Prevalence of, and Factors Associated with, HIV/AIDS-related Stigma and Discriminatory Attitudes in Botswana

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1 J HEALTH POPUL NUTR 2003 Dec;21(4): ISSN $ ICDDR,B: Centre for Health and Population Research Prevalence of, and Factors Associated with, HIV/AIDS-related Stigma and Discriminatory Attitudes in Botswana Gobopamang Letamo Department of Population Studies, University of Botswana, Private Bag UB Gaborone, Botswana ABSTRACT Botswana has the highest prevalence of HIV in the world. The epidemic of HIV/AIDS is often accompanied by stigma and discrimination that create the circumstances for spreading HIV. To facilitate the design of effective programmes to fight the high prevalence of HIV/AIDS-related stigma and discriminatory attitudes, this study examined survey data on the prevalence of, and factors associated with, such attitudes in Botswana. While most respondents showed discriminatory attitudes towards a teacher or a shopkeeper with HIV/AIDS, only 11% of 4,147 respondents reported unwillingness to care for a family member with HIV/AIDS. The more tolerant attitudes towards a family member with HIV/AIDS appeared to be promoted by the fact that family members have been and continue to care for their sick members through a government project called Community Home-based Care aimed at relieving public hospitals of HIV/AIDS patients. Since the burden of caring for sick relatives rests on the shoulders of women, they portrayed more tolerant attitudes towards HIV/AIDS patients. Young people and those who believed a person could get HIV infection by sharing a meal with an HIV/AIDS patient had discriminatory attitudes towards people with HIV/AIDS. The national information, education and communication programme needs to be strengthened to reach more people for HIV/AIDS education. Finally, programmes that aim to promote more tolerant attitudes towards people with HIV/AIDS may be more effective if the human rights of those with HIV/AIDS are promoted and respected. Key words: HIV; HIV infections; Acquired immunodeficiency syndrome; Prevalence; Stigma; Discrimination; Attitudes; Botswana INTRODUCTION Botswana has the highest prevalence of HIV in the world. About 36.2% of pregnant women were HIV-positive in 2001, though this figure declined to 35.4% in 2002 (1). The impact of HIV/AIDS is substantial and has resulted in a tremendous increase in costs. One of the major impacts of HIV/AIDS is that of stigma and discrimination against those living with the disease. Correspondence and reprint requests should be addressed to: Dr. Gobopamang Letamo Department of Population Studies University of Botswana Private Bag UB 00705, Gaborone Botswana gobopamang@yahoo.co.uk or gobopamang.letamo@undp.org Fax: (267) Right from the beginning, the epidemic of HIV/AIDS has been accompanied by an epidemic of fear, ignorance, and denial, leading to stigmatization of, and discrimination against, people with HIV/AIDS and their family members (2). HIV/AIDS-related stigma and the resulting discriminatory acts create circumstances for spreading HIV (3). The fear of being identified as HIV-positive prevents people from learning their serostatus, changing unsafe behaviour, and caring for people with HIV/AIDS. A study in Botswana and Zambia found that stigma against HIV-positive people and fear of mistreatment prevented people from participating in voluntary counselling and testing and programmes to prevent mother-to-child transmission (4). The authors argued that stigma and its resulting discrimination also

2 348 J Health Popul Nutr Dec 2003 Letamo G intensify the pain and suffering of people with HIV/ AIDS and their families. There exists little or no research on how people with HIV/AIDS, or those suspected of having HIV/AIDS, are perceived and treated in Botswana because of their illness. It is quite evident from studies done elsewhere that people with HIV/AIDS are unfairly treated and/or discriminated against because of their actual or suspected HIV/AIDS status (1,2,5-7). Discrimination against people with or suspected of having HIV/AIDS is not just wrong and unjust, it is also an ineffective publichealth measure. The Government of Botswana Vision 2016 envisages a compassionate, just and caring nation (8). To achieve this goal, HIV/AIDS-related stigma and discrimination need to be addressed. HIV in Botswana is mainly transmitted through heterosexual intercourse. Most young people in Botswana become sexually active before marriage, many of them in their teens. The average age at first intercourse is 17.5 years, the average age at first marriage is 19.0 years, and the average age at first birth is 18.6 years (9). Unequal gender relations sustain the epidemic of HIV/ AIDS in the sense that there exists exploitative sexual relationship between adult males and teenagers; the misuse of power and money in sexual relations; and rape and other forms of violence against women (10). Because girls entering into relationships with older men are relatively ignorant and submissive rather than equal partners, they are unable to negotiate safer sex. Too high pregnancy-related school drop-out rates suggest the high incidence of unprotected sex in the country. People with HIV/AIDS may become implicitly associated with stigmatized behaviour, regardless of how they actually became infected. People with HIV/AIDS are stigmatized, ostracised, rejected, and shunned, and may experience sanctions, harassment, and even violence because of their infection or association with HIV/AIDS (3). Discrimination may stem from fear due to lack of knowledge about how HIV/AIDS can or cannot be transmitted. Since discrimination often includes public restrictions and punishing actions, it can be more frequently identified (3). Stigma is often rooted in social attitudes. In this study, variables of social attitudes were used for investigating the prevalence of HIV/AIDSrelated stigma and discrimination in Botswana and the factors associated with it. Individuals with HIV/AIDS are stigmatized because their illness is: (i) associated with deviant behaviour; (ii) viewed as the responsibility of the individual; (iii) tainted by a religious belief as to its immorality and/or thought to be contracted via morally-unsanctioned behaviour and, therefore, thought to represent a character blemish; (iv) perceived to be contagious and threatening to the community; (v) associated with an undesirable and an unaesthetic form of death; and (vi) not wellunderstood by the lay community and viewed negatively by healthcare providers (11). The present paper adopted a similar framework in studying the factors influencing discriminatory attitudes towards people with HIV/AIDS in Botswana. Variables that reflect knowledge and misconceptions about the transmission of HIV and those that show the socioeconomic and demographic profiles of individuals were used as predictors of discriminatory attitudes among respondents. National responses to the HIV/AIDS epidemic In responding to the HIV/AIDS epidemic, the Government of Botswana has adopted various strategies to combat the disease. Three distinct response phases can be identified (10). The early phase ( ) focused mainly on screening blood to eliminate the risk of transmission of HIV. At this early stage of the disease, HIV/AIDS was seen more as a disease that targeted male homosexuals in the West and people from other African countries. An interim short-term plan was developed for to create awareness about HIV/AIDS and to train health workers in its clinical management. During the second phase ( ), information, education and communication programmes were introduced. The first five-year Medium-term Plan (MTP1) was developed to contain the rapidly-spreading epidemic; strengthen epidemiological surveillance activities; prevent sexual and perinatal transmission of HIV and through blood and blood products; strengthen diagnosis and infection control; and set up systems for monitoring and evaluation (10). The 1993 National Policy on HIV/AIDS, which provides for a collective multi-sectoral (individual agencies, private and public) response to fight against HIV/ AIDS (12), was revised in 1998 to incorporate home-based care as a major component in the management of the HIV/AIDS epidemic. The third phase ( ) involved a more comprehensive and wide-ranging action by the political leadership (10). The 1994 Medium-term Plan (MTPII) was much more thorough and participatory, included largely-neglectedd stakeholders, such as NGOs and private sector, and redressed the shortcomings of the

3 HIV/AIDS-related stigma and discriminatory attitudes in Botswana 349 earlier response phases. The goals were to reduce infection, transmission, and impact of HIV/AIDS at all levels of society (10). One of the important oversights of the approach in previous responses was the omission of gender inequality as a prime determinant of HIV transmission. The MTPII recognizes that HIV/AIDS is not just a medical and health problem, but also has social, economic and cultural dimensions (10). The National AIDS Council (NAC), chaired by the President of Botswana, the highest national policymaking institution after the Parliament and Cabinet on issues of HIV/AIDS policy and implementation guidelines, has established various technical multisectoral sub-committees (12). A Parliamentary Select Committee on HIV/AIDS has been formed to ensure that HIV/AIDS remains a priority on the political and economic agenda of the country (12). The National AIDS Control Programme was begun in 1987, and in 1992, the AIDS/STD Unit was established. Based on the lessons learnt from 1992 to 1999, and given the expanded multi-sectoral approach, the Government in 2000 created the National AIDS Coordinating Agency to coordinate the implementation of the multi-sectoral national response, in addition to providing policy guidance to other sectors (12). District and sub-district multi-sectoral AIDS committees have been created mainly to coordinate and promote response programmes at the local level. Other interventions include the nation-wide prevention of mother-to-child transmission, voluntary counselling and testing, provision of highly-active antiretroviral therapy to the public at no cost, community home-based care, and orphan and vulnerable children programme (1). Other partners involved in the fight against HIV/ AIDS include the private sector and civil society. The private sector has formed a coalition Botswana Business Coalition on AIDS to coordinate HIV/AIDS interventions. Civil society organizations have formed several networks, such as Botswana Network of AIDS Service Organizations, Botswana Network of People Living with HIV/AIDS, Botswana Network of Law and Ethics, and Botswana Christian AIDS Intervention Programme, to support and promote coordination, networking, and collaboration among them (12). The primary goal of this study was to investigate the prevalence of, and examine the factors associated with, discriminatory attitudes towards HIV/AIDS patients in Botswana. Specifically, it measured the prevalence of negative attitudes of the people of Botswana towards HIV/AIDS patients, i.e. whether or not people are willing to care for a family member with HIV/AIDS; an HIVpositive teacher should or should not be allowed to continue teaching; and whether or not they would buy food or vegetables from an HIV-positive shopkeeper. It also examined the social, economic and demographic factors associated with negative attitudes towards people with HIV/AIDS. MATERIALS AND METHODS Definition of concepts Stigma generally refers to a negatively-perceived defining characteristic, either tangible or intangible (3), and is divided into felt or perceived stigma and enacted stigma (6). Felt stigma refers to real or imagined fear of societal attitudes and potential discrimination arising from a particular undesirable attribute, disease (such as HIV), or association with a particular group. Enacted stigma, on the other, refers to the real experience of discrimination. Stigma is most frequently associated with diseases that have severe, disfiguring, incurable and progressive outcomes, especially when modes of transmission are perceived to be under the control of individual behaviour (6). It is also common in diseases that are perceived to result from the transgression of social norms, such as socially-sanctioned sexual activity (6). Stigmatization often leads to discrimination, which refers to any form of distinction, exclusion, or restriction affecting a person by virtue of a personal characteristic (2). Inadequate understanding of the modes of transmission of HIV leads to fear of transmission from casual contact (2). Through stigma, society often blames infected people for being ill and justifies discriminatory acts against them while asserting innocence and health of those who stigmatize (13). For the purpose of this study, stigma and discrimination were conceptualized as negative attitudes towards people with HIV/AIDS. Stigma and discrimination were measured by assessing negative attitudes of respondents towards persons with HIV/AIDS. For instance, respondents who reported that they did not want an HIV-positive teacher to continue teaching although he was not sick reflects distinction, exclusion, or restriction against persons with HIV/AIDS. The reason for not allowing the teacher to continue teaching is based on his serostatus. Data Data for this paper were drawn from the Botswana AIDS Impact Survey (BAIS) conducted in Selection of

4 350 J Health Popul Nutr Dec 2003 Letamo G the sample was done in two stages. First, 98 enumeration areas were selected with probability proportional to measures of size, where measures of size are the number of households in the enumeration area. At the second stage, the households were systematically selected from a fresh list of occupied households prepared at the beginning of fieldwork of the survey, i.e. listing of households for selected enumeration areas. The sample was designed to provide estimates of AIDS indicators at the national level, urban and rural areas, and for 14 districts (14). Overall, 2,126 households were drawn systematically, 2,023 of which were occupied. Of the 2,023 households, 1,781 (88.0%) were successfully interviewed, with the highest response rate in towns (90.8%), followed by urban villages (89.7%) and rural areas (85.8%). In the interviewed households, 4,728 eligible persons aged years were identified. Of these, 4,494 (95.1%) were successfully interviewed (14). The sets of questionnaire for the BAIS study were based on the UNAIDS Model Questionnaire (at with some modifications and additions. The modifications included lowering the age limit of eligible persons to 10 years and increasing the upper limit to 64 years. Two sets of questionnaire household questionnaire and individual questionnaire for men and women aged years were administered in the survey. Respondents who did not complete the individual questionnaire were excluded from the present analysis. Data were believed to be of high quality for a number of reasons. First, the interviewers were thoroughly trained for two weeks. Second, the interviewers were closely supervised during data-collection. Third, the sets of questionnaire were thoroughly edited to check that relevant questions had been responded to and coded according to the codes designed for the study. Finally, consistency checks on the dataset were performed by the Computer Edit Specifications designed by a subjectmatter specialist (14). Measures The Botswana AIDS Impact Survey has several questions that were used for addressing the objectives of this study. Response variables The following three response variables were used in this study as measures of stigma and discriminatory attitudes towards people with HIV/AIDS: Unwillingness to care for a family member with HIV/ AIDS: Respondents were asked If a member of your family became sick with HIV/AIDS, would you be willing to care for him or her in your household? This indicator is a dummy variable that equals one for respondents who gave a negative response and zero otherwise. Should not allow a teacher with HIV/AIDS to teach: Respondents were asked If a teacher has HIV/AIDS but is not sick, should s/he be allowed to continue teaching in school? This binary variable was coded in such a manner that the response no equals one and zero otherwise. Would not buy vegetables from a shopkeeper with HIV/ AIDS: Respondents were asked If you knew that a shopkeeper or a food-seller had HIV/AIDS, would you buy vegetables from them? This variable was a dummy variable that equals one for respondents who responded negatively and zero otherwise. Control variables Control variables used for this study included age (10-24 years vs years), current marital status, the highest level of education attained, place of residence, and questions asking about knowledge of HIV/AIDS, such as Can a person get infected with HIV/AIDS by sharing a meal with a person who has HIV/AIDS? Regarding the place of residence, three categories were used: usual urban, urban villages, and rural areas. An urban area in Botswana is defined as all settlements on state land and settlements on tribal land with population of 5,000 or more persons with at least 75% of the labour force in non-agricultural occupations (15). Usual urban settlements are towns and cities. Urban villages are settlements that qualify to be urban areas, excluding towns and cities according to the above definition. Usually, these settlements have modern facilities, such as tribal administration headquarters and modern social amenities. The remaining settlements are rural areas. Statistical methods Both descriptive and multivariate analyses were done. Logistic regression analysis was used for evaluating the effects of a select group of predictor variables on the probability of expressing negative attitudes towards people with HIV/AIDS, while controlling for other variables in the model. Logistic regression was used because it provided an interpretable linear model for a binary dependent variable and also allowed the testing

5 HIV/AIDS-related stigma and discriminatory attitudes in Botswana 351 of the significance of a given predictor while controlling for all other predictors in the model (16). Separate logistic regression models were used for evaluating the effects of individual factors on the probability of expressing negative attitudes towards people with HIV/AIDS. The SPSS-PC logistic programme was used for estimating regression coefficients through the maximum likelihood procedure (17). Sample description Table 1 shows the sociodemographic characteristics of the sample which did not vary much by sex. The sample Table 1. Sociodemographic characteristics of the sample, Botswana, 2001 Characteristics Sex Total Male Female (n=4,147) (n=1,897) (n=2,250) Age (years) < Marital status Married Living together Not married Education No education Primary Secondary Place of residence Usual urban Urban village Rural areas Total includes more females than males. About 60% of the respondents were aged 25 years or above; more than two-thirds were unmarried; about half had attained a secondary or higher education; and about 47% reside in rural areas. The high proportion of unmarried people corresponded fairly well with the national figures. RESULTS Prevalence of HIV/AIDS-related stigma and discriminatory attitudes Table 2 presents the percentage distribution by sex of the 4,147 respondents who expressed discriminatory attitudes towards people with HIV/AIDS. Only 11% of the respondents were unwilling to care for a family member with HIV/AIDS, i.e. almost nine of 10 respondents were willing to care for a family member with HIV/AIDS. This finding suggests that the majority of HIV/AIDS patients were taken care of by their relatives through the project. Overall, a high proportion of the respondents expressed negative attitudes towards a teacher or a shopkeeper with HIV/AIDS. Sixty percent stated that they would not buy vegetables from a shopkeeper with HIV/AIDS, while 42% reported that a teacher with HIV/AIDS should not be allowed to teach, even when he or she is not sick. The prevalence of HIV/AIDS-related stigma was lower among females than among males. Factors associated with unwillingness to care for a family member with HIV/AIDS The factors associated with unwillingness to care for a family member with HIV/AIDS are presented in Table 3. Males aged less than 25 years were 5.7 times more likely than other males to say that they were unwilling to care for a family member with HIV/AIDS. Males who believed that a person could reduce HIV infection by having one partner were 55% less likely than those who thought otherwise to report that they were unwilling to care for a family member with HIV/AIDS. Males who believed that a person could get HIV infection by sharing a meal with a person suffering from HIV/AIDS were 3.8 times more likely than their counterparts to state that they were unwilling to care for a family member with HIV/AIDS. The results for females showed similarities with those for males. The respondents aged less than 25 years were 5.4 times more likely than other respondents to report that they were unwilling to care for a family member with HIV/AIDS. Those with primary education were 3.3 times more likely to report their unwillingness to care for a family member with HIV/AIDS than were those with secondary or higher education. Females who believed that HIV infection could be transmitted by sharing a meal with an HIV/AIDS patient were 3.6 times more likely than their counterparts to say that they were unwilling to care for a family member with HIV/AIDS. Comparison of findings for men and women showed that age and belief that a person could get HIV infection by sharing a meal with a person with HIV/AIDS were the only factors significantly associated with discriminatory attitudes towards a family member with HIV/AIDS for both the sexes. Although the level of education and the place of residence were significantly associated with negative attitudes towards people with HIV/AIDS among females, this association did not apply to males. The belief that a person could reduce infection by having one sexual partner was associated with more tolerant attitudes towards people with HIV/AIDS among both females and males.

6 352 J Health Popul Nutr Dec 2003 Letamo G Factors associated with discriminatory attitudes towards a teacher with HIV/AIDS The factors influencing discriminatory attitudes towards a teacher with HIV/AIDS are shown in Table 4. The results showed that younger males were 3.3 times more likely than older males to report that a teacher with HIV/ AIDS should not be allowed to teach although he or she is not sick. This relationship was statistically significant at 1% level. Males who were living together with their partners were 7.4 times more likely than married counterparts to state that a teacher with HIV/AIDS should not be allowed to teach. Males with no education were 7.2 times more likely than males with secondary or higher education to indicate that a teacher with HIV/ AIDS should not be allowed to teach. Males residing in urban villages were 52% less likely than males residing in usual urban areas to report that a teacher with HIV/ AIDS should not be allowed to teach. Men who believed that they could get HIV infection by sharing a meal with HIV/AIDS patient were 2.4 times more likely than those who believed otherwise to indicate that a teacher with an HIV/AIDS should not be allowed to teach. For female respondents, similar responses to those of males were observable. Young women were 2.8 times more likely than older women to state that a teacher with HIV/AIDS should not be allowed to teach. Women with no education were 4.4 times more likely than those with secondary or higher education to report that a teacher with HIV/AIDS should not be allowed to teach. Women with primary education were 2.1 times more likely than those with secondary or higher education to report that a teacher with HIV/AIDS should not be allowed to teach. Residing in any place outside usual urban areas was associated with negative attitudes towards people with HIV/AIDS among women. For instance, females living outside usual urban areas were 3.2 times more likely than those living in usual urban areas to report that a teacher with HIV/AIDS should not be allowed to teach. Among female respondents, those who believed a person could get HIV/AIDS infection through witchcraft were 2.3 times more likely than those who believed otherwise to state that a teacher with HIV/AIDS should not be allowed to teach. Females who believed that a healthy-looking person could be infected with HIV were 68% less likely than those believing otherwise to indicate that a teacher with HIV/AIDS should not be allowed to teach. Women who believed they could get HIV infection by sharing a meal with an HIV/AIDS patient were 2.4 times more likely than those who believed otherwise to indicate that a teacher with HIV/AIDS should not be allowed to teach. Table 2. Percentage distribution of people (n=4,147) expressing discriminatory attitudes towards people with HIV/AIDS, according to sex, Botswana, 2001 Characteristics Male Female Total No. % No. % No. % Would you be willing to care for a family member sick with HIV/AIDS? Yes 1, , , No Should a teacher who has HIV/AIDS be allowed teach? Yes No , ,128 1, Would you buy vegetables from a shopkeeper who has HIV/AIDS? Yes No 669 1, , ,526 2, Comparison of findings for men and women showed that being young, having no education, and having the belief that a person could get HIV infection by sharing a meal with a person with HIV/AIDS were the only factors significantly associated with discriminatory attitudes towards a teacher with HIV/AIDS for both the sexes. Although the place of residence was significantly associated with negative attitudes towards people with HIV/AIDS among females, this association did not apply to males. Factors associated with discriminatory attitudes towards a shopkeeper with HIV/AIDS Table 5 shows the factors associated with discriminatory attitudes towards a shopkeeper with HIV/AIDS. The results showed that younger males were 3.4 times more likely than their older counterparts to report that they would not buy vegetables from a shopkeeper with HIV/ AIDS. Males who were living together with their sexual

7 HIV/AIDS-related stigma and discriminatory attitudes in Botswana 353 Table 3. Adjusted odds ratios that respondents are not willing to care for a family member with HIV/AIDS, by selected explanatory variables, according to sex, Botswana, 2001 Explanatory variable Odds ratio Male Female Age (years) < ** ** Marital status Married Living together Not married Education No education Primary *** Secondary Place of residence Usual urban Urban village * Rural area Can a person get HIV/AIDS through witchcraft? Yes Can condom use reduce contracting HIV/AIDS? Yes Can a healthy-looking person be infected with HIV/AIDS? Yes Can a person reduce HIV/AIDS by having one partner? Yes * * Can mosquito transmit HIV/AIDS? Yes Can HIV/AIDS be transmitted from mother to child? Yes No Can a person get HIV infection by sharing a meal with a person with HIV/AIDS? Yes *** *** Predicted correctly (%) Log likelihood (N) (259) (277) Significance level * p<0.1, ** p<0.05, *** p<0.01 Table 4. Adjusted odds ratios that a teacher with HIV/ AIDS should not teach, by selected explanatory variables, according to sex, Botswana, 2001 Explanatory variable Odds ratio Male Female Age (years) < *** ** Marital status Married Living together *** Not married Education No education *** *** Primary * ** Secondary Place of residence Usual urban Urban village * *** Rural area *** Can a person get HIV/AIDS through witchcraft? Yes * Can condom use reduce contracting HIV/AIDS? Yes Can a healthy-looking person be infected with HIV/AIDS? Yes *** Can a person reduce HIV/AIDS by having one partner? Yes Can mosquito transmit HIV/AIDS? Yes Can HIV/AIDS be transmitted from mother to child? Yes No Can a person get HIV infection by sharing a meal with a person with HIV/AIDS? Yes *** *** Predicted correctly (%) Log likelihood (N) (254) (268) Significance level * p<0.1, ** p<0.05, *** p<0.01

8 354 J Health Popul Nutr Dec 2003 Letamo G partners were 3.5 times more likely than those married to state that they would not buy vegetables from a shopkeeper with HIV/AIDS. Men with no education were 4.9 times more likely than those with secondary or higher education to indicate that they would not buy vegetables from a shopkeeper with HIV/AIDS. Again, men with primary education were 2.6 times more likely than those with secondary or higher education to indicate that they would not buy vegetables from a shopkeeper with HIV/AIDS. Males who believed that a person could get HIV infection by sharing a meal with a person with HIV/AIDS were 4.0 times more likely than those who believed otherwise to state that they would not buy vegetables from a shopkeeper with HIV/AIDS. For female respondents, women with no education were 5.1 times more likely than those with secondary or higher education to indicate that they would not buy vegetables from a shopkeeper with HIV/AIDS. Females with primary education were 2.1 times more likely than those with secondary or higher education to indicate that they would not buy vegetables from a shopkeeper with HIV/AIDS. Females who believed that a healthy-looking person could be infected with HIV were 59% less likely than those believing otherwise to indicate that they would not buy vegetables from a shopkeeper with HIV/AIDS. Women who did not know that HIV could be transmitted from mother to child were 64% less likely than their counterparts to state that they would not buy vegetables from a shopkeeper with HIV/AIDS. Women who believed that a person could get HIV infection by sharing a meal with a person with HIV/AIDS were 4.6 times more likely than those who believed otherwise to report that they would not buy vegetables from a shopkeeper with HIV/AIDS. Comparison of findings for men and women showed that education and the belief that a person could get HIV infection by sharing a meal with a person with HIV/AIDS were the only factors associated with negative attitudes towards a shopkeeper with HIV/AIDS for both the sexes. Marital status was associated with negative attitudes for males but not for females. The place of residence was associated with negative attitudes towards a shopkeeper with HIV/AIDS for females but not for males. The belief that a healthy-looking person could be infected with HIV and those who were not aware that HIV could be transmitted from mother to child were associated with more tolerant attitudes towards a shopkeeper with HIV/ AIDS for females but not for males. Table 5. Adjusted odds ratios that respondents would not buy vegetables from a shopkeeper with HIV/AIDS, by selected explanatory variables, according to sex, Botswana, 2001 Explanatory variable Odds ratio Male Female Age (years) < *** Marital status Married Living together 3.538* 0.65 Not married Education No education *** *** Primary *** ** Secondary Place of residence Usual urban Urban village *** Rural area *** Can a person get HIV/AIDS through witchcraft? Yes Can condom use reduce contracting HIV/AIDS? Yes Can a healthy-looking person be infected with HIV/AIDS? Yes * Can a person reduce HIV/AIDS by having one partner? Yes Can mosquito transmit HIV/AIDS? Yes Can HIV/AIDS be transmitted from mother to child? Yes No * Can a person get HIV infection by sharing a meal with a person with HIV/AIDS? Yes *** *** Predicted correctly (%) Log likelihood (N) (255) (274) Significance level * p<0.1, ** p<0.05, *** p<0.01

9 HIV/AIDS-related stigma and discriminatory attitudes in Botswana 355 DISCUSSION Since HIV/AIDS-related stigma and the resulting discriminatory attitudes create an environment that fuels the spread of HIV, programmes targeted at educating young people about HIV/AIDS can play an important role in reducing stigma and discrimination against people with HIV/AIDS. The study revealed that a large majority (60%) of Batswana expressed negative attitudes towards a teacher or a shopkeeper with HIV/AIDS (People of Botswana are called Batswana plural and Motswana singular). However, more tolerant attitudes prevailed among the majority of the respondents when a person with HIV/AIDS is a family member. Generally, women have more tolerant attitudes towards people with HIV/ AIDS than men. Young people and those who believed a person could get HIV infection by sharing a meal with a person with HIV/AIDS were significantly more likely than those who did not report discriminatory attitudes towards a family member with HIV/AIDS. Those who believed a person could reduce HIV infection by having one partner showed more tolerant attitudes towards a family member with HIV/AIDS. The results were similar for both the sexes. Among females, those with primary education compared to those with secondary or higher education had discriminatory attitudes towards a family member with HIV/AIDS. Younger respondents, those with no education, and those who believed a person could get HIV infection by sharing a meal with a person with HIV/AIDS had discriminatory attitudes towards a teacher who had HIV/ AIDS for both the sexes. In addition, among males, living together with a sexual partner was associated with discriminatory attitudes towards a teacher with HIV/ AIDS. Among females, residence in urban villages and rural areas and the belief that a person could get HIV infection through witchcraft were associated with discriminatory attitudes towards a teacher with HIV/ AIDS. No or low level of education and the belief that a person could get HIV infection by sharing a meal with a person with HIV/AIDS were associated with discriminatory attitudes towards a shopkeeper with HIV/AIDS. Among males, those who were young and those living with their sexual partners were more likely to portray negative attitudes towards a shopkeeper with HIV/AIDS. As for females, residing in urban villages and rural areas was associated with discriminatory attitudes towards a shopkeeper with HIV/AIDS. In addition, females who believed that a healthy-looking person could be infected with HIV and those who believed that HIV could be transmitted from mother to child had more tolerant attitudes towards a shopkeeper with HIV/AIDS. A consistent finding was: the belief that a person could get HIV infection by sharing a meal with someone with HIV/ AIDS was associated with discriminatory attitudes toward people with HIV/AIDS. Implications for the prevention and care of HIV/AIDS patients The findings of this study have important implications not only for the goal of a compassionate, just and caring nation as espoused by the Government in its Vision 2016 document but also as a human rights issue. The observation that stigmatization and denial remains the greatest challenges in community mobilisation against HIV/AIDS (12) appeared true. A large majority (60%) of the respondents in this study revealed discriminatory attitudes towards a shopkeeper with HIV/AIDS. This finding implies that the national information, education and communication programme needs to be strengthened to reach more people for HIV/AIDS education. An encouraging result of the study was that most respondents were willing to care for a family member with HIV/AIDS. This more tolerant attitude is probably attributable to the promotion of community home-based care programme. The concept of the Community Homebased Care project was introduced in 1992 when it became clear that public hospitals were not coping with the increasing number of AIDS patients. In this project, care is provided to individuals in their homes by their families, who are, in turn, supported by social welfare officers and the wider community (10). Traditionally, the sick have been and continue to be taken care of by the relatives. The concept of community-home based care is designed to take advantage of this traditional set-up of care. Since most families have been caring and continue to care for their sick relatives, it can be expected that more and more people will be willing to continue the tradition of caring for their sick family members. However, a worrisome issue that needs to be addressed immediately is the observation that more often than not, family members have had to care for relatives with HIV and AIDS without the support or counselling an active CHBC [community home-based care] system could offer (10:44). This observation calls for the Government to inject more resources into the community home-based

10 356 J Health Popul Nutr Dec 2003 Letamo G programmes. Non-governmental organizations in Botswana are actively involved in running the community home-based care systems which may help alleviate the problem of caring for HIV/AIDS patients at their homes. In short, the expansion of governmentsupported homed-based care programmes for people with HIV/AIDS is more likely to increase the willingness of the people to care for their sick relatives. The finding that generally women were more tolerant of people with HIV/AIDS reflects that women are the principal caregivers to all members of most families. Home-based care programmes rely almost exclusively on women who also shoulder the burden of caring for orphans (18). The gender-based ascription of roles to men and women based on tradition and custom is still pervasive in Botswana. Traditionally, women are confined to household work, which includes caring for the family. Thus, women see caring for other members of the household as their duty and nobody else s. The consistent finding that a person can get HIV infection by sharing a meal with an HIV/AIDS patient is a serious misconception that needs to be addressed. The information, education and communication programme needs to intensify its educational campaigns to dispel these misconceptions. The finding that most people who portrayed discriminatory attitudes were predominantly young people also calls for a focus on the formal education programmes and revision for introduction from pre-school level to tertiary education level since the majority of young people are at these institutions. The commitment of the Government of Botswana to the information, education and communication campaign on HIV/AIDS to not only expand and increase the level of awareness from the current percent to 100 percent but also to ensure that the campaign effectively empowers people to undertake behaviour change (12) is a most welcome move. Again, the focus of the policy on the youth is expected to create more tolerant attitudes towards people with HIV/AIDS among young people. Educational programmes need to be designed to change discriminatory attitudes. Programmes aimed at promoting more tolerant attitudes towards people with HIV/AIDS may be more effective if the human rights of those with HIV/AIDS are respected. HIV/AIDS has been mainly addressed in relation to health in relevant core international documents on human rights of women, and not enough attention has been paid to human rights (18). The commitment by the Government to respect basic human rights of people living with HIV/AIDS (12) needs to be explicit enough in terms of what the statement really means. Such vague statements may be interpreted differently by different people. Limitations of the study The major limitation of this study was that secondary data were used, thereby limiting the researcher to variables collected by the survey. Another limitation was that the information collected was self-reported, which was subject to reporting errors and biases. The third limitation was that the questions used for measuring HIV/ AIDS-related stigma and discriminatory attitudes were hypothetical questions. What people said and what they might actually do was not quite clear (19). As a result, a direct relationship between attitudes and behaviour could not be established. Finally, this study was based on cross-sectional data, implying that the direction of relationships could not be determined. The interpretation of the results, therefore, limits it to associations between variables rather than cause-and-effect relationships. ACKNOWLEDGEMENTS The author wishes to thank anonymous reviewers for their valuable comments on the earlier version of the paper and also wishes to express great gratitude to the Central Statistics Office in the Ministry of Finance and Development Planning for allowing permission to use the data. REFERENCES 1. National AIDS Co-ordinating Agency. Botswana 2002 second generation HIV/AIDS surveillance: a technical report. Gaborone: National AIDS Coordinating Agency, p. 2. International Center for Research on Women. Addressing HIV-related stigma and resulting discrimination in Africa: a three-country study in Ethiopia, Tanzania, and Zambia. ( accessed on 12 December 2002). 3. Busza J. Challenging HIV-related stigma and discrimination in Southeast Asia: past successes and future priorities (review). New York: Population Council Horizons, p. 4. Nyblade L, Field ML. Women, communities, and the prevention of mother-to-child transmission of HIV: issues and findings from community research in Botswana and Zambia. ( publications_hivaids.htm, accessed on 12 December 2002).

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