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Are integrated HIV services less stigmatizing than stand-alone models of care? A comparative case study from Swaziland

Kathryn Church, Alison Wringe, Phelele Fakudze, Joshua Kikuvi, Dudu Simelane, Susannah H Mayhew, and The Integra Initiative


Introduction: Integrating HIV with primary health services has the potential to reduce HIV-related stigma through delivering care in settings disassociated with HIV. This study investigated the relationship between integrated care and felt stigma. The study design was a comparative case study of four models of HIV care in Swaziland, ranging from fully integrated to fully stand-alone HIV care.

Methods: An exit survey (N=602) measured differences in felt stigma across model of care; the primary outcome ‘‘perception of HIV status exposure through clinic attendance’’ was analyzed using multivariable logistic regression. In-depth interviews (N=22) explored whether and how measured differences in stigma experiences were related to service integration.

Results: There were significant differences in perceived status exposure across models of care. After adjustment for potential confounding between sites, those at a partially integrated site and a partially stand-alone site had greater odds of perceived status exposure than those at the fully stand-alone site (aOR 3.33, 95% CI 1.98-5.60; and aOR 11.84, 95% CI 6.89-20.36, respectively). There was no difference between the fully stand-alone and the fully integrated clinic. Qualitative data suggested that many clients at HIV-only sites felt greater confidentiality knowing that those around them were positive, and support was gained from other HIV care clients. Confidentiality was maintained in various ways, even in stand-alone sites, through separate waiting areas for HIV testing and HIV treatment, and careful clinic and room labelling.

Conclusions: The relationship between model of care and stigma was complex, and the hypothesis that stigma is higher at standalone sites did not hold true in this high prevalence setting. Policy-makers should ensure that service integration does not increase stigma, in particular within partially integrated models of care.

Keywords: systems integration; health services research; stigma; HIV; primary care; reproductive health services

(Published: 11 January 2013)

Church K et al. Journal of the International AIDS Society 2013, 16:17981 |

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Journal of the International AIDS Society | eISSN 1758-2652 | Editors-in-Chief: Susan Kippax, Kenneth Mayer and Papa Salif Sow 

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