Trends in Responses to DHS Questions Should Not Be Interpreted as Reflecting an Increase in “Anticipated Stigma” in Africa

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To the Editors:
In sub-Saharan Africa, measurements of change in levels of HIV-related stigma have not been well reported. Years of data have been collected through the Demographic and Health Surveys (DHS) and AIDS Indicator Surveys on responses to questions aimed at determining attitudes toward people living with HIV (PLHIV). Chan and Tsai (August 2016 issue) recently analyzed the data from 31 African countries between 2003 and 2013, and we applaud the efforts of the authors for taking on this challenge.1 The authors conclude that over time, there has been an increase in “anticipated stigma,” but a decrease in “social distancing” toward PLHIV.
We recently concluded a similar analysis of stigma trends by examining the same DHS survey data from Africa. We are concerned that the conclusion that anticipated stigma has increased over time in sub-Saharan African countries may not be a sound interpretation of these data. Cognitive interviews of the DHS stigma measures conducted by Macro International and the International Center for Research on Women in Tanzania in 2004 identified problems with the question “If a member of your family got infected with the AIDS virus, would you want it to remain a secret or not?” used by Chan and Tsai as indicating “anticipated stigma.”1 A “Yes” response to this question is supposed to reflect the respondents' anticipation that a family member may experience stigma if their HIV-positive status became known.1 Conversely, a “No” response is assumed to reflect that the respondent does not anticipate that their family member will experience stigma if their status become known. However, the cognitive interviews suggested another interpretation all together. In a few cases, a “No” response was actually a stigmatizing one, with disclosure linked to “protecting” others in the community from being infected with HIV by their family member, even if their family member may then experience stigma (Laura Nyblade, oral communication, January 2014).2 The potential problem with this question may explain the puzzling significant association with gender but no significant association with country HIV prevalence reported by Chan and Tsai. Given the multiple interpretations of this question possible, it is not a credible measure of “anticipated stigma,” thus we believe that serious caution is warranted when considering Chan and Tsai's interpretation of these data as reflecting an increase in “anticipated stigma” over time.3
In addition, our analyses support the conclusion of a downward trend in “No” responses to two of the three questions used by Chan and Tsai to reflect “social distancing.” The questions “Would you buy fresh vegetables from a shopkeeper or vendor if you knew that this person had the AIDS virus?” and “In your opinion, if a female teacher has the AIDS virus but is not sick, should she be allowed to continue teaching in the school?” have been shown to be useful measures of discriminatory attitudes.2 However, we have concerns about the third question used by Chan and Tsai in their composite measure of “social distancing.” Specifically, research in Tanzania suggested that when responding to the question “If a member of your family became sick with AIDS, would you be willing to care for her or him in your own household?,” men and women interpreted the term “care” differently, with men perceiving “care” to mean “financial support” and women as “physical and emotional support.”3 Given prevailing social and gender norms in many African settings that place women in charge of providing physical care and support for sick relatives, a women's “no” response to this question is not comparable to a man's “no” response.
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