International Journal of Human and Health Sciences Vol. 04 No. 01 January’20 26 Original article: Stigma Among Patients with HIV/AIDS: A Cross Sectional Study in Malaysia Azreen Abdullah1, AdibahHanim Ismail2, Ching Siew Mooi3 Abstract Introduction:HIV stigma refers to negative beliefs, feelings and attitudes towards people living with HIV (PLWH), groups associated with PLWH and other key populations at higher risk of HIV infection, such as people who inject drugs, sex workers, men who have sex with men and transgender people. Despite the advancement made in the knowledge and treatment of HIV, PLWH continues to be stigmatized. Objective: To determine the level of HIV stigma and its predictors among people living with HIV/AIDS in a tertiary hospital in Malaysia. Methods: A cross sectional study was conducted among HIV/AIDS patients aged 18 and above at infectious disease clinic in Hospital Sungai Buloh, Gombak, Malaysia. HIV stigma was assessed using Berger’s HIV stigma scale, which is available in Bahasa Malaysia and English.A self-administered questionnaire was used to determine their demographic and clinical characteristics. Multiple linear regression analysis was used to identify the predictors.Results: 526 subjects participated in this study. The mean age of the study population was 33.5± 8.4 years. The majority of the participants were male (90.9%) and contracted HIV through sexual activities (87.8%). The mean score of HIV stigma was 104.7 ± 19.5. Based on multiple linear regression analysis, patients who were unemployed (B = -8.00, 95% confidence interval (CI) = -12.12,-3.88, p = < 0.001) and being on antiretroviral treatment (B = 4.95, 95% (CI) = 0.30, 9.60, p = < 0.037) had higher level of HIV stigma.Conclusions: The level of HIV stigma was high (mean score =104.7 ± 19.5). HIV/AIDS patients who are unemployed and on antiretroviral agents were at risks of having higher level of HIV stigma. Future study is needed urgently to implement intervention that can minimize the stigmatization among patients with HIV/AIDS. Keywords: HIV, AIDS, stigma, Malaysia , hospital, predictors, factors Correspondence to: Adibah Hanim Ismail, Family Medicine Department, Faculty of Medicine & Health Sciences, Universiti Putra Malaysia, 43400, Serdang, Selangor, Malaysia. E-mail : adibahanim@upm.edu.my 1. Dr. Azreen Abdullah, Family Medicine Specialist, Klinik Kesihatan Kajang, Jalan Semenyih, 43500 Kajang, Selangor. 2. Dr. Adibah Hanim Ismail, Family Medicine Specialist & Medical Lecturer, Department of Family Medicine, Faculty of Medicine & Medical Sciences, University Putra Malaysia, Selangor, Malaysia. 3. Dr. Ching Siew Mooi, Family Medicine Specialist & Medical Lecturer, Department of Family Medicine, Faculty of Medicine & Medical Sciences, University Putra Malaysia, Selangor, Malaysia. International Journal of Human and Health Sciences Vol. 04 No. 01 January’20 Page :26-35 DOI: http://dx.doi.org/10.31344/ijhhs.v4i1.116 Introduction HIV stigma is one of the major obstacles since it was first diagnosed more than 30 years ago. Research has shown that HIV stigma and discrimination discourage people living with HIV, disclosing their HIV status to their family or their partners, seeking HIV information, treatment and prevention1,2. Even until antiretroviral therapy was introduced people still have high stigma thus renders the preventive measures to reduce HIV burden and prevent the spreads of the disease3. Although antiretroviral treatment can halt the replication of Human Immunodeficiency Virus (HIV), it is a major global healthissue and one of the most dreaded pandemics. Experiencing HIV- related stigma has increased the risk of sexual transmission behavior, depression, anxiety, and panic disorder4. HIV-related stigma is fortified by many factors such as misconceptions, lack of access to treatment, and other socially sensitive issues which can lead to discrimination5. Joint United Nations Programme on HIV/AIDS (2014) defines HIV stigma as negative beliefs, feelings and attitudes 27 International Journal of Human and Health Sciences Vol. 04 No. 01 January’20 towards people living with HIV, groups associated with people living with HIV and other key populations at higher risk of HIV infection, such as people who inject drugs, sex workers, men who have sex with men and transgender people6. HIV- related stigma and discrimination are the leading hurdles for HIV treatment, preventions, alleviating impact and providing adequate care, support and treatment. Stigma and discrimination can prejudice, discourage, negative feelings and abuse people living with HIV and to seek information and services7. HIV-related discrimination also refers to other populations such as sex workers, homosexual, transgender, people in prisons and others8. HIV-related stigma and discrimination weaken the ability of individuals and communities in preventing and treating HIV. Globally, there are conflicting results of factors associated with HIV stigma. Although, Malaysia has limited study pertaining to HIV stigma, stigmatization and discrimination are widely present especially in health care and social welfare settings9. Taking that into account, the purpose of this study was to determine the level of HIV stigma and its associated factors among patients with HIV/ AIDS. The outcome of the study will assist health care providers to detect stigmatization earlier among patients with HIV/AIDS. This will reduce HIV-related stigma and help to improve the lives of people affected by HIV/AIDS. Methodology Study Subjects:A cross-sectional study was conducted and the patients were conveniently selected from the Outpatient Infectious Disease Clinic in Hospital Sungai Buloh, Gombak, Malaysia. The sample size for the proposed study was calculated based on a previous study10. The sample size estimated was 562 at significance level of 5% and power of 80%. The respondents were initially approached by the staff nurses and subsequently interviewed by the researchers. To be eligible for this study, patients must be 18 years old and above and had been diagnosed with HIV and registered at the clinic. Both male and female were included as well as all of the three main ethnics; Malay, Chinese and Indian were recruited. Data Collection and Instrument:The data were collected using validated, pre-tested, and standardized questionnaires in Bahasa Malaysia and English version. The questionnaire has two parts; Part 1: sociodemographic and clinical characteristics such as age, gender, ethnicity, education level, marital status, duration of illness, high risk behavior, sexual orientation, CD4 count, and antiretroviral treatment, and Part 2: HIV Stigma Scale. HIV stigma scale: It is a self-administered questionnaire available in English and Bahasa Malaysia. The 40-item, 4-point Likert-type HIV stigma scale was used to measure the level of HIV-related stigma11. The scale has four subscales which are: (I) Personalized stigma has 18 items and the score range 18-72, (II) Disclosure concerns has 10 items and the score range 10-40, (III) Negative self-image contains 13 items and the score range 13-52 and (IV) Concerned about public’s attitude contains 20 items and the score range 20-80. If a subject selects a response in between two options (between Strongly Disagree and Disagree), a numerical value midway between the two options would be used. Items 8 and 21 are reversed items. After reversing these two items, each scale or subscale’s score is calculated by simply adding up the raw values of the items belonging to that scale or subscale. Sixteen items belong to more than one subscale, reflecting the intercorrelations of the factors on which the subscales are based. The range of possible scores depends on the number of items in the scale. For the total HIV stigma scale, scores can range from 40 to 160. The higher the score, the more perceived HIV stigma experienced. The validated Malay version of HIV stigma scale was used to determine the level of HIV stigma in this study. It was found to be reliable and valid instrument for measuring HIV-related stigma12. The internal consistency reliability 0.92 of the Malay version is comparable to 0.96 of the original English version11. A pilot study was conducted with the estimated participants (n = 56), prior to recruiting the subjects. An anonymous self-administered questionnaire was given to all the patients with HIV (n=562) with numerical coding. If any of the participants felt uneasy or uncomfortable during the questionnaire, they were allowed not to complete the questions. The returned questionnaire was checked for completeness by the data collector. Data Analysis:All data were entered and analyzed using Statistical Package for the Social Sciences (SPSS) version 22.0. The normality of data was International Journal of Human and Health Sciences Vol. 04 No. 01 January’20 28 established using histogram and Kolmogorov- Smirnov test. A descriptive analysis was conducted to obtain mean, frequency and percentage of the variable. A simple linear regression was calculated to predict the level of HIV stigma based on a sociodemographic and clinical characteristic of the respondent. Variables with p value less than 0.25 were selected for multivariate regression analysis to determine the significant relationship between the levels of HIV stigma, while the confounders were controlled. The p value less than 0.05 was considered as statistically significant. Results: Out of 562 respondents, 94% (n-526) of the respondents completed the questionnaire. Majority of respondents were men (90.9%, n=478). Table 1 shows the sociodemographic characteristics of the respondents with HIV/AIDS. The mean age of the respondents was 33.5 ± 8.4 years and the majority of them were less than 50 years old. Majority of the respondents were Malay (59.4%, n=312), followed by Chinese (30.2%, n=159), Indian (6.3%, n=33), and other races (4.2%, n=22). Most of the respondents were single (87.7%, n=461) and employed (79.8%, n=420). More than half of the respondents (62.8%, n=330) obtained education up to university/college. Table 2 describes the clinical characteristics of the respondents with HIV/AIDS in this study. The mean duration of the illness was 42.3 ± 48.5 months. Majority of the respondents were diagnosed with HIV less than 60 months (76.8%) and practiced homosexual orientation (46.4%, n=244), followed by heterosexual (33.7%, n=177) and bisexual (19.9%, n=20). Most of the participants were infected with HIV through sexual activities which was 87.8% (n=462), followed by sharing needles 10.9% (n=57) and 85.4% (n=450) of them were on antiretroviral therapy. The mean level of CD4 count was 391.4 ± 235.3 cells/uL and most of the participants had CD4 level ≥ 200 cells/mm3 (77.2%). The total mean score of HIV stigma inour study was 104.7 ± 19.5(ranged from 40 to 160) as shown in Table 3. The personalized stigma subscale scores ranged from 18 to 72 (mean 43.9 ± 10.8); disclosure stigma subscale scores ranged from 10 to 40 (mean 30.3 ± 4.8); negative self-image subscale scores ranged from 13 to 52 mean 33.0 ± 7.0 and concerned with public attitude subscales scores ranged from 20 to 80 (mean 51.7 ± 10.9). A simple linear regression was calculated to predict the level of HIV stigma based on sociodemographic characteristic among patients with HIV/AIDS (Table 4). A significant regression equation was found (F (1,524) =13.3, p< 0.001), with an R2 of 0.025. The respondents who are unemployed had a significant relationship with the level of HIV stigma (p< 0.001). However, no significant relationship between HIV stigma, age, gender, marital status, ethnicity and education level (p> 0.05). The relationship between the level of HIV stigma and clinical characteristic among patients with HIV/AIDS is shown in Table 5. The respondents involved in sharing needles have significant regression with F (1,524) = 7.026, p = 0.008, with R2 of 0.013. This shows that the respondents who were involved in sharing needles have a level of HIV stigma higher of 0.116 than the respondents involved in other high risk activities. The respondents involved in sexual activities also have significant regression with the law F (1,524) = 7.374, p< 0.007, with R2 of 0.014. They have lower 0.118 level of HIV stigma than the respondents involved in other high risk activities. A significant regression equation was also found in respondents who were on antiretroviral treatment (F (1,524) =4.181, p< 0.041), with an R2 of 0.008. The respondents with antiretroviral treatment have higher level of HIV stigma compared to the respondents without antiretroviral treatment. A multiple linear regression was calculated to predict the level of HIV stigma based on sociodemographic and clinical characteristics among patients with HIV/AIDS (Table 6). All variables with p value less than 0.25 and clinically significant variables were included in multiple linear regressions. The p value was set larger (< 0.25) than the level of significance to allow for more important variables to be included in the model. The p value ≤ 0.05 was considered statistically significant in multiple linear regressions. Based on the regression analysis, the respondents who were unemployed and received antiretroviral treatment were statistically significant predictors of HIV stigma F (2,523 = 8.685, p< 0.001. 3.2% of the variance in HIV stigma were explained by the variance in unemployment and receiving antiretroviral treatment. 29 International Journal of Human and Health Sciences Vol. 04 No. 01 January’20 Discussions: In the present study we found that the total level of HIV stigma scores was high (mean score of 104.69 ± 19.47) and the public attitudes stigma subscale scores was the highest subscale of HIV stigma experienced by the subjects in this study.Similarly, a study done at the infectious disease out-patient clinic and among prisoners in northeastern of Malaysia were also found that the level of HIV stigma was high with mean score of 122.7±16.8 and 99.1 ± 9.7, respectively12,13. These findings indicated that races and culture play an important role in determining the perception of stigmatization among this population. This is in contrast with another study done overseas among HIV-positive African Americans had shown a low HIV stigma. This can be explained by the fact that majority of them are having higher socioeconomic status14. However, there is a controversial finding with other studies whose findings showed there was no association between the level of HIV stigma and socioeconomic status15,16. This highlights the inequality and discrimination towards people with HIV/AIDS are still an issues in certain countries17. Most of the respondents in this study were among younger age group (94%) and males (90.9%) compared to elderly age group (5.5%) and females (9.1%), respectively. Generally, most of the studies found similar findings where the majority of the HIV/AIDS respondents were among younger age group10,13,18,19,20. Malays were the higher ethnic (59.4%) compared to the other ethnic groups. The previous local study also had similar finding12,13. In comparison, the other studies conducted in the United States reported that the majority of their respondents with HIV/AIDS were African American ethnic group10,21,22,23. These results may indicate that certain ethnic groups are more vulnerable in getting HIV/AIDS diseases than others, although HIV/AIDS can affect anyone. In our study, the mean duration of illness was 42.4 ± 48.5 months and most of the respondents were diagnosed with HIV/AIDS in less than 60 months’ duration. The majority of the participants were on antiretroviral therapy (85.5%), with a mean of CD4 level 391.5 ± 235.1 cells/uL. About 7.7% of the respondents were single and more than half of them were educated (62.8%) and still working (79.8%).Nearly half of the respondents (46.4%) were homosexual and majority of them (87.9%) were infected with HIV through sexual activities. In contrast, a study in northeastern Malaysia reported that most of the respondents with HIV/ AIDS had low economic and education status12,13. Majority of their respondents with HIV/AIDS were married, heterosexual and infected with HIV through sharing needles13. The difference in population, cultural, job opportunities and economic status were some of the possible reasons to explain the differences in the above findings. Unemployment has been recognized as a factor associated with HIV related stigma. It is also regarded as one of the major barriers that prevent HIV/AIDS patients from returning back to normal life and getting a job. Our study also found that unemployment was significantly associated with higher HIV stigma, which is in line with the previous research21,24,25. HIV stigma is also related to those who were taking ARV treatment.We also found an association between antiretroviral treatment and the level of HIV stigma. These findings are consistent with other studies in which HIV/AIDS patients who received antiretroviral treatment had high level of HIV stigma, possibly because they were required to regularly visit the clinic for drugs monitoring19,26. However, a few studies reported that the level of HIV stigma is independent on duration of antiretroviral treatment24,27,28,29,30. This may be due to the difference in study design in which prospective study design may start with antiretroviral treatment naïve patients’. HIV stigma is not associated with other variables such as age, gender, ethnicity, marital status, education level, high risk activities, sexual orientation, CD4 levels and duration of illness. This study ishospital-based and does not represent HIV in its wider context.The cost-effective interventions and programmatic data demonstrating the impact of stigma and discrimination reduction on HIV prevention and care outcomes are much needed. Strength and limitation of the study: The strength of this study is huge sample (n=526) compared to the two previous local studies where there werearound 100 participants. Secondly, there was lack of reporting on HIV stigma by the respondents’ spouses, or their sexual partners. It is pertinent to include them as part of the study, as International Journal of Human and Health Sciences Vol. 04 No. 01 January’20 30 we can get more information on their occupation or relationship status. However, most of the respondents (81.4%) in this study were single and this clearly makes it difficult to obtain relevant sexual information from the spouse. Thus, we have to interpret the results of this study cautiously within the context of its limitations. Conclusion: The mean score of HIV stigma in our study was high (104.6±19.5) and consistent with other local studies.Unemployment and on antiretroviral therapy are associated with HIV stigma. The health care professionals should identify those at risk groups for further intervention. Ethical approval: Approvals were obtained from Ethics Committee of Universiti Putra Malaysia, National Medical Research Register (NMRR-16- 765-29793), Ethical review of Clinical Research of Health Department, Selangor and Hospital Sungai Buloh. Informed consent was obtained and confidentiality of responses, were stringently ensured throughout the study. Conflict of interest:None. Acknowledgement: The author would like to thank the Director General of Health Malaysia for the permission to publish this paper. We wish to thank the Selangor State Health Department, Director, and Head of Department of Hospital Sungai Buloh who had given the permission to conduct the study in Hospital Sungai Buloh. Also not forgetting our respondents, the staff of Hospital Sungai Buloh who had assisted in data collection. Table 1: Sociodemographic characteristics of the respondents (N=526) Variable N % Mean + SD Age 33.5 + 8.4 < 50 years old 497 94.5 ≥ 50 years old 29 5.5 Gender Male 478 90.9 Female 48 9.1 Ethnicity Malay 312 59.4 Chinese 159 30.2 Indian 33 6.3 Others 22 4.2 Marital Married 65 12.3 Single 461 87.7 Employment status Employed 420 79.8 Unemployed 106 20.2 Education no schooling 11 2.1 primary school 18 3.4 secondary school 167 31.7 university/college 330 62.8 31 International Journal of Human and Health Sciences Vol. 04 No. 01 January’20 Table 2: Clinical characteristics of the respondents (N=526) Variable n % Mean + SD Duration of illness 42.3 + 48.5 0 - 60 months 404 76.8 61- 120 months 88 16.7 121 - 180 months 17 3.2 181 - 240 months 17 3.2 Sexual orientation Heterosexual 177 33.6 Bisexual 105 20 Homosexual 244 46.4 High risk activities sharing needles 57 10.9 sexual activities 462 87.8 others 7 1.3 Antiretroviral treatment (ARV) On ARV 450 85.4 Not on ARV 77 14.6 Level of CD4 count, cells/uL 391.4 + 235.3 CD4 < 200 u/L 120 22.8 CD4 ≥ 200 u/L 406 77.2 Table 3: The levels of HIV stigma and subscales among patients with HIV/AIDS (N = 526) Stigma Reference range Mean + SD Total 40 to 160 104.7 ± 19.5 Personalised 18 to 72 43.9 ± 10.8 Disclosure 10 to 40 30.3 ± 4.8 Negative self-image 13 to 52 33.0 ± 7.0 Concerned about public’s attitude 20 to 80 51.7 ± 10.9 International Journal of Human and Health Sciences Vol. 04 No. 01 January’20 32 Table 4: Relationship between HIV stigma and sociodemographic characteristics among patients with HIV/AIDS by using simple linear regression. Variables B SE β (95% CI) F p value Age 0.08 0.10 0.04 (-0.12,0.28) 0.69 0.407 Gender Female Ref Male 3.55 2.95 0.05 (-2.24,9.34) 1.45 *0.229 Marital status Married Single 2.22 2.58 0.04 (-2.85,7.29) 0.74 0.39 Employment Employed Ref Unemployed -7.64 2.09 -0.16 (-11.75,-3.53) 13.3 *< 0.001 Ethnicity Others Ref Malay 1.01 1.73 0.25 (-2.39,4.41) 0.34 0.561 Chinese -0.38 1.85 0.05 (-4.02,3.26) 0.42 0.838 Indian -1.06 3.50 -0.13 (-7.94,5.83) 0.09 0.838 Education Primary school Ref No schooling -2.84 5.94 -0.02 (-14.50,8.83) 0.23 0.633 Secondary school 2.10 1.82 0.05 (1.48,5.68) 1.38 0.250 University/college -0.72 1.76 -0.02 (-4.17,2.73) 0.17 0.682 *p< 0.25 33 International Journal of Human and Health Sciences Vol. 04 No. 01 January’20 Table 5: Relationship between HIV stigma and clinical characteristics among patients with HIV/ AIDS by using simple linear regression Variables B SE β (95% CI) F p value Duration of illness 0.009 0.018 0.02 (-0.025,0.044) 0.268 0.605 High risk activities Others Ref Sharing needles 7.199 2.716 0.12 (1.864,12.535) 7.026 *0.008 Sexual activities -7.01 2.580 -0.12 (-12.080,-1.940) 7.037 *0.007 Sexual orientation Heterosexual Ref Bisexual 0.868 2.126 0.02 (-3.308,5.044) 0.167 0.683 Homosexual 0.662 1.704 0.02 (-2.686,4.009) 0.151 0.698 ARV Not on ARV Ref On ARV 4.897 2.395 0.09 (0.192,9.601) 4.181 *0.041 CD4 level 0.002 0.004 0.02 (-0.009,0.005) 0.246 0.620 *p < 0.25 Table 6:Relationship between HIV stigma, sociodemographic and clinical characteristics among patients with HIV/AIDS by using the multiple linear regression. Variables B SE β (95% CI) F p value Unemployed -8.00 2.09 -0.16 -12.12,-3.88 8.69 <0.001 On ARV 4.95 2.37 0.09 0.30,9.60 0.037 Gender 5.24 2.93 0.08 -0.51,10.99 0.074 Sexual activities -3.40 2.75 -0.06 -8.79,1.99 0.216 Sharing needles -0.85 7.75 -0.01 -0.04,9.31 0.913 International Journal of Human and Health Sciences Vol. 04 No. 01 January’20 34 References: 1. Antiretroviral Therapy Cohort Collaboration. Life expectancy of individuals on combination antiretroviral therapy in high-income countries: a collaborative analysis of 14 cohort studies. The Lancet 2008;372(9635):293-299. 2. Kuteesa MO, Wright S, Seeley J, Mugisha J, Kinyanda E, Kakembo F et al. Experiences of HIV- related stigma among HIV-positive older persons in Uganda–a mixed methods analysis. SAHARA J 2014;11(1):126-137. 3. Wolfe WR, Weiser SD, Bangsberg DR, Thior I, Makhema JM, Dickinson DB et al. Effects of HIV- related stigma among an early sample of patients receiving antiretroviral therapy in Botswana. AIDS care 2006;18(8):931-933. 4. Hatzenbuehler ML, O’cleirigh C, Mayer KH, Mimiaga MJ, Safren SA. Prospective associations between HIV-related stigma, transmission risk behaviours, and adverse mental health outcomes in men who have sex with men. Annals of Behaviour Medicine 2011;42(2):227-234. 5. Hong KT, Van Anh NT, Ogden J. Because this is the disease of the century: understanding HIV and AIDS- related stigma and discrimination. Washington, DC: International Center for Research on Women (ICRW) 2004, pp. 1–48. 6. Joint United Nations Programme on HIV/AIDS. Guidance note Reduction of HIV Related Stigma and Discrimination. Geneva. 2014. 7. Karim, A.Q., Meyer-Weitz A, Mboyi L, Carrara H, Mahlase G, Frohlich JA, et al. The influence of AIDS stigma and discrimination and social cohesion on HIV testing and willingness to disclose HIV in rural KwaZulu-Natal, South Africa. Glob Public Health 2008;3(4):351–365. 8. Parker R, Aggleton P, HIV and AIDS-related Stigma and Discrimination: a conceptual framework and implications for action. SocSci Med 2003; 57(1): 13-24. 9. Zulkifli SN, Huang MS, Low WY, Wong YL. Study on the impact of HIV on People Living with HIV, their families and community in Malaysia. Kuala Lumpur: United Nations. 2007. 10. Shacham E, Rosenburg N, Önen NF, Donovan MF, Turner Overton E. Persistent HIV-related stigma among an outpatient US clinic population. International Journal of STD & AIDS 2015;26(4):243- 250. 11. BergerBE.Measurement of perceived stigma in people with HIV infection. Research in Nursing and Health. 2001;24:518- 529. 12. Choi P, Kavasery R, Desai MM, Govindasamy S, Kamarulzaman A, Altice FL. Prevalence and correlates of community re-entry challenges faced by HIV-infected male prisoners in Malaysia. International journal of STD & AIDS 2010;21(6):416-423. 13. Fadzil NA, Othman Z, Mustafa M. Stigma in Malay Patients with HIV/AIDS in Malaysia. International Medical Journal 2016;23(4):1-4. 14. Galvan FH, Davis EM, Banks D, Bing EG. HIV stigma and social support among African Americans. AIDS Patient Care and STDs. 2008;22(5):423-436. 15. Wagner AC, Hart TA, Mohammed S, Ivanova E, Wong J, Loutfy MR. Correlates of HIV stigma in HIV-positive women. Archives of Women’s Mental Health 2010;13(3):207-214. 16. Kumar N, Unnikrishnan B, Thapar R, Mithra P, Kulkarni V, Holla R, Bhagawan D, Kumar A. Stigmatization and Discrimination toward People Living with HIV/AIDS in a Coastal City of South India. Journal of the International Association of Providers of AIDS Care (JIAPAC) 2017;16(3):226- 232. 17. Sidibé M, Goosby EP. Global action to reduce HIV stigma and discrimination. Journal of the International AIDS Society 2013;16(3S2):1-6. 18. Emlet CA, Brennan DJ, Brennenstuhl S, Rueda S, Hart TA, Rourke SB. The impact of HIV-related stigma on older and younger adults living with HIV disease: does age matter?. AIDS Care 2015;27(4):520-528. 19. Datta S, Bhattacherjee S, SherPa PL, Banik S. Perceived HIV Related Stigma among Patients Attending ART Center of a Tertiary Care Center in Rural West Bengal, India. Journal of Clinical and Diagnostic Research (JCDR) 2016;10(10):VC09. 20. Li Z, Sheng Y. Investigation of perceived stigma among people living with human immunodeficiency virus/acquired immune deficiency syndrome in henan province, china. International Journal of Nursing Sciences 2014;1(4):385-388. 21. Sayles JN, Hays RD, Sarkisian CA, Mahajan AP, Spritzer KL, Cunningham WE. Development and psychometric assessment of a multidimensional measure of internalized HIV stigma in a sample of HIV-positive adults. AIDS and Behavior 2008;12(5):748-758. 22. Relf MV, Mallinson K, Pawlowski L, Dolan K, Dekker D. HIV-related stigma among persons attending an urban HIV clinic. Journal of Multicultural Nursing & Health 2005;11(1):14. 35 International Journal of Human and Health Sciences Vol. 04 No. 01 January’20 23. Loutfy MR, Logie CH, Zhang Y, Blitz SL, Margolese SL, Tharao WE, Rourke SB, Rueda S, Raboud JM. Gender and ethnicity differences in HIV-related stigma experienced by people living with HIV in Ontario, Canada. PloS one 2012;7(12):e48168. 24. Peltzer, K., &Ramlagan, S. Perceived stigma among patients receiving antiretroviral therapy: a prospective study in KwaZulu-Natal, South Africa. AIDS care 2011;23(1): 60-68. 25. Vanable, P. A., Carey, M. P., Blair, D. C., &Littlewood, R. A. Impact of HIV-Related Stigma on Health Behaviors and Psychological Adjustment among HIV-Positive Men and Women. AIDS and Behavior 2006;10(5):473–482. 26. Makoae LN, Portillo CJ, Uys LR, Dlamini PS, Greeff M, Chirwa M et al. The impact of taking or not taking ARVs on HIV stigma as reported by persons living with HIV infection in five African countries. AIDS Care 2009;21(11):1357-1362. 27. Kaai S, Sarna A, Luchters S, Geibel S, Munyao P, Mandaliya K et al. Changes in stigma among a cohort of people on antiretroviral therapy: findings from Mombasa, Kenya. Horizons Research Summary. Nairobi: Population Council 2007:2-4. 28. Tsai AC, Bangsberg DR, Bwana M, Haberer JE, Frongillo EA, Muzoora C et al. How does antiretroviral treatment attenuate the stigma of HIV? Evidence from a cohort study in rural Uganda. AIDS and Behavior 2013;17(8):2725-2731. 29. Pearson CR, Micek MA, Pfeiffer J, Montoya P, Matediane E, Jonasse T et al. One year after ART initiation: psychosocial factors associated with stigma among HIV-positive Mozambicans. AIDS and Behavior 2009;13(6):1189. 30. Dowshen N, Binns HJ, Garofalo R. Experiences of HIV-related stigma among young men who have sex with men. AIDS Patient Care and STDs 2009;23(5):371-376.