95 goals.