Stigma and Discrimination Indicator 1

Accepting attitudes towards those living with HIV

Core indicator for all epidemics

Definition

The percent of people expressing accepting attitudes towards people with HIV, of all people surveyed aged 15-49

Measurement tool

UNAIDS general population survey; DHS AIDS Module; FHI BSS (adult); FHI BSS (youth); MICS (UNICEF)

What it measures

This is an indicator based on answers to a series of hypothetical questions about men and women with HIV. It reflects what people are prepared to say they feel or would do when confronted with various situations involving people living with HIV.

How to measure it

Respondents in a general population survey are asked a series of questions about people with HIV, as follows:

• If a member of your family became sick with the AIDS virus, would you be willing to care for him or her in your household?
• If you knew that a shopkeeper or food seller had the AIDS virus, would you buy fresh vegetables from them?
• If a female teacher has the AIDS virus but is not sick, should she be allowed to continue teaching in school?
• If a member of your family became infected with the AIDS virus, would you want it to remain a secret?

Only a respondent who reports an accepting or supportive attitude on all four of these questions enters the numerator. The denominator is all people surveyed.

Strengths and limitations

Methodologically, this is a relatively easy way to construct an indicator of attitudes to people with HIV. A low score on the indicator is a fairly sound indication of high levels of stigma, and for that reason alone it is worth measuring.

There are, however, difficulties in interpreting indicators based on hypothetical questions, and a high score on the indicator is harder to understand. It could mean there is little real stigma attached to HIV. Or it could mean that people know they should not discriminate, and therefore report accepting attitudes. This may not change their behaviour, which may continue to be discriminatory towards people with HIV. Changes in the indicator could therefore reflect a reduction in stigma or simply a growing awareness that it is not nice to own up to one's prejudices. That in itself may, however, constitute the first step in programme success. High scores may also reflect the respondent's limited personal experience with someone who is HIV-infected.

The proposed indicator is similar to an earlier measure developed by WHO, but questions have been changed following field testing to better reflect situations in which people with HIV actually suffer from stigma. Field tests revealed that responses are greatly affected by the exact wording of the indicator. When the gender of the teacher was not specified, for example, one country registered very high levels of "discriminatory" attitudes on that question, for example. Further investigation showed that the negative attitudes were related to recent news reports of male teachers infecting female pupils with HIV.

The earlier WHO indicator has been little used, calling into question the utility of this measure. It is possible that it was little used because so little programming effort to date has gone in to reducing stigma surrounding HIV in most countries. As the power of stigma to obstruct prevention and care efforts becomes ever clearer, however, it is likely that more national AIDS programmes will turn their attention to this area. It is expected, therefore, that use of this indicator will increase.

It has been suggested that this indicator be used to measure differences in discrimination or stigma by gender. Although some research suggests that women are more likely than men to be treated and viewed harshly if they have HIV or AIDS, other recent surveys have shown little difference in response to gender specific questions about stigma and discrimination.

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