An intervention program to combat internalized stigma among people living with HIV/AIDS in Chennai city of Tamil Nadu, India

Abstract

Background: Stigma is a mark of disgrace or reproach and a perceived negative attribute, which leads one to undervalue and demean oneself. HIV/AIDS is highly stigmatized and is attributable to the fact that its routes of transmission are associated with already-marginalized behaviors (drug abuse, commercial sex work, multiple sex partners, homosexual and transgender sexual practices). HIV/AIDS stigmatization has two major components: externalized stigma and internalized stigma. Social inequality, prejudicial approach, discrimination and abuse by the society towards People Living with HIV (PLHIV) are known as externalized stigma. Externalized stigma can result in internalization of negative responses of the society in people living with HIV (PLHIV), which in turn can affect their mental wellbeing leading to low pride/self-worth/self-esteem/self-blame, isolation from society, depression, and suicide contemplation. This is commonly known as internalized stigmatization. Consequences of such internalized stigma include poor mental health of PLHIV, unsafe sexual practices, compromised life style and livelihood, rejection of HIV testing, prevention, treatment, and available support services. Magnitude: In Chennai, Tamil Nadu, the magnitude of internalized stigma among PLHIV remains high. Self-blame (56%), very low self-esteem (56%), shame (53%), guilt (53%), self-punishment (24%), and suicidal-intent (26%) were predominant forms of internalized stigma observed in this population. Studies also show that actual/externalized stigma experienced by PLHIV is much less (26%) when compared to internalizing stigma (97%) in Chennai, Tamil Nadu. Intervention program: The proposal suggests piloting a three-phase intervention program (socio-psychological support, information, educational and communication campaign and participatory approaches) aimed at reduction of the internalized stigma’s burden and its impact among PLHIV in Chennai city of Tamil Nadu state of India. The proposed three phase intervention will be implemented after collection of baseline data. As a first phase of intervention, the target population will be recruited to the sociopsychological support center where a trained psychologist will assess the psychological needs of participants and render mental health first aid during the first six months of the intervention program. In the second phase of the intervention, the participants will be assigned into several self-help groups. Information, education and communication sessions will be rendered once per month for one year. Revised version of the “Understanding and Challenging Stigma: A Toolkit for Action” will be used to train the study participants to combat internalized stigma. The third phase of the intervention will empower the study participants by training and encouraging active participation in implementing stigma-reduction efforts to other PLHIV in their community. Methods: This pilot intervention program will be evaluated to assess its effectiveness in reducing internalized stigma among target population. Target population will include PLHIV aged 18 years and above, living in Chennai city of Tamil Nadu. Simple random sampling will be used to choose participants from the intervention (Chennai) and control groups (Karur) for evaluation. The evaluation will apply a quasi-experimental non-equivalent control group (pre and postpanel design) to estimate and compare the mean cumulative score of “internalized stigma, disclosure concerns, negative self-image, and concern with public attitudes towards PLHIV” between the intervention and control groups. Data collection and Analysis plan: Berger’s HIV Stigma Scale (HSS), a 40-item validated and reliable scale will be used to collect baseline and follow-up data among all the participants from the intervention and the control groups. SPSS, version 22 will be used to analyze the data. Descriptive analysis, independent t-test for comparing the means of two groups and paired t-test for comparing the baseline and followup means of the intervention group will be performed. ANOVA will also be conducted to analyze ‘mean internalized stigma score, mean disclosure concerns score, mean negative selfimage score, and mean concern with public attitudes score’ between intervention and control groups respectively. Bivariate and multivariate linear regression analysis will be performed to analyze relationship between dependent and independent variables. Aim: The three phase intervention program will be considered effective if we observe 30% or more reduction in the mean cumulative score of ‘internalized stigma, disclosure concerns, negative self-image, and concern with public attitudes towards study participants living with HIV/AIDS’ in Chennai, when compared with their control group. Conclusion: If the evaluation demonstrates that the three-phase intervention program is effective in plummeting internalized stigma and its impact among the study participants, then this program can be considered for a statewide implementation.