Page 1

Review Article

HIV-Stigma in Nigeria: Review of Research Studies,

Policies, and Programmes

Clifford O. Odimegwu,1 Joshua O. Akinyemi,1,2 and Olatunji O. Alabi1,3

1Demography and Population Studies Programme, Schools of Public Health and Social Sciences,

University of the Witwatersrand, Johannesburg, South Africa

2Department of Epidemiology and Medical Statistics, Faculty of Public Health, College of Medicine,

University of Ibadan, Ibadan, Nigeria

3Department of Demography and Social Statistics, Federal University, Birnin Kebbi, Nigeria

Correspondence should be addressed to Joshua O. Akinyemi; odunjoshua@gmail.com

Received 16 September 2017; Accepted 22 November 2017; Published 27 December 2017

Academic Editor: Robert R. Redfield

Copyright © 2017 Clifford O. Odimegwu et al. This is an open access article distributed under the Creative Commons Attribution

License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly

cited.

Nigeria has about 3.8 million people living with HIV, the second largest globally. Stigma and discrimination are major barriers to

testing, treatment uptake, and adherence. In this review, we synthesized information on research studies, policies, and programmes

related to HIV-stigma in Nigeria. This was with a view to identify critical areas that research and programmes must address in

order to accelerate the progress towards zero (new infections, discrimination, and death) target by year 2030. Existing studies were

mostly devoted to stigma assessment using varieties of measures. Research, policies, and programmes in the past two decades have

made very useful contributions to stigma reduction. We identified the need for a consistent, valid, and objective measure of stigma

at different levels of the HIV response. Nigeria does not lack relevant policies; what needs to be strengthened are design, planning,

implementation, monitoring, and evaluation of context-specific stigma reduction programmes.

1. Introduction

One of the successes recorded in the Millennium Develop-

ment Goals was target 6A which aimed to halt HIV by 2015

and begin to reverse its spread. As of 2014, the number of

new HIV infections and AIDS-related deaths has declined by

40% and 42%, respectively [1]. Sub-Saharan Africa region was

not left behind in this achievement despite the fact that the

region is home to 70.0% of persons living with HIV globally

[1]. This progress has been attributed to massive improvement

in funding which enhanced wider coverage of antiretroviral

treatment, innovative approaches to treatment, and preven-

tion interventions [1]. Some challenges still remain which

include the need to attain universal treatment coverage and

eliminate new infections; treatment of comorbidities; stigma;

and discrimination [2]. To confront these challenges and

build on the laudable progress so far recorded, one of the

health targets under the new Sustainable Development Goals

(SDG) is to end the AIDS epidemic by 2030. In pursuit of this,

the Joint United Nations Program on HIV/AIDS (UNAIDS)

has proposed a global strategy whose target is reducing the

number of new HIV infections by 90% and number of AIDS-

related deaths by 80% of the level at year 2010 [1]. In fact,

UNAIDS has a new vision of “zero new HIV infections, zero

discrimination, and zero AIDS-related deaths” [3].

Meanwhile, recent statistics shows that 36.7 million per-

sons were living with HIV as of the end of 2015 of which about

46% have access to treatment [3]. Of these, Nigeria has the

second highest number, 3.8 million with adult prevalence of

3.1% [4]. About 44% of adults and children living with HIV

have access to ART based on the eligibility criteria of CD4

count of 350 cells/mm

3

. With the largest population in SSA,

only 26% of its people have ever done HIV testing [4]. HIV

epidemiology in Nigeria indicates that infections are higher

among women while prevalence varied across the six geopo-

litical regions with the highest rate in the South South (5.5%).

One of the main factors driving the infection in Nigeria

includes low risk perception, concurrent sexual partnerships,

Hindawi

AIDS Research and Treatment

Volume 2017, Article ID 5812650, 13 pages

https://doi.org/10.1155/2017/5812650

2

AIDS Research and Treatment

and inadequate access to quality healthcare services [4]. At

the centre of these factors is the challenge of HIV-stigma and

discrimination which are a major barrier militating against

the national response to the epidemic.

According to UNAIDS 2015 guidelines on terminologies,

stigma refers to beliefs and/or attitudes marking or staining

a person or group of people as unworthy or discreditable

[5]. Discrimination results from stigma when any form of

distinction, exclusion, or restriction is displayed against an

individual because of an attribute or a personal characteristic.

For operational and programmatic purposes, HIV-related

stigma is described as “negative beliefs, feelings, and attitudes

towards people living with HIV (PLHIV), groups associated

with PLHIV and other key populations at higher risk of HIV

infection” [2]. HIV-related discrimination is the “unfair and

unjust treatment (act or omission) of an individual based

on his or her real or perceived HIV status.” Stigma Stigma

and discrimination are formidable threats to the success

of HIV care and treatment programs. Several studies have

shown stigma and discrimination to affect HIV testing [6],

disclosure of serostatus [7], retention, and adherence to treat-

ment [8]. Meta-analysis of 64 studies conducted in different

settings demonstrated significant effects of HIV-stigma on

mental health, quality of life, use of health services, and

physical health of PLHIV [9]. Manifestations or expression of

stigma is influenced by sociocultural, political, and economic

factors all of which translates into different forms of inequal-

ities in access to HIV care, treatment, and support [10]. The

consequence of these multilevel influences is that HIV-stigma

operates at individual, family, community, and institutional

levels and many of these factors also varied across cultures,

thereby necessitating context-specific strategies to address

the phenomena.

In congruence with the advancement in the global re-

sponse, research and programmes on HIV-related stigma

have witnessed improvement since the entrance of HIV into

public health discourse. For instance, beyond the initial com-

plexities associated with definition, measurement, impact

assessment, and reduction of HIV-stigma [11], empirical

measures for different domains of stigma have been proposed

and validated in some sub-Saharan African countries [12].

Systematic reviews and other forms of research studies have

provided evidence on various interventions to reduce HIV-

stigma [13–15]. Examples of these interventions which have

dominated the HIV-stigma reduction efforts include infor-

mation-based approaches such as behaviour change commu-

nications; capacity building (training of healthcare providers

and other allied workers); counselling and support for PLHIV

(support groups and network); and involvement of PLHIV in

different activities as a way of humanizing the infection such

that it is seen as any other chronic health condition.

Nigeria as one of the countries with the largest number of

PLHIV has strived to combat HIV-stigma and discrimination

to curtail the epidemic. The early (1990s) and peak years

(mid-2000s) of the epidemic in Nigeria were characterised by

various forms of stigma and discrimination at different levels

of human interaction [16]. A review of studies on HIV-related

stigma in Nigeria between 1987 and 2008 found eight peer-re

viewed articles [17]. The main findings include the following:

HIV-stigma manifests mostly as negative attitudes against

PLHIV by individuals and community members and unwill-

ingness to treat PLHIV by healthcare workers. The potential

of educational interventions to reduce HIV-related stigma

was also demonstrated among secondary school pupils, stu-

dents in nursing schools, and practicing healthcare workers.

Some critical gaps identified by the review were absence of

coherent and consistent measure of stigma across studies

and near absence of intervention studies on stigma reduction

[17]. An obvious gap in the previous review of HIV-stigma

in Nigeria was the lack of evidence on the experiences

of stigma among PLHIV. Furthermore, almost one decade

after the review, the national response to HIV in Nigeria

has experienced positive shifts in diverse ramifications. For

instance, information and awareness about HIV are almost

universal; political will and stakeholder involvement have

become more robust [4]. It is also expected that research work

on HIV-stigma must have advanced beyond the level it was

in 2007. Therefore, this paper is aimed at reviewing studies,

policies, and programmes related to HIV-stigma in Nigeria.

We synthesized data and information on these issues and

identified critical areas that research and programmes must

address to accelerate progress towards zero (new infections,

discrimination, and death) target set by UNAIDS.

2. Methods

In March 2017, we searched electronic databases for articles

on HIV-stigma in Nigeria between 1999 and 2016. The

databases were PubMed, African Journal Online, and JSTOR.

Search terms involved different combination of the following:

HIV, AIDS, Stigma, Discrimination, and Nigeria. The word

“attitude” was also used as a search term because many of the

related articles used it to connote stigma or discrimination.

Abstracts of each article in the search results were reviewed

to determine whether they met criteria for inclusion in the

review. For an article to be included in the review, it must

address HIV/AIDS stigma or discrimination as a dependent

or independent variable. Inclusion was not restricted to any

study design; therefore, both quantitative and qualitative

studies that addressed HIV-stigma and/or discrimination in

Nigeria were selected. Full text of articles that met the inclu-

sion criteria were retrieved and reviewed. For each reviewed

article, information was extracted on authorship and year of

publication; objective; research design; how stigma was mea-

sured (and whether as a dependent or independent variable);

and the main findings. These details were summarised in

a Table 1. Since this review also includes policies and pro-

grammes related to HIV-stigma in Nigeria, we searched the

website of relevant organisations for documents related to the

subject of interest. Such organisations included the National

AIDS Control Agency (NACA), Federal Ministry of Health and

Joint United Nations Programme on HIV/AIDS (UNAIDS),

Network of People Living with HIV in Nigeria (NEPWHAN).

References of retrieved articles, policy documents, and pro-

gramme reports were also physically scrutinized.

3. Results

Compared to the previous review by Monjok et al. [17],

we found greater number of research articles related to

AIDS Research and Treatment

3

T

able

1:L

iterature

m

atrix

o

f

studies

o

n

HIV

-stigma

in

N

igeria:20

02–2016.

SN

Ref:au

th

o

r

(year)

Stud

y

d

esign

Stu

d

y

p

o

p

u

latio

n

an

d

lo

catio

n

O

b

jectives

(1)

1999:F

aw

o

le

et

al.

Quasi-exp

erimen

talstud

y

Seco

n

dary

studen

ts

in

So

u

th

W

est

N

igeria

T

o

assess

th

e

eff

ect

o

f

ed

ucatio

nalin

terven

tio

n

o

n

attitudes

o

f

studen

ts

to

p

eo

p

le

livin

g

w

ith

H

IV/AIDS

(2)

2000

:

Uw

ak

w

e

Quasi-exp

erimen

talstud

y

Studen

t

n

urses

in

SW

N

igeria

T

o

in

vestigate

th

e

eff

ect

o

f

edu

cation

alpro

gram

o

n

attitudes

and

b

ehavio

u

r

regardin

g

HIV/AIDS

(3)

2002:A

lu

bo

et

al.

Qualitative

stu

d

y

C

o

mm

unity

mem

b

ers

in

so

u

th

ern

p

art

o

f

B

en

ue

State,

No

rth

C

en

tralNigeria

T

o

do

cumen

t

th

e

p

ercep

tio

n

s

o

f

P

LHIV

,family,an

d

co

mm

unity

mem

b

ers

ab

o

u

t

HIV

stigma

(4)

2002:

Ezedinachi

et

al.

Quasi-exp

erimen

talstud

y

F

acility-b

ased

am

ong

h

ealth

w

orkers

in

South

South

Nigeria

T

o

assess

th

e

eff

ect

o

f

ed

ucatio

nalin

terven

tio

n

o

n

kno

w

ledge

and

attitudes

o

f

w

o

rkers

to

PLHIV

(5)

2003:

Ad

eb

ajo

et

al.

Cross-sectio

nalsurvey

N

urses

an

d

m

edicallab

scien

tists

in

p

ub

lic

h

ealth

facilities

in

L

agos,So

u

th

W

est,N

igeria

T

o

do

cumen

t

attitudes

to

P

LHIV

(6)

2005:

A

d

edigba

et

al.

C

ro

ss-sectio

n

alstu

d

y

O

ralh

ealth

w

o

rkers

in

O

su

n

State,So

u

th

W

est

N

igeria

A

ssessed

K

A

P

o

f

infectio

n

co

n

tro

lin

m

an

agin

g

HIV

-infected

p

atien

ts

(7)

2005:Reis

et

al.

Cross-sectio

nalsurvey

H

ealth

w

o

rkers

at

a

tertiary

facility

in

4

states

o

f

N

igeria

T

o

assess

th

e

exten

t

o

f

discriminatio

n

again

st

PLHIV

(8)

2006:

Ad

eo

ku

n

et

al.

H

IV

surveillan

ce

p

ro

ject

M

arket

wo

men

in

Ib

ad

an

and

Ogb

o

mosho,So

u

th

W

est

Nigeria

T

o

assess

th

e

eff

ect

o

f

b

ehavio

u

ralchange

in

terven

tio

n

o

n

HIV

stigma

and

discriminatio

n

(9)

2007:

Babalo

la

Cross-sectio

nalsurvey

P

o

p

u

latio

n

-b

ased

sam

p

le,B

au

chi

(N

o

rth

E

ast)

an

d

K

ano

(N

o

rth

W

est),N

igeria

T

o

assess

th

e

relatio

n

ship

b

etw

een

individ

u

alp

erceived

stigma,co

mm

unity

stigma

(so

cialn

o

rm),and

attitude

to

V

CT

.M

ale

an

d

females

w

ere

an

alysed

sep

arately

Stigma

was

u

sed

as

m

ain

IV

(10)

2008:B

ukar

et

al.

Cross-sectio

nalstud

y

am

o

n

g

D

en

talprofession

als

in

on

e

state

in

each

region

of

Nigeria

T

o

in

vestigate

d

iscriminatio

n

again

st

PLHIV

amo

n

g

d

en

talprofession

als

(11)

2008:

Lap

in

sk

i

an

d

Nw

u

lu

Field

exp

erimen

t:G

ro

u

p

1

exp

osed

to

a

fi

lm

versus

ano

th

er

gro

u

p

n

o

t

exp

o

sed

C

o

mm

unity-based

stud

y,A

b

u

ja,N

o

rth

C

en

tralN

igeria

The

assess

th

e

efficacy

o

f

an

ed

u

catio

n

-en

tertainmen

t

in

terven

tio

n

(fi

lm)

o

n

H

IV

risk

p

ercep

tio

n

s

and

p

erceived

stigm

a

(12)

2009:

Ad

ew

u

ya

et

al.

Cross-sectio

nalstud

y

P

L

HIV

at

a

p

rivate

H

IV/AIDS

care

cen

tre

in

So

u

th

West

N

igeria

D

etermine

p

revalence

and

facto

rs

asso

ciated

w

ith

PT

SD

ind

u

ced

b

y

a

stigmatisin

g

even

t

amo

n

g

PLHIV

(13)

2009:

Babalo

la

et

al.

Seco

n

d

ary

an

alysis

o

f

cro

ss-sectio

n

al

survey-N

atio

nalHIV/AIDS

and

Rep

ro

d

uctive

H

ealth

Su

rvey

(N

ARHS)

2005

P

opu

lation

-b

ased

n

ation

ally

represen

tative

sam

p

le

T

o

determine

the

relatio

n

ship

b

etw

een

m

edia

exp

osure,

co

mm

unity

media

saturatio

n,an

d

accep

tin

g

attitudes

to

PLHIV

in

N

igeria

(14)

2009:Sad

o

h

et

al.

Cross-sectio

nalstud

y

H

ealth

care

w

o

rkers

at

a

facility

in

So

u

th

E

astern

N

igeria

T

o

do

cu

men

t

th

e

attitude

o

f

health

w

o

rkers

to

co

lleagues

infected

w

ith

H

IV

(15)

2010

:

Fako

lad

e

et

al.

Seco

ndary

analysis

o

f

N

ARHS

20

03,

2005,an

d

2007

data

P

opu

lation

-b

ased

n

ation

ally

represen

tative

sam

p

le

A

ssess

th

e

im

p

act

o

f

m

ass

m

edia

exp

o

sure

o

n

HIV

stigma

an

d

d

iscriminatio

n

(16)

2010

:M

bo

n

u

et

al.

Qualitative

m

etho

d:in-dep

th

in

terview

(ID

I)

C

o

mm

unity

mem

b

ers,health

care

wo

rkers

and

PLHIV

in

P

o

rt-H

arco

urt,So

u

th

So

u

th

N

igeria

T

o

exp

lo

re

p

o

w

er-related

diff

erences

b

etw

een

m

en

an

d

w

o

men

in

their

reactio

n

s

to

p

eo

p

le

livin

g

w

ith

HIV/AIDS

at

family,co

mm

unity,and

so

cietal

(in

stitu

tio

n

al)

level

(17)

2010

:Smith an

d

Mbak

w

em

ID

I

and

observatio

n

in

20

0

4,20

0

6

,and

2007

PLHIV

selected

fro

m

a

tertiary

treatm

en

t

facility

in

O

w

erri,So

u

th

E

ast

N

igeria

T

o

explore

th

e

repro

d

u

ctive

life

of

H

IV

-p

o

sitive

m

en

an

d

wom

en

an

d

u

n

d

erstan

d

h

o

w

th

ey

b

alan

ce

m

ed

ical

ad

vice

with

so

cietalexp

ectatio

n

s

ab

o

u

t

m

arriage

and

repro

du

ction

4

AIDS Research and Treatment

Ta

b

le

1:C

o

n

tin

u

ed

.

SN

Ref:au

th

o

r

(year)

Stud

y

d

esign

Stu

d

y

p

o

p

u

latio

n

an

d

lo

catio

n

O

b

jectives

(18)

2011:

Ad

eb

ayo

et

al.

Seco

ndary

analysis

o

f

N

ARHS

20

03,

2005,an

d

2007

data

P

opu

lation

-b

ased

n

ation

ally

represen

tative

sam

p

le

E

xp

lo

re

levels,trends,and

geograp

hicalvariatio

n

s

in

accep

tin

g

attitude

to

PLHIV

(stigma

measure)

(19)

2011:

Win

skellet al.

T

extualanalysis

o

f

n

arratives

fro

m

a

writin

g

co

n

test

o

n

HIV

stigma

Y

outh

p

articip

an

ts,E

n

u

gu

,South

E

ast

N

igeria

C

o

mp

are

so

cialrep

resentatio

n

o

f

sym

b

o

lic

stigm

a

(mo

ralistic

b

lamin

g

and

shamin

g

o

f

those

infected)

across

6

co

un

tries

(20)

2012:

Ow

o

lab

i

et

al.

Cross-sectio

nalstud

y

PLHIV

at

a

tertiary

treatm

en

t

facility

in

Ilo

rin

N

o

rth

Cen

tral,N

igeria

D

escrib

e

th

e

levelo

f

stigma

an

d

d

iscriminatio

n

faced

b

y

AR

T

p

atien

ts

(21)

2013:B

lessed

an

d

O

gb

alu

Cross-sectio

nalstud

y

PLHIV

at

a

tertiary

facility

in

SE

N

igeria

D

escrib

e

the

fo

rm

s

o

f

stigm

a

exp

erienced

b

y

PLHIV

(22)

2013:

K

avanaugh

et

al.

Cross-sectio

nalstud

y

C

o

mm

unity-based

sam

p

le;L

agos

(So

u

th

W

est),B

en

ue

(N

o

rth

C

en

tral),K

ad

una

(N

o

rth

W

est),and

En

ugu

(So

u

th

W

est)

D

escrib

e

co

mm

unity

attitudes

to

wards

p

o

ssib

le

outcom

es

of

pregn

an

cy

b

y

H

IV

-p

o

sitive

w

om

en

(ab

o

rtio

n

o

r

b

irth)

(23)

2013:

O

dimeg

wu

et

al.

M

ixed-meth

o

d

cross-sectio

nalstud

y

C

o

mm

unity-based;O

sogb

o

(So

u

th

W

est)

an

d

Orlu

(So

u

th

E

ast)

N

igeria

D

escrib

e

attitude

o

f

co

mm

unity

mem

b

ers

to

P

LHIV

an

d

h

o

w

th

is

affects

V

C

T

u

ptake

(24)

2013:O

ko

ro

r

et

al.

Q

u

alitative

exp

lo

ration

(F

G

D

an

d

IDI)

C

om

m

u

n

ity-b

ased

organ

isation

in

South

W

est

N

igeria

E

xp

lo

re

h

o

w

stigma

aff

ects

AR

T

ad

h

erence

an

d

the

eff

ect

o

f

A

R

T

o

n

p

erceived

stigm

a

(25)

2013:Seko

n

i

an

d

O

wo

aje

Cross-sectio

nalstud

y

H

ealth

care

workers

at

P

rim

ary

H

ealth

care

C

en

tres

in

K

w

ara

State,N

o

rth

C

en

tralN

igeria

T

o

in

vestigate

stigma

and

discriminatio

n

again

st

PLWH

A

amo

ng

PH

C

w

o

rkers

(26)

2014

:

Aran

siola

et

al.

Qualitative

stu

d

y

PLHIV

at

a

seco

ndary

h

ealth

facility

in

So

u

th

W

est

Nigeria

T

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AIDS Research and Treatment

5

Electronic search of

databases: 164 articles

Excluded: 132 articles

[did not address HIV

stigma or discrimination]

32 articles selected for

review

Population-based

studies: 13 articles

Facility-based studies:

19 articles

PLHIV: 12 articles

Healthcare worker:

7 articles

Figure 1: Flow chart of articles selected for review.

HIV-stigma in Nigeria. Figure 1 shows the search results,

exclusions, and the number of articles eventually included in

the review. Of the 32 articles reviewed, 13 were population-

based studies. The remaining 19 articles were based in health

facilities (11 among PLHIV; 1 among men who have sex with

men [MSM]; and 7 among health workers). Apart from 6

articles with national representation, majority of the others

(especially those that utilised qualitative techniques) were

based in the Southern regions of Nigeria. About 60% of

all articles used quantitative techniques while qualitative

papers constituted 21.9%. Substantive findings from review of

research articles are summarised according to the study pop-

ulation: general population (community members); health-

care workers; and people living with HIV (PLHIV).

3.1. Population-Based Studies of HIV-Stigma. Many popula-

tion-based studies in Nigeria have attempted to measure

HIV-related stigma using attitudinal questions as proxy. A

tenuous challenge that emanates from many of these studies

was that the attitudinal questions used to represent stigma

were rarely the same across different studies. One of the earli-

est community-based research on HIV-stigma in Nigeria was

a mixed-method study conducted in South West and South

East Nigeria in the early 2000s [18] but published in 2013 [19].

Seven dimensions of HIV-stigma were measured using ques-

tions about attitudes of community members towards anyone

living with HIV. These dimensions were negative feelings,

coercive attitudes, attribution of blame, avoidant behaviours,

symbolic contact, interaction with PLHIV, and attitude to an

infected partner. Results showed that there was a high preva-

lence of stigma and discrimination across these domains and

stigma was also found to be associated with low uptake of

voluntary counselling and testing. It was as high as 85% for

avoidant behaviours. Participants from the South Eastern

region exhibited stigma more than those from the South West

[19]. Negative relationship between HIV-stigma and VCT was

also documented among youths in North Eastern and North

Western part of Nigeria [20]. Adopting the collectivity of

behaviour model, the authors investigated three dimensions

of perceived stigma (labelling, relationship, and status disclo-

sure) at individual and community levels. High level of stigma

was associated with lower odds of VCT and the effect was

even stronger at the community level. There were also gender

differences with females showing greater level of stigma.

Other population-based studies of HIV-stigma in Nigeria

have used accepting attitude as indicator [21, 22]. Incidentally,

these were based on nationally representative samples of men

and women aged 15–59 and 15–49 years, respectively, with

higher prevalence of stigma among women. Analysis of the

2005 National HIV/AIDS and Reproductive Health Survey

(NARHS) data revealed that exposure to media information

about HIV/AIDS was associated with increased knowledge

about the infection and ultimately translated to better accept-

ing attitude [22]. Regional differences in HIV-stigma were

also observed despite adjustment for individual character-

istics and community media exposure. Adebayo et al. [21]

analysed data from the NARHS 2003–2007 to provide evi-

dence on improvement in the level of accepting attitude in

Nigeria over this period. In a recent analysis of Nigeria Demo-

graphic and Health Survey (NDHS) 2013 data, Dahlui et al.

[23] showed that about half of Nigerians still exhibited stig-

matizing attitude against PLHIV. This was found associated

with younger age, urban residence, lack of formal education,

and poor household wealth quintile. The measure of stigma

6

AIDS Research and Treatment

was two attitudinal questions which focused on blaming and

shaming of persons living with HIV.

Fertility desires among people living with HIV have

attracted attention of researchers especially with improved

quality of life offered by ART [24]. To fill important gap about

the attitude of people to reproductive decisions of HIV-

positive women, a community-based study was conducted in

Nigeria and Zambia to describe attitudes towards abortion or

childbirth by HIV-positive pregnant women [25]. The Nigeria

arm of the study was conducted in selected enumeration areas

in Lagos (South west), Enugu (South east), Benue (North

Central), and Kaduna (North West). Findings revealed that

the level of stigma against birth or abortion by HIV-positive

pregnant women was low and similar between men and

women. Lack of formal education was the main factor

independently associated with stigmatizing attitude towards

abortion or childbirth by HIV-positive woman [25]. Analysis

was not stratified by state because of the multicountry nature

of the study. Therefore, it is not known whether there were

variations across the four states (regions) where the study was

conducted in Nigeria.

Few of the population-based studies of HIV-stigma in

Nigeria have some semblance of interventions to assess the

effectiveness of health educational intervention on stigma re-

duction. All the three studies in this category utilised a quasi-

experimental design and showed that stigma reduction can

be achieved using educational interventions. Although the

interventions were conducted among market women [16],

secondary school students [26], and student nurses [27], the

efficacy of this approach in the larger population has been

demonstrated in a field experiment [28] and analysis of

repeated cross-sectional data [29].

Very few community-based qualitative studies of HIV-

stigma were found in the course of the review. Incidentally,

these were mostly based in Southern parts of Nigeria. Evi-

dence from the south west revealed that social constructions

of HIV-stigma are deeply rooted in cultural beliefs and per-

ceptions about the lifestyle of those infected [16, 19]. A cross-

national textual analysis of narratives from a writing contest

among youths was conducted to compare social represen-

tation of symbolic stigma in six SSA countries including

Nigeria [30]. The findings pointed to the fact that social

representation of stigmatizing attitudes often pertained to the

circumstances around the process of HIV infection though

there were variations across the six sociocultural contexts

analysed. Negative views about PLHIV were more predom-

inant in low HIV prevalence settings. The study further

revealed that Nigerian participants who were selected from

the South Eastern part displayed the highest cases of symbolic

stigma [30]. To shed more light on the gender differences

in HIV-stigma, Mbonu et al. [31] adopted Cornell’s theory

of gender and power to explore power-related differences

between men and women in their reactions to PLHIV at fam-

ily, community, and institutional level. In-depth interviews

were conducted among community members, healthcare

providers, and PLHIV. The study also showed that stigmatiz-

ing behaviour was worst against women and was a reflection

of the subsisting power imbalance that exists in patriarchal

societies such as Nigeria. This imbalance manifested in forms

of financial inequality, authority, and structural norms.

3.2. Facility-Based Studies of HIV-Stigma in Nigeria. The sec-

ond group of studies on HIV-stigma found to be common in

Nigeria were those conducted in health facilities. As expected,

the study population were either healthcare providers or

PLHIV who receive care and treatment from the facilities. An

important observation about many of these studies was that

they were domiciled mostly in facilities providing specialist or

tertiary care and as such were in urban areas. Findings from

the review of these studies are summarised according to the

study population, healthcare workers and PLHIV.

3.2.1. Healthcare Workers. Majority of the studies among

healthcare workers were conducted around early and mid-

2000s. This was a time that could be referred to as the peak of

the HIV epidemic in Nigeria. Virtually all of them were aimed

at accessing attitudes towards care and treatment of PLHIV.

The earliest among these studies was a quasi-experimental

study in South South Nigeria by Ezedinachi et al. [32]. They

documented unwillingness to treat, fear, and avoidance of

PLHIV among clinicians. Following educational interven-

tions, data collected one year later showed there was signif-

icant decline in stigmatization and discriminatory behaviour

towards PLHIV [32]. Preponderance of stigma against

PLHIV was very common in all the other studies found in this

category and this was similar among clinicians [33], dental

and oral health professional [34–36], nurses, and medical

lab scientists [37]. In anticipation of the potential roles of

primary healthcare workers in care and treatment of PLHIV,

a study in North Central Nigeria showed similar findings of

a high level of stigma which often manifest in form of fear of

casual transmission, shaming and blaming, discrimination,

and status disclosure [38].

3.3. Stigmatization Experiences among People Living with

HIV. The second group of facility-based studies are those

that documented stigmatization and discrimination experi-

ences among PLHIV. Prevalence of stigmatizing experiences

varied widely, ranging from 8% to 60%. This wide variation is

due to the diverse indices/measures used for stigma. In fact,

no two studies defined or measured HIV-stigma in the same

manner. This posed limitations to study comparisons and

generalisation from one study setting to another. As observed

earlier, majority of the studies in this category were conducted

at tertiary health facilities in Southern Nigeria except one at a

Teaching Hospital in North Central region by Owolabi et al.

[39]. In the paper, 25% of ART patients reported that they

had experienced stigma or discrimination at family, hos-

pital, and community levels and at the workplace. Forms

of stigma experienced included blaming for being HIV-

positive and name calling (prostitute, skeleton, and unfaithful

person among others). Examples of discriminatory practices

against PLHIV were hospital (selective use of gloves, poor

quality care, and isolation from other patients); community

(social isolation, restriction in family events, and hostility);

family (not sharing of cutleries and toilet facilities, breach

of confidentiality); workplace (threat of employment termi-

nation, isolation by coworkers). Adapting the Berger stigma

scale [40], forms of stigma experienced by PLHIV were

also documented in a cross-sectional study conducted at

AIDS Research and Treatment

7

another tertiary facility in South East Nigeria [41]. These were

personalised/internalised stigma, status disclosure, negative

self-image, and concerns about public attitude. Females were

found to experience higher degree of the first three dimen-

sions. A weakness of the paper was that the stigma scale was

treated as a continuous measure and scores were generated

for analyses. It was therefore difficult to estimate the magni-

tude or prevalence of stigma in the four domains examined.

The burden of stigma among PLHIV may be higher than

documented in quantitative studies as findings from FGD

participants in Lagos, Nigeria, showed that almost 75%

reported that life has become very traumatic due to stigmati-

zation from friends, family members, healthcare workers, and

workplace [42]. Studies have shown that stigma was associ-

ated with ART adherence and mental health status of PLHIV.

For instance, low stigma level was found to be associated

with good ART adherence among participants in a cross-

sectional study at a tertiary facility in South West Nigeria [43].

Regarding the consequences of HIV-related stigma, Adewuya

et al. [44] found that 27.3% of patients who had experienced

stigmatizing events such as isolation and blaming had post-

traumatic stress disorder (PTSD). The study was conducted

at a private HIV/AIDS care facility in South West Nigeria. It

is suspected that the situation could be worst in public health

facility where there are larger patient population and there-

fore greater pressure on healthcare providers. Evidence from

another study in South East region suggests that the preva-

lence of depression was 33.3% and this was associated with

negative self-image domain on the Berger HIV scale [45].

Personalised or internalised stigma was also associated with

lesser likelihood of status disclosure among PLHIV [46].

These limit the self-esteem and confidence among PLHIV

with a negative consequence on their overall mental health

status.

Quite a few qualitative studies have also explored the

experiences of stigma and discrimination among PLHIV.

Results from focus group discussion in Southern parts of

Benue State in North Central region of Nigeria highlighted

the high level of rejection and discrimination of PLHIV in the

late 1990s [47]. Isolation and avoidance of those infected by

HIV were a common practice fuelled by fear of being infected

by “a disease without cure.” Community members believed

that caring for anyone infected by HIV was waste of resources

because HIV was more like a death sentence [47]. With better

awareness and availability of ART, the negative perception

has waned over time such that PLHIVs also desire to fulfil

social expectations about marriage and reproduction [48].

Ethnographic case studies from South East Nigeria actually

showed that marriage and reproduction by HIV-positive men

and women are strategies used to confront the problem of

HIV-stigma [48].

Drawing on Deacon’s framework [49], a qualitative explo-

ration of stigma before and after ART initiation revealed very

interesting findings about the dynamic nature of stigma [50].

The central argument of the Deacon’s framework was that

stigma is a dynamic sociocultural phenomenon that changes

in response to different situations [49]. Based on this premise,

stigma could be classified as self-stigma, anticipated stigma,

and enacted stigma. Before ART, there were experiences of

self-isolation, fear of death, family withdrawal, rejection, and

abandonment [50]. After ART commencement, with better

or healthier physical appearance, family and community

members began to accept PLHIV and status disclosure also

improved. In sum, stigma was a motivator for treatment

adherence which in turn reduced self-stigma, enacted stigma,

and anticipated stigma [50]. This evidence needs to be further

substantiated because participants in the study were recruited

from a community-based organisation. If participants had

been recruited from a public health facility, could the findings

be different? Another exploratory study of stigma and sur-

vival challenges among ART patients at a secondary health

facility in South West Nigeria revealed that stigmatizing

experiences were low among family members but high from

nonfamily members including health workers [51]. The study

also showed that some well-intentioned social interventions

(such as packaged food parcels for nutritional supplementa-

tion) for PLHIV ended up stigmatizing them. In the face of

these daunting challenges of stigma and discrimination, a

study in Lagos, South West Nigeria, documented the coping

strategies that have been deployed by PLHIV. The most

common were maintaining a low public profile by avoiding

public functions, avoiding seeking care in public health facil-

ities, and nondisclosure of serostatus [42]. Of course, these

approaches do not augur well for universal coverage of care,

treatment, or support and it is a serious threat to secondary

prevention of HIV infection.

We found a study conducted among MSM in North Cen-

tral Nigeria which investigated the impact of the law prohibit-

ing such relationship in Nigeria [52]. The authors argued that

there was increased fear of stigma and discrimination among

this key population and as a result, access to care was affected.

3.4. Policies Related to HIV-Stigma in Nigeria. In Nigeria,

policies and programmes for the national HIV response are

coordinated by the National AIDS Control Agency (NACA).

Other key partners include the Federal Ministry of Health

(FMoH) as well as the State AIDS Control Agency (SACA)

and Ministries of Health in the 36 states of the Federation.

Policies are usually formulated at the national level and

domesticated by the states. Though the administrative struc-

ture in Nigeria stipulates that states are federating units with

autonomy to develop their own policies and programmes on

issues such as health and education, there is a lot of synergy

and cooperation among the federal and state government

agencies. In this review, only policies and programmes

enacted by the national government are reviewed because

they apply across the entire country. Also, in order not to lose

sight of the aim of this paper, we focused on the policy and

programme components related to HIV-stigma.

3.4.1. National HIV/AIDS Policy. The current HIV/AIDS pol-

icy in Nigeria was launched in 2009 [53]. Prior to that, similar

policies have been formulated in 1997 and 2001. The 2009 pol-

icy document adopted a multisectoral approach to the fight

against HIV in Nigeria. Therefore, its formulation involved

extensive stakeholder engagement across public sector, pri-

vate sector, and international development partners. Among

the guiding principles of the 2009 policy was protection of

8

AIDS Research and Treatment

rights of PLHIV and reduction of stigma and discrimination.

The six strategic thrusts of the policy were (1) behaviour

change and prevention of new infections; (2) treatment; (3)

care and support for infected and affected persons; (4) institu-

tional architecture and resourcing; (5) advocacy, legal issues,

and rights; (6) monitoring and evaluation; (7) research and

knowledge management. Stigma and discrimination were

part of several policy objectives under strategic thrusts 1, 2, 3,

and 5. The policy document clearly stated that “the rights

of PLHIV include freedom from stigma and discrimina-

tion.” Stakeholders with stigma related responsibilities were

national and state legislative assemblies (promoting policy

dialogue and leading advocacy to reduce stigma and discrim-

ination); faith-based organisations (advocacy for care and

support; promoting stigma and discrimination reduction);

traditional and religious leaders (supporting HIV/AIDS pro-

grammes and advocate for stigma reduction). Surprisingly,

the policy document was silent on specific strategies to

reduce stigma and discrimination under treatment, care, and

support services.

3.4.2. The 2010–2015 HIV/AIDS National Strategic Plan (NSP).

This was the third in a series of plans to combat HIV epidemic

in Nigeria. The first plan captioned HIV/AIDS Emergency

Action Plan (HEAP) 2001–2003 was developed in early 2001

and targeted at public awareness about the epidemic. Its

successor was the National Strategic Framework for Action

2005–2009 developed in 2004/2005. It served as blueprint

on implementation for different stakeholders. The 2010–2015

NSP [54] which has already completed its lifespan at the

time of this review had six thematic areas which were lifted

directly from the strategic thrust in the 2009 HIV/AIDS

policy document. In the NSP, stigma and discrimination

featured as an objective under care and support services. The

strategic aim was “to reduce stigma and discrimination (S and

D) against PLHIV and PABA by at least 60% of the baseline

value by 2015.” Though the baseline year was 2010, the value

is unknown. Thus, it is difficult to assess whether the target

of 60% reduction has been met or not. Furthermore, S and D

reduction was also listed among the activities to be carried

out under policies, rights, and legal issues. Perhaps, the

revision and eventual publication of the National HIV/AIDS

Workplace policy in 2014 is an evidence of achievement on

this note. Related to this are the passing and signing into law

of the Nigeria’s HIV/AIDS Antidiscrimination bill.

3.4.3. National Workplace Policy on HIV and AIDS. The

Nigeria National Workplace Policy on HIV and AIDS was

first developed in 2005 to address the workplace response to

the epidemic. The latest review was adopted and published

in 2013 [55]. Such a policy became necessary because the

population most affected by HIV in Nigeria are youths and

those who are in the reproductive age groups. These also

constitute the workforce of the country. Latest review was

necessitated by three factors: changing epidemiology of HIV

in the country; revision of the national HIV/AIDS policy

which was its parent document; and implementation of the

International Labour Organisation (ILO) recommendation

200 on HIV and AIDS in the workplace [56]. Nigeria is

a signatory to several ILO recommendations and conven-

tions. Guided by the 2009 National Policy on HIV and

AIDS, the workplace policy document showed linkages with

several other documents and legislations in Nigeria. One

of the eight specific objectives of the policy focused on

“eliminating discrimination and stigmatization in the work-

place based on real or perceived HIV status including deal-

ing with HIV testing, confidentiality, and disclosure.” The

scope of the policy includes both public and private sectors

including the uniformed services. Its guiding principles also

conspicuously included “nondiscrimination” alongside nine

others. To ensure that majority of Nigerians remain HIV-

negative, the strategies itemised to achieve the objectives

of the policy include prevention, HIV testing, treatment,

care, and support, and promotion and protection of workers’

rights. Responsibilities for the following stakeholders were

also spelt out: Federal Ministry of Labour and Productivity,

employers, workers, and their organisations, National Agency

for Control of AIDS, State Agency for Control of AIDS,

and National Steering Committee for HIV Workplace Issues.

Curiously, implementation and action plans which were to be

developed by different stakeholders are still being awaited.

3.4.4. Nigeria’s HIV and AIDS Antidiscrimination Act, 2014.

First introduced to the National Legislature in 2005, the

bill was passed and signed into law in April and November

2014, respectively. It serves a significant milestone in the

national response to HIV/AIDS in Nigeria. This is because the

nonpassage of the bill was a recurrent comment in the PLHIV

stigma index and gender assessment report which are both

reviewed in the next sections. The antidiscrimination act was

very clear on rights of individuals [57]; their responsibilities;

institutional obligations; and penalties for violations. It stipu-

lates that PLHIV have rights to privacy about their serostatus,

employment, welfare benefits, compensation, appeal, and

recourse to courts as well as occupational safety. All Nigerians

have responsibility to prevent stigma and discrimination. The

responsibilities of PLHIV were disclosure of status to partner,

demand for their right, and reporting of violations. Obli-

gations of institutions, employers, and communities include

protecting rights of PLHIV; providing equal opportunities

to PLHIV; confidentiality of information; development of

HIV/AIDS workplace policy; compensation for occupational

HIV infection. Penalties for violations of the laws in the

antidiscrimination act could be fines and/or imprisonment.

Available information from the legal unit of NACA is that

the act has been domesticated in 17 states across Nigeria.

Two years after the law became active, there is a need for

empirical evidence on the level of awareness; compliance; and

the impact of the law on different aspects of the national HIV

response in Nigeria. This is very crucial for the development

of the next strategic response plan. Anecdotal evidence shows

that lack of laws is not the main problem.

3.5. National HIV/AIDS Stigma Reduction Strategy, 2016. In

response to the formidable threats posed by stigma and dis-

crimination to the success of HIV prevention and treatment

programmes, NACA in collaboration with other stakeholders

developed the stigma reduction strategy for Nigeria [58].

AIDS Research and Treatment

9

Launched in November 2016, the goal of the strategy docu-

ment was to “eliminate all forms of stigma and discrimination

against people infected and affected by HIV in Nigeria by

the year 2020.” It has nine strategic objectives with one

contributing to the goal from different operational perspec-

tives cutting across community-based organisations, faith-

based organisations, media, entertainment and art industry,

health and education institutions, and employers of labour

(private and public), PLHIV and PABA. In other words, it was

designed to achieve synergy among different players work-

ing with responsibilities to reduce/eliminate HIV-stigma

with each entity leveraging on its comparative strengths

in their jurisdictions, domains of coverage, and influence.

Several strategic actions were listed including survey on

behavioural, biomedical, and structural drivers of stigma and

discrimination at different levels, increasing awareness about

related laws. This national stigma reduction strategy actually

integrated many of the UNAIDS suggestions on programmes

and initiatives to promote stigma reduction at individual,

community, structural, and institutional levels [2, 59].

3.6. Programmes Related to HIV-Stigma in Nigeria. Country

annual report on the global response to HIV usually sub-

mitted to UNAIDS provides a comprehensive description of

programmes implemented as part of the national response to

HIV in Nigeria [4]. The commonest programme targeted at

HIV-stigma and discrimination reduction in Nigeria is media

and awareness campaigns aimed at educating the populace

about HIV and ultimately reduce stigma and discrimination.

Other approaches include the strategies deployed for univer-

sal counselling, testing, and treatment. The main philosophy

of the approach was that if HIV is seen as a chronic condition

just like hypertension or any other, then the infection would

be better humanized thereby reducing stigma and discrim-

ination against those infected and affected by HIV. Two

other programmes related to HIV-stigma in Nigeria were the

PLHIV stigma index measurement [60] and the Legal Envi-

ronment Assessment in the HIV response [61].

3.6.1. The PLHIV Stigma Index. The stigma index was

designed to collect data on stigma, discrimination, and rights

of people living with HIV. It was also aimed at serving as an

advocacy tool and a way to operationalize the principle of

Greater Involvement of People Living with HIV (GIPA). As

of September 2013, it has been used in more than 50 countries

including Nigeria. Further details on the development and

processes involved in using the index are available on its

dedicated website (www.stigmaindex.org).

In Nigeria, the index was applied by Networks of Peo-

ple Living with HIV and AIDS in Nigeria (NEPWHAN)

in late 2009. Data was collected from 706 persons living

with HIV selected from support groups in 12 states of the

federation. The interviewers were also PLHIV. Report from

the assessment documented several experiences of stigma

and discrimination across three themes: exclusion, access to

work, health, and educational services; internalised stigma;

and fears [60]. Nearly one-third of respondents reported

that they have been excluded from family and religious or

other social functions due to their HIV status. A similar

percentage also reported that they have experienced denial to

health and educational services. Internalised stigma in form

of shame, feeling of low self-esteem, and blaming oneself was

reported by about 63%. In a nutshell, the index showed that

stigma and discrimination experiences were prevalent among

PLHIV in Nigeria. It is noted that the stigma assessment was

done before the enactment of antidiscrimination law. Also,

several programmes and initiatives have been implemented

which must have influenced the narratives about HIV S and

D in Nigeria. A repeat application of the stigma index is

necessary to empirically assess the impacts of these various

interventions.

3.7. Legal Environment Assessment for HIV/AIDS Response

(LEA) in Nigeria. There has been a drive at international

and regional levels to use laws as tools for HIV elimination.

Particularly, to improve equity in access to services among

key populations, law and regulatory environment must not

be prohibitive. For instance, in Nigeria, HIV prevalence is

higher among brothel-based female sex workers (19.4%),

non-brothel-based female sex workers (8.6%), and men

having sex with men (22.9%) [62]. Incidentally, there is a

law prohibiting same-sex relationships in Nigeria. Empirical

investigation of the effect of this law showed that it increased

the incidence of stigma and discrimination against MSM such

that they are afraid of accessing HIV care and treatment from

public health facilities [52].

Stigma and discrimination are a main driver of inade-

quate access to care and treatment among these key pop-

ulations. This would constitute a weak link in the HIV

prevention efforts if an enabling environment is not created

to protect this group against marginalisation and stigma.

The LEA in Nigeria was therefore designed to identify

and review existing laws, regulations, and policies that could

impact the national HIV response. Varieties of qualitative

research methodologies (desk review, focus group discus-

sion, in-depth interview, and key informant interview) were

employed for the exercise. Findings showed that the legal

environment in Nigeria is weak for effective human rights

based response to HIV/AIDS [61]. Even though the 1999 con-

stitution (amended) guaranteed rights of individuals against

stigma and discrimination in any form, the institutional

mechanisms for seeking redress could be easily exploited to

the disadvantage of those in lower socioeconomic strata.

Some of the legal provisions under different laws such as the

criminal codes (which operates in Southern regions), penal

codes (in the Muslim dominated northern regions), and

same-sex marriage laws were found inconsistent [61]. While

advocating for review of many of the existing laws related

to stigma and discrimination, the LEA report also called for

legal literacy among key populations and stakeholders in the

justice sector.

4. Discussion

Although the measures used have not been consistent, there

is evidence to show that the level of HIV-stigma in Nigeria

has declined in the past two decades. This is demonstrated

in results from analysis of attitudinal questions about people

10

AIDS Research and Treatment

living with HIV in nationally representative surveys such as

the NARHS 2003, 2005, 2007, and 2012 and NDHS 2013 [21,

23, 29, 63]. At least, early stories of isolation, abandonment,

avoidance, and so forth have reduced drastically while uptake

of HIV counselling and testing have improved [4]. HIV-

stigma exists beyond the individual level and persists in

families, communities, workplace, and other institutional

contexts. Forms of HIV-stigma and discriminatory practices

vary from one setting to another and this contextual dif-

ference is driven by economic and sociocultural diversity

characteristic of Nigeria. At the base of this is the problem

of power and inequality which visibly manifests as gender

differences in HIV-stigma. Apart from the effect of stigma

on testing, treatment uptake, adherence, care, and support,

there is emerging evidence of a negative effect on treatment

outcomes (quality of life and mental health). This review also

found that PLHIVs have devised different positive and nega-

tive responses to stigma. Example of a positive response is by

choosing to maintain good adherence so that physical health

and overall quality of life can be like that of HIV-negative

individuals. Another one is their family formation behaviour

which is strongly motivated by a desire to demystify the

misconceptions that fuel HIV-stigma and discrimination.

This review also revealed that the Government of Nigeria

with support from development partners have done a lot to

confront HIV-stigma. National policies and strategic plans

have been revised about three times to align with interna-

tional best practices as well as respond to the epidemiolog-

ical and structural dynamics of the HIV epidemic in the

country. A robust multisectoral approach with stakeholders

involvement, political will, and policy advocacy at national

and state levels have all contributed to general awareness

about the urgent need to eliminate stigma and curtail HIV

spread. To further improve on the successes recorded so far,

some recommendations are made which could strengthen the

stigma reduction programmes in the country.

There is a need for reliable, validated empirical measures

of HIV-stigma. Even though the Berger HIV-stigma scale was

applied at a facility in SW Nigeria [46], its internal consist-

ency (reliability) was just average. Measures already validated

in other SSA settings [12] can be revalidated in the country.

Availability of reliable and validated measures will facilitate

objective assessment which is very important for the monitor-

ing of the recent stigma reduction strategy in the country. The

need to monitor the impact of the 2014 antidiscrimination law

also makes this necessary.

Another reason for new measures of stigma stems from

the scale-up of ART services to secondary and primary

healthcare facilities. It is expected that a deeper population

penetration of ART would help correct the wrong belief that

HIV is a death sentence. This misconception has been respon-

sible for abandonment in the early 2000s. It also heightened

the fear of casual transmission via mere physical contact. Now

that treatment is closer to the grassroots, it ought to have

indirectly mitigated some of the stigma. Operational research

studies need to be undertaken to explore this proposition.

Much of what is known about HIV-stigma in Nigeria have

come largely from research studies in North Central, South

East, South West, and South South regions. Considering the

evidence about the dynamic sociocultural nature of stigma,

there is need for complimentary evidence from the North

East and North West regions. The case for the North East

is even more sacrosanct because of the internal population

displacement occasioned by the Boko Haram insurgency.

There is anecdotal evidence of increased new HIV infections

in internally displaced persons (IDP) camps. Although some

of these internally displaced persons are being resettled in

their communities, the level of HIV-stigma in IDP camps

must have been enormous. The experiences of those affected

and how they coped with the challenges would provide useful

lessons for stigma reduction programmes in Nigeria.

Another implication of the preponderance of HIV-stigma

studies in Nigeria being domiciled in tertiary health facilities

is that they also provide information about urban areas.

Could stigma be higher in rural areas? Evidence from

population-based surveys suggests that stigmatizing attitudes

towards PLHIV was associated with lower education, poverty,

and poor knowledge of HIV [23, 63]. These features are

characteristic of rural settings in Nigeria. In addition, the only

facility-based study among health workers in primary health

centres also showed that stigma was high among this cadre of

health workforce [38]. These are kinds of facilities that exist

in most rural areas. Therefore, it can be expected that stigma

will be higher in rural areas.

The legislative environment in Nigeria is not favourable to

key populations at risk of HIV such as MSM. This may also

explain why investigation of HIV-stigma in this population is

rare. The only study among this group showed that enactment

of the law prohibiting same-sex partnership in Nigeria has

contributed to higher level of fear [52], although, prior to the

legislation, the existing social environment cannot be claimed

to be conducive to MSM. Therefore, it is difficult to draw a

definitive conclusion about the effect of the new law.

5. Conclusion

Without prejudice to other strategies aimed at eliminating

HIV by year 2030, stigma and discrimination reduction is

a priority. Research, policies, and programmes in the past

decade have made tremendous contributions to this drive.

Newer approaches tailored to the epidemiological and social

contexts of individual countries would continue to evolve. In

this regard, this paper reviewed research studies, policies, and

programmes related to HIV stigma in Nigeria, the country

with the second largest number of people living with HIV

in the world. This review identified the need for a consistent

valid and objective measure of stigma at different levels of

the HIV response. Empirical evidence on the awareness and

effect of anti-HIV discrimination law and other interventions

are urgently needed. Nigeria is not lacking in policies as this

review shows that the country is nearly up to date in com-

pliance with UNAIDS guidelines on several policy require-

ments. What need to be strengthened are programmes de-

sign, planning, monitoring, and evaluation. It is necessary to

intensify advocacy, awareness, and enforcement of the anti-

HIV discrimination law. It is also very important to develop

systems for evaluating the impact of stigma and discrimi-

nation reduction programmes at national and subnational

levels.

AIDS Research and Treatment

11

Conflicts of Interest

The authors declare that there are no conflicts of interest

regarding the publication of this paper.

Acknowledgments

The authors are grateful to CODESRIA African Academic

Diaspora Support for Diaspora Research Partnership Net-

work/Visiting Professorship to African Universities, for the

financial support to implement this study. They appreciate

Yomi Olatunji and Adeoluwa Aiyewumi of the National

Agency for the Control of AIDS in Abuja, Nigeria, for helping

with some policy documents used for this review.

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