CHAPTER ONE Introduction

1.1

Background to the study

In Nigeria, as in the rest world, HIV/AIDS stigma and discrimination are predominantly the factors creating obstacles in public action for prevention and treatment services and the spread of HIV/AIDS epidemic. Fear associated with HIV/AIDS Stigma is responsible for inhibiting people from seeking HIV testing to ascertain their HIV status, while persons living with HIV and AIDS (PLWHAs) may be less likely to gain access to available treatment services within their proximity, less willing to disclose and openly acknowledge their HIV status. The results can lead to increased HIV transmission, under-reporting of the HIV epidemic, limit access to prevention, treatment, care, and support programmes. Currently, in a population of about 140 million, 2.95 million people are living with HIV virus. This makes Nigeria the second largest number of people living with HIV in Africa, exceeded only by South Africa (UNAIDS, 2008, FMOH, 2008). Among the PLWHV, women seem to have a high level of infection as 1.72 million women are living with HIV virus (FMOH, 2008). The consequences of high level of stigma are numerous; it reduces the risk vulnerability of PLWHV because they are classified and labelled as social deviants. It also decreases uptake of HIV information, practice of prevention behaviour, and anti retroviral treatment services and adherence (UNAIDS, 2002). Among women, stigma poses a threat to their well being and quality of life, threatens social exclusion, isolation and possible ostracization. With these challenges, there have been plethora attempts of HIV interventions since 1985 when HIV was first discovered in Nigeria to address the issues of stigma (Hilhorst et al, 2006). The interventions include information awareness on ABC of prevention: abstain, be faithful and use a condom, campaigns and education. These initiatives have succeeded to enhance public awareness on HIV stigma, but have failed in going beyond awareness, to stimulate positive changes in attitudes and practices toward creating a desired lasting social change-HIV stigma reduction. This led to the introduction of strategic

behaviour communication change (SBC) which currently in the global picture dominates the intervention preference on mitigating HIV/AIDS stigma and discrimination because it 1

promises to impact on sustainable behaviour change among individuals and communities (FHI, 2005). Although, researches has proven that SBC is effective in reducing stigma across the globe ,but with the high infection level among women in Nigeria amidst the implementation of some interventions, this study seeks to explore specifically the effectiveness of SBC in addressing HIV stigma among women in Nigeria. In this study, I will address the key research question: to what extent does SBC mitigate the impact of HIV/AIDS related stigma in the context of understanding female vulnerability.

The purpose of this study is to explore the critical role of SBC in addressing HIV/AIDS stigma. With particular focus HIV programme such as Promoting Sexual and Reproductive health and HIV/AIDS reduction in Nigeria (PSRHH), which have been at the forefront of mitigating the impact of HIV including its stigma and the discrimination associated with it. The next chapter looks at the methodology utilised to elicit information engaged for literature review, discussions and analysis of this research. Chapter two will be in two parts. First, it will discuss the concepts and provide an overview of stigma, discrimination, poverty, gender, power and SBC in Nigeria. Secondly, it will describe the framework of convergence of social actors and power dominance adapted from three theoretical frameworks namely; (structural violence theory and Cornell theory of gender and power) for analysing the process by which gender, cultural, poverty and power reproduce stigma. In doing this, it will highlight factors in the Nigerian context that initiate and maintain stigma at three levels, the family, institutional and societal levels. Chapter three further discusses the situational analysis of stigma and discrimination in Nigeria, it examines why women are most vulnerable based on the factors mentioned such as poverty, cultural and societal expectations. This will be discussed within the specificity of three levels; the family, society and the healthcare setting. Besides recognising that these inequalities can enhance vulnerability to HIV infection and stigma, this study discusses how poverty accelerates isolation, rejection and unemployment due to stigma and negatively influences the coping mechanisms of women living with and affected by HIV/AIDS. Chapter four will provide the background of SBC in Nigeria and examine how it addresses stigma in both men and women. In addition, it will identify the gaps of SBC based on the three inequalities that affect women in chapter three. Finally, it will discuss my findings by linking to the adapted framework and address the research question: to what extent does SBC mitigate the impact of HIV/AIDS related stigma among Nigerian women. The study finds 2

that HIV/AIDS stigma has the potential to aggravate economic inequality by pushing more women into poverty and forcing them into deeper impoverishment. As such, this research will add to existing body of knowledge about the implications of poverty to stigma reduction but intends to provide further information for review and redesign of intervention for scholars and policy makers in addressing women development.

1.2 OBJECTIVES OF THE STUDY The general objective of this study is to determine the impact and consequences of HIV related stigma and discrimination on women and the role of SBC in reducing the problem. Specifically, the objectives are: 1. To identify the context and forms of HIV stigma and the different levels which stigma and discrimination affects women in Nigeria. 2. To determine to what extent HIV stigma affects women and their coping strategies. 3. To ascertain the role of SBC in effectively addressing the consequences of HIV stigma among Nigerian women.

1.3 SIGNIFICANCE OF THE STUDY HIV/AIDS strategies and programs need to address the real world issues faced by women ...... Antonio Maria Costa, Executive Director, U.N. Office on Drugs and Crime.

The significance of this study is to identify the peculiar issues that trigger HIV stigma among women and provide geographical and culturally informed interventions to address these issues. HIV program practitioners must develop a clear understanding of the female

populations they serve, to address their specific health needs and concerns. An understanding of geographical space and implications of HIV stigma will equip program practitioners to plan and implement culture-specific programs. Finally, this study will also help NGOs and projects to design effective strategies to tackle the root problems fuelling HIV stigma hence, reducing HIV prevalence among the women.

1.4

RESEARCH QUESTIONS

Specific research questions this study aims to answer are: 1. What are the forms and context stigma experienced by women in Nigeria? 2. What factors influence their experiences?

3. To what extent does SBC mitigate the impact of HIV/AIDS related stigma in the context of understanding female vulnerability?

1.5

METHODOLOGY

1.5.1 Purposes and Objectives The purpose of this study is to explore the impact of SBC interventions in stigma reduction among women and those living with HIV/AIDS. This study analysed HIV situation and Strategic Behaviour communication (SBC) programmes on HIV/AIDS stigma and discrimination in Nigeria. It made analysis of diverse journals, books, newspaper, articles organization reports, UN reports and books. The study sought the effectiveness of SBC activities in reducing HIV Stigma among women in Nigeria. Also, there was a review of online abstracts on stigma and HIV with key words such as; HIV/AIDS Women, Discrimination, Stigma, interventions, Power, Poverty and Nigeria.

1.5.2 Methods a) The literature review consists of literature which was found in the University of East Anglia library, using search engines such as Google, PubMed, Medline, Bridge gender and development and KIT internet library. Information on website of relevant related individual organisations were also used. This includes Society Family Health Nigeria, International Centre for Research on Women (ICWR) and Journalists Against AIDS in Nigeria (JAAIDS). Most literature presented connects with gender analysis to reveal the theory of gender and power, the interplay of poverty context of HIV/AIDS. The review aimed to cover:

b) Most literature presented connects with gender analysis to reveal the theory of gender and power, the interplay of poverty context of HIV/AIDS. The review aimed to cover: a. Anecdotal evidence of experiences of PLWHV b. Existing or previous stigma reduction interventions

c. Nigeria policy documents such as the National Strategic framework, National HIV and AIDS Behaviour Change Communication Strategy (NBCC) and the NARHS surveys. The benchmark in this study focuses on the analysis of HIV related stigma reduction interventions. In addition, the analysis is based on data from the 2003, 2005 and 2007 Nigeria Reproductive Health Surveys (NARHS).

1.5.3 Ethical Considerations

Ethical considerations relating to this research was not over sighted. All secondary sources were properly referenced to avoid plagiarism however subtle.

1.5.4 Limitations The perspective provided in this study to an extent reflects an understanding of how women could be empowered in the given context. Research reveals that there is sparse suitable research on HIV/AIDS stigma and discrimination plague in Nigeria as it relates to women particularly. In addition, most of the HIV interventions that are available were not evaluated yet for its effectiveness but they were relative to achieving the purpose as showed in their framework. Majority of the publications found were on PLWHV, there was minimal consideration for gender segregation in designing the interventions. Finally, this research seems narrowed due to its time frame; and that the topic could be a potential for future higher research. It is a secondary research is another limitation and primary was impossible due to finances and the research time frame.

CHAPTER TWO Literature Review

The first part of this literature review introduces the main concepts such as Stigma, Discrimination, poverty, gender, power, culture and Strategic Behaviour Communication

(SBC) in relation to HIV/AIDS stigma context among women, which is primary to this research. The second part discusses the theoretical frameworks underpinning the structural barriers that produce and maintain HIV stigma and the linkages between the concepts. Before entering into the analysis, it is necessary to understand what stigma means.

2.1.1 Stigma

Erving Goffman offered the pioneer definition of Stigma in his classic: Notes on the Management of Spoiled Identity. Goffman 1963: conceptualized stigma is an attribute that is deeply discrediting within a society and that reduces the individual from a whole and usual person to a tainted, discounted one. Stigma is any characteristic that sets an individual or group separate from the rest of the population, with an outcome that the person with the disease is treated with suspicion or hostility (Giddens, 2000:127 cited in AIDS legal Network, 2006). While Goffmans interpretation of stigma focuses on the societies attitude toward a person who possesses an attribute that falls short of societal expectations, Link and Plenan (2001) incorporates the context in which stigma originates and flourishes. occurs when: rudiments of labelling, stereotyping, separation, status loss, and discrimination occur together in a power situation that allows them (Link and Phelan, 2001:377) Stigma

Stigma is conceptualised as a process of devaluation which exists within the context of power (Parker and Aggleton 2003), where individuals are identified, tarnished or labelled as deviants, separating them from other people by associating negative attributes to them with labelling remarks. This brings a classification between us the untainted ones and them the 6

deviants. The process degenerates to the extent that the stigmatised individuals eventually lose their social status. As Fife and Wright (2000) points that:

persons become labelled as outsiders, and expectations are associated with the individual from which patterns of response from others materialise during the interaction. As the person internalizes this label, it features as an element of his/her identity.....

This identity loss and rebranding with a rather negative status treats the vulnerable to negative treatment. The negative treatment given to such individual could be termed as discrimination.

2.1.2 Discrimination There is a thin line between stigma and discrimination. Discrimination serves to devalue the stigmatised individual based on prejudice or societal expectation and there is an interphase between stigma and discrimination as stigmatising attitudes perpetuates inequalities by confining the ability of the stigmatised to a marginalised status through social structures such a family, religion and culture (Parker and Aggleton 2003). It is a process in which dominant groups privileges are maintained at the expense of less privileged groups. Discrimination usually occurs an individual is treated unjustly, knowing or subtly based on perception or attribute. The United Nations define discrimination as an action that treats people unfairly because of their membership in a particular social group. While this takes many forms such as gender, disability, race, class or health, it does involve some form of exclusion or rejection. Maluwa et al (2002), in view of stigma reconceptualises discrimination, as an aftermath of stigma: when, in the absence of objective justification, a distinction is made against a person that results in unjust treatment on the basis of belonging or being perceived to belong, to a particular group. These definitions vary based on the views as expression of thought. Anybody could subject to discrimination but for the purpose of this study, specifically; the discrimination against women will be reviewed. According to the United Nations Convention on the Elimination of all forms of Discrimination Against Women of 1979 (CEDAW) Discrimination against women is:

any distinction, exclusion or restriction made on the basis of sex which has the effect or purpose of impairing or nullifying the recognition, enjoyment or exercise by women, irrespective of their marital status, on a basis of equality of men and women, of human rights and fundamental freedoms in the political, economic, social, cultural, civil or any other field.

Other definitions indicate that discriminatory acts are shaped by societal norms. Discrimination is emblematic of a situation where patterns of structural inequality are maintained by rules, norms and procedures that dictate a subordinate role for women in all spheres of society (Okome, undated http://web.africa.ufl.edu/asq/v6/v6i3a3.htm). The underlining factor is that discrimination is a resultant effect of a belief system, reinforced by culture and values of a society. Although stigma and discrimination are distinct, for the purpose of this research, their usage will be construed to mean the same thing. Stigma can be applied to a range of circumstances and diseases such as epilepsy, gonorrhoea and mental illness, cancer, leprosy and HIV/AIDS. However, studies have shown that illness like cancer would generate sympathy while diseases like HIV/AIDS and leprosy would induce stigma (Fife and Wright, 2000).

2.1.3 HIV related stigma and discrimination globally

HIV as a disease has given a new definition of discrimination. UNAIDS report in 2003 describes HIV related stigma and discrimination as a process of devaluation. Among other definitions of HIV related stigma by scholars, include Brimlow et.al. (2003). They define HIV and AIDS related stigma as:

...... all unfavourable attitudes, beliefs and policies directed toward people perceived to have HIV/AIDS as well as their loved ones, close associates, social groups and communities. Patterns of prejudice, which include devaluing, discounting, discrediting, and discriminating against these groups of people, play into and strengthen existing social inequalities especially those of gender, sexuality, and race that are at the root of HIV-related stigma. People who are stigmatised are perceived to possess some attribute or characteristic that conveys a social identity, which is devalued in society in a social context (Crocker et al 1998:505).

Scholarly literature has identified a spectrum of reasons why HIV is stigmatised and which groups of persons are categorised as vulnerable. First, the fact that HIV is not curable and a death sentence is an immense reason why people react negatively to it (Herek and Glunt 1988; Muyinda et al 1997). Other reasons include, that the virus is associated with intravenous drug use, homosexuality, and promiscuity (Oyediran et al, 2005). These behaviours are already stigmatised hence with HIV it forms layers of stigma (Brown et al, 2001). In addition, misconceptions and inaccurate information about basic transmission of HIV has led to discriminatory behaviours, although knowledge is said to have increased, compared to the last decade, PLWH are still subject of discrimination (FMOH, 2005). Understanding that behaviours of certain people such as homosexuals, sex workers and drug users attract stigma, the worst hit are the PLWHV themselves. The reason is that irrespective of their identity in life, first they are HIV positive then they could be mothers, teachers or nurses, whatever their identity may have been prior to the viral infection. The predictors of discrimination are a strong force that reckons global attention. In 2000, Peter Piot of the UNAIDS defined stigma as a continuing challenge that prevents concerted action at community, national, and global levels (Piot 2000). Does stigma matter? This question was addressed by Ban Ki-Moon when he stated, Stigma remains the single most important barrier to public action Stigma factor is global and remains a fact of daily life for PLWHV.. ....It is the main reason too many people are not seeking medical help, in one-third of all countries have virtually no laws protecting their rights. Almost all laws permit at least some form of discrimination - against women, children, gay men and against communities at risk. The fear of social disgrace makes AIDS a silent killer. Stigma is a chief reason the AIDS epidemic continues to devastate societies ...... (http://www.washingtontimes.com/news/2008/aug/06/the-stigma-factor)

Stigma and discrimination has grave consequences for PLWHV and other vulnerable populations. PLWHV are more socially and economically vulnerable than others because they are often banned from the existing social networks that usually provide an informal safety net. They often cannot rely on the informal welfare systems present in the community to overcome poverty because of their stigmatized status. Social isolation from family networks therefore has severe emotional, economic and financial consequences.

On the other hand, stigma is a highly multidimensional and complex social construction ( OBrien & Major, 2005). Not only does stigma negatively affect PLWHV and their families, it constitutes a significant hindrance to public health as it hampers HIV/AIDS prevention efforts (Valdiserri, 2002). Some countries in order to take a public health steps, restrict the movement of PLWHV from overseas travel. This could be discriminatory as in the recent case of Australian writer Robert Dessaix, who was denied visa to China based on his HIV status (Reuters UK, 2010). Stigma constitutes one of the greatest obstacles to preventing new HIV infections and alleviating the impact of AIDS (Aggleton & Parker, 2002). Stigma is a barrier to access and uptake of preventive, treatment and care behaviours, including PMTCT and condom use, (Adeokun et al, 2006). Stigma also hinders disclosure of HIV sero-

positivity status to sexual partners, friends and families (Carr and Gramling, 2004). Additionally, stigma results in poor treatment of people infected and affected by HIV/AIDS from family, community members and even health workers (Holzemer et al., 2007). It also contributes to human rights violation of PLHIV including loss of employment and physical abuse (Whiteside 1993) Finally, the space within which stigma thrive can be the - family, community, work place and health care setting (UNAIDS, 2001; Malcolm et al, 1998). On the other hand, stigma is a highly multidimensional and complex social construction (OBrien & Major, 2005). It is the complexity of HIV stigma that places culture, power, gender difference and poverty at the centre stage and opens up ways in which these social processes function and operate (Parker and Aggleton, 2003).

Parker and Aggleton (2003) draw from the work of Foucault (1977) who assert that structures of social control are lodged in established knowledge systems that legitimize forms of social inequality and thence limit the ability of marginalized peoples to oppose these hegemonic forces. One other perspective enunciated with reference to HIV/AIDS identifies stigma in a broader framework of power and domination and as central to reproducing structures of hegemony and control. They further argue that stigma occurs at the fusion of culture, power and difference and that stigma is employed by social actors who legitimate their dominant societal positions by perpetuating social inequalities. Farmer (1992) asserts that Stigma validates exclusion rules against vulnerable groups such as women and, therefore becomes a form of social control and gradually a part of structural violence. An example is, refusing a PLWHV from accessing medical health care.

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2.1.4 Poverty

One of the predictors of HIV stigma is poverty. Although there are sundry definitions of poverty, they all describe deprivation, lack and position of despondency of individuals to whom it is attributed. Poverty can be seen as low level of capability, or, as Sen asserts, the failure of basic capabilities to reach certain minimally acceptable levels (Sen1992:109). The United Nations defined poverty as a condition characterised by lack of basic human needs such as food, health shelter and education which depends not only on income but on access to services (UN, 1995:57). Also, it is the inability of an individual to attain a minimum standard of living (World Development Report, 1990). Similarly, according to Payne (2006), poverty is the absence of resources which include financial, emotional, mental, spiritual and physical support systems and relationships. Nevertheless, Payne further analysed in two terms as generational and situational. For instance, cycle of poverty, a concept that suggests that the poor are trapped in poverty because of their adaptation to the burdens of poverty can be termed as situational poverty. Though the concept of poverty is relative, it does possess similarities with stigma in its capacity to promote social exclusion. Its grave consequence is its ability to reduce poor peoples self-worth and affects their ability to interact and behave normally (Adepoju, 2004). Even the concept of poverty is stigmatising on its own because it strips people of the opportunity to improve their position and this could lead to social exclusion (Castro and Farmer 2005, Brown et al 2001).

2.1.5 Gender The broad understanding of gender as a concept is important in exploring HIV and the determinant factors of its related stigma. Gender is defined as a social construction and the cultural role that society imposes upon the individual (Abbot and Wallace 1997). The individuals role may depend on their gender and economic class within their cultural setting which helps to establish their personal and social identity. Gender attributes, opportunities and relationships are socially constructed and are learned through the process of socialization. In any society, gender determines the societal expectation, what is valued and permissible behaviour of women or a man in a given context. In most societies as well as Nigeria, there are differences and inequalities between women and men in various forms and contexts. They vary in activities assigned, responsibilities, decision making and in access to and control over

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resources. Since gender as a concept is part of the broader socio-cultural context, the next concept to review is culture.

2.1.6 Culture Culture, in the broad sense of the term, results from a complex human interaction with nature and generalized ways of social interaction, including knowledge, languages and belief systems shared by a group of people. It over time shapes and determines the attitudes and behaviour of people. A classic definition of culture from Kroeber and Kluckhohn (1952)

"patterned ways of thinking, feeling, and reacting, acquired and transmitted mainly by symbols, constituting the distinctive achievements of human groups, including their embodiments in artifacts; the essential core of culture consists of traditional ideas and especially their attached values" Kessing (1981:74) also puts it as, systems of shared ideas, systems of concepts and rules and meanings that underlie and are expressed in the ways that humans live. Furthermore, culture could be defined as, the system of shared beliefs, values, customs, behaviours and artifacts that the members of society utilise to cope with their worlds and with one another, and that are transmitted from generation to generation through learning. (Bates & Plog, 1976). Understanding culture is critical for this study because it is one of the social structures, which produce and reinforce the patterns of behaviour, establish norms and customs which people live by. While culture constructs norms and values of a particular group (s), it also comprises of the way the norms, customs and values are expressed through class systems. For instance, these norms may be expressed through gender roles, socio-economic position, tribal status, marital status, age grade or any number of other axes. Culture is a complex concept, with diverse dimensions yet with certain fundamental characteristics. The common characteristics are shared beliefs and values that guide the way people live.

2.1.7 Power

In understanding of the processes and dynamics of stigma and discrimination, the concept of power needs to be explored since stigma is more than a process or a social identity of the stigmatised but it is also about power engraved by structural forces. The concept of power 12

can be seen as a measure of an individuals ability to dominate the environment including the behaviour of other people. Variations of power may be perceived as good or evil, restraining or enabling( Giddens, 1984) but in the broad context of HIV stigma, power stands at the heart of social life and is used to legitimize inequalities of status within the social structure (Parker and Aggleton2003). According to Foucault, power is not possessed by few individuals, instead it is found everywhere and individuals are always in the position of simultaneously exercising power (Foucault, 1980:98). An implication of this in gender analysis is that while women may be subjected or dominated by men, they are not totally powerless and passive in their social sphere. This may not be completely realistic as power can be constraining and empowering,

Lukes insight on power provides a useful alternative. For Luke, power is in three dimensions. He expounded, the most effective use of power is to prevent resistance from occurring. Power, he asserts can be seen as various forms of constraint on human action as well as enabling although in a limited scope.

....A may exercise power over B by getting him to do what he does not want to do, but he also exercises power over him by influencing, shaping or determining his very wants. it is the supreme exercise of power to get another to have the desires you want them to have - that is, to secure their compliance by controlling their thoughts and desires? (Lukes 1974: 23) The concepts of culture and patriarchy exercises power through laws and norms to control the thoughts of people and subject them to its expectation. Power can be understood in terms of patriarchal structures. For Foucault, power is actions upon another's will and behaviour in order to interfere with them. In other words, power interferes with and infringes on an individuals rights and issues threats of hostility and discrimination hence achieving hegemony.

In gender analysis, power enters the equation in the sense that the men through structures of religion and cultural social norms exercises power over the women in all spheres (family, institutional or society. The nature of their relationship specifies the broad nature of their power relationship. Having understood these social actors, another concept, which defines the

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nature of intervention to mitigate discrimination unleashed by structural violence, is strategic behavioural communication (SBC).

2.1.8 Strategic Behaviour Communication

Strategic Behavioural Communication (SBC) is defined as; an interactive process with individuals and communities to develop tailored communication strategies, messages and approaches using a mix of communication channels and interventions to promote healthier behaviours and support individual, community and societal behaviour change (FHI, 2005). Its activities include but peer education, counselling, support groups, mass media, community mobilization and advocacy (ibid). The primary thrust of SBC is the use of communication and evidence based research to achieve desired health goals. This is a major stride from the Information Education and Communication (IEC) model used which was not evidence based. It is believed that SBC can make positive inputs in diverse program areas targeting different population segments: such as influencing the adoption of positive health behaviours, increasing knowledge on HIV basic modes of transmission, promoting demand for HIV counselling and reduction of stigma (ibid).

The strength of SBC is grounded in the delivered of activities and mix of channels to reinforce the same key messages overtime to the specific populations. Only a few NGOs has utilised this process in fighting HIV epidemic and the stigma related to it. Consequently, research shows that communication programs aimed at improving knowledge of the infection potentially have roles to play in reducing stigma (Babalola et al, 2009). Although some studies have demonstrated a negative relationship between stigma and communication exposure (Health Communication Partnerships, 2006 cited in Babalola et al, 2009).

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Table.1 Overview of Models showing transition from IEC to SBC

IEC Model Information +

Campaigns

Behaviour change model Peer education +advocacy +Road shows+ mobile testing+ Community mobilisation [targeting everyone without addressing specific needs]

Strategic behaviour communication Model

(Peer education +advocacy +gender mainstreaming +media + Road shows+ mobile testing+ Community mobilisation + Research)

Source: Authors conception adapted from King R. Sexual Behaviour Change for HIV: Where Have
Theories Taken Us? UNAIDS, 1999

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2.2 Theoretical frameworks for analysing the elements of culture, power, gender and poverty in relation to HIV Stigma:

One theory may not adequately fit into the description of this study.

There are three

theoretical frameworks, which seems appropriate to describe to the dynamics of stigma and discrimination among women. They are the theory of structural violence, framework of patriarchy and the theory of gender and power. This section will highlight the strengths and limitations of the aforementioned theoretical frameworks, and how the author derived her framework from them.

Firstly, this study borrows ideas from the patriarchal analytical framework in understanding the position of women in HIV stigma. Within gender inequality, patriarchy refers to a system, which women are constructed as subordinate to men and men are seen as superior to women. Nigerian society has been a patriarchy society, and the notions of masculinity and femininity are founded in relational power dynamics between both sexes (Aina, 1998). Patriarchy structure has been a significant feature of the traditional society. The practice of this system widens the imbalance between men and women. It is a structure of a set of social relations with material base, which enables men to dominate women (Aina, 1998). It is a socio-cultural system, which provides privileges to males while simultaneously applying arduous inhibitions on the roles and activities of females. This framework focuses on the agency of cultural norms through which dominance and oppression against women are initiated and reproduced. Some critics have argued that this framework is extreme to radical form of feminism, which lacked depth in political analysis of gender relations (Gregson and Foord, 1987). While this framework best explains the origin and context gender relations between men and women, it does not articulate other social structures and the link in understanding the dynamics of HIV related stigma and discrimination. Patriarchal society and expected societal gender roles are contexts of often unequal power relations. The patriarchal

framework can be linked with the theory of gender and power for the issue of gender inequality and the second for understanding the vulnerability of women living with HIV/AIDS, the theory of structural violence and social inequality by Parker and Aggleton (2003).

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Connell (1987) theory of gender and power expounds in detail, an understanding of the complex correlation between gender and power within the societal perspective. The theory of gender and power characterises three principal structures that show the gendered relationships between men and women: the sexual division of labour, the sexual division of power, and the structure of cathexis, which are embedded in the societal and institutional levels (Amaro and Raj, 2000). Although this theory has been applied in applied to clarify the gender dimension and vulnerability in societal beliefs and attitudes towards women living with HIV and precisely within the family, society and health facilities in Nigeria (Mbonu et al, 2010), it can be restrictive in analysing the interplay of the social forces existing within a society. When adopting the theory of gender and theory, can be challenging to isolate and quantify the effect of a particular social structure on womens health (Wingood and DiClemente, 2000). I will apply Cornells framework of gender and power to show the three structures where gender relationships and power dimensions interplay. The third aspect suggests the broad understanding of societal forces such as gender inequality, political violence, racism and poverty which determine the victims of stigma and shape how access to interventions are distributed (Castro and Farmer 2005).

Since the multiplicity of social actors has been reconceptualised as the framework for understanding HIV stigma, they highlighted that stigma can be analyzed within frameworks of Foucault and Bourdieu drawing on concepts of power, dominance, hegemony, and oppression. Here, stigma is utilised by tangible and discernible social players searching to legitimize their dominant position within existing societal structures of inequality (Parker and Aggleton, 2003). They further proposed interventions that permeate social, political, and economic structures. Consequently, Castro and Farmers structural violence framework allowed considerations to understand the predictors of HIV/AIDS stigma among PLWHV and will be adapted to explore the complexity of the problem for the design of interventions, which may address the inequalities. Castro and farmer (2005) posit that stigma and discrimination are considered part of complex systems of beliefs about diseases, which are often grounded in social inequalities. The forces of inequalities include poverty, and other social differences that are embedded in historical and economic processes that determine the spread and outcome of HIV/AIDS.

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This framework describes the broad interplay of social inequalities as a cause and result of HIV/AIDS from a social and biological aspect. Structural violence actuates an individual to pathogenic vulnerability by sculpting risk of infection, rate of disease progression and

access to SBC interventions. Unfortunately, the feminine poor almost experience violations of their basic rights particularly social and economic rights. Consequently, I apply Castro and Farmers framework of structural violence. The framework highlight that poverty is a consequence of and a cardinal reason why poor people living with HIV suffer from greater HIV/AlDS-related stigma.

Table 2. Convergence of tripartite social structures and power dominance.

Stigma and discriminatio n

Gender Inequality

Power

Cultural Inequality

Poverty

Stigma

Stigma

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Source: Authors conceptualisation of the relationship of power, poverty, gender, culture and HIV Stigma. This is adapted from Castro and Farmers structural violence and Cornells theory of gender and power.

The next chapter will present the socio demographic characteristic of Nigeria, the trend of HIV stigma, the category of individuals affected and why women are more vulnerable. It also examines the determinants of HIV stigma, the spaces where stigma thrives and specific interventions has been engaged to combat HIV stigma.

CHAPTER THREE Context of HIV Stigma in Nigeria

3.1 Stigma in Nigeria Nigeria is the most populous country in Africa with a population of about 140 million inhabitants with about 48.3% of the population in urban area while 51.7% are in the rural area (NPC, 2007). Nigeria is situated on the coast of West Africa, bounded on the West by the Republic of Benin, Niger Republic on the North, Republic of Chad and Cameroon on the East and Gulf of Guinea on the South. Nigeria as a state came into being following independence from Britain in 1960. Nigeria is made of three major ethnic groups, Igbo, Yoruba and Hausa. It has thirty-six states, 774 Local Government Areas and a Federal Capital Territory- Abuja. It is the sub-Saharan Africans most populous nation and currently has national HIV prevalence rates estimated at 4.4% (FMOH, 2007). The result implies an estimation of about 2.9million people are living with the HIV in Nigeria. Several identifiable factors have contributed to the rapid spread of HIV/AIDS in Nigeria. These include the high prevalence of other sexually transmitted diseases, poverty, incorrect and inconsistent use of condoms, lack of health care, and the silence and denial of HIV/AIDS due to stigma and discrimination (UNAIDS 2002).

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Source: http://sahelblog.files.wordpress.com/2009/07/nigeriamap2.gif Illnesses and diseases are reasons why people are being stigmatised and examples of such diseases that are associated with stigma are leprosy and HIV/AIDS. For instance, though Nigeria has achieved less than one case of leprosy per ten thousand people in 2003, there is still discrimination against people with discernable signs of leprosy. Hence, majority of people, find it difficult to seek help because of fear of stigmatisation. The same issue is applicable to HIV/AIDS (Nigeria - ILEP).

Stigma and discrimination in Nigeria seem not to differ from the global experience except for some cultural and geographic context. In the advent of HIV discovery in Nigeria in 1985 in a female hawker (Alubo et al, 2006), in order to curb the spread of HIV several methods including use of fearful imagery of the final clinical stages of AIDS; skeletons, lean flesh dying persons were used to create fear and awareness (Adeyi, 2006). This resulted to characterisation of HIV infection as a death sentence and this channelled peoples responses negatively towards PLWHA, people with HIV were called echieteka meaning death is 20

eminent. (Alubo et al.(2002); Hilhorst et al, (2006); Adeokun et al., (2006); Muyinda, Seeley, Pickering, & Barton, (1997) ). The phobia of AIDS linked with the stigmatising high-risk groups (sex, workers, homosexuals and intravenous drug users had a multiplier effect on the level of stigma associated with HIV/AIDS. In the early days in Nigeria, anecdotal evidence showed that HIV infection meant an instant transition from the realm of the dead to the living. But progressively, knowledge of HIV began to increase and HIV was conceptualised as the disease of foreigners because, only persons who have lived in cosmopolitan cities, mostly female sec workers (FSWs) returned to the rural communities with the disease, so everyone dreaded any form of association with it (Alubo et al ,2002).

3.2 Predictors of HIV Stigma: Broadly, the determinants of HIV Stigma in Nigeria may be classified into four themes and explored as follows; a) Cultural constructions b) Gender beliefs, c) Religion, d) Poverty In the cultural context, since stigma is a matter of perception, these perceptions varies considerably across cultures according to the norms of acceptable behaviour. For instance in Igbo land, the culture of wife inheritance has aggravated the spread of HIV, while the issue of wife sharing in Yoruba culture has been perceived to be responsible for spread of HIV infection. Again, in both Igbo and Yoruba culture, it is permissible for men to practice multiple sex partnering, trans-generational sex and transactional sexual activities, which put women at risk of HIV infection. Women resistance against these are treated as rebellion therefore met with punishments (divorce and beating and withdrawing household allowance). Odimegwu (2003) highlighted that cultural diversity between the Yoruba the Ibo tribes is responsible for the manifestations of HIV/AIDS stigma. Socio-cultural norms, especially gender norms, often dissuade people from condom use, even when they risk contracting HIV/AIDS. Men normally determine the circumstances of intercourse and usually refuse to protect themselves and their spouses. Conversely, these factors ultimately influence HIV vulnerability, prevention services and stigma (Obichukwu, 2004). To further reiterate, someone said; because women are already culturally

21

disadvantaged, in the country, they are easily accused of infecting their husbands (JAAIDS, 2004).

3.2.1 Who is stigmatised? In the Nigeria context it is assumed a case that but the infected and relations are infected, but the PLWHV seems to bear the brunt. The 'relations of PLWA hide it from outsiders but accept it within themselves mostly because of shame. Although studies reveal that males living with HIV/AIDS are victims of discriminatory attitudes, (Pallikadavath et al cited in Mbonu 2009), it is argued that female PLWHV suffer more punishments that are aggressive compared with punishments for males. Men abandon women who are HIV positive, but I dont know of any women who abandon their men for that reason. (CEDPA, 2006)

I believe if a woman gets HIV/AIDS it will be worse. People will discriminate against her more than a man. In Nigeria, some people do not believe a man can carry HIV/AIDS; they say it is only women.-female, single, company worker (Mbonu et al, 2010)

3.3 Gender:

There is an explicit gender difference in the way men and women perceive stigma and are discriminated against. Gender imbalances exist because the female identity is constructed based on the functionality in relation to man. For instance, a woman is, a wholly relative existenceSydneys sister, Pembrokess motherbut, never by any chance Pembroke herself. (Charlotte Gilman 1911 cited in Diclemente and Wingood 2000:2) In Nigeria, gender inequalities do exist and it is based on power differences. The gender belief is driven by the patriarchy system, which thrives as the dominant concept. Through in some parts of Nigeria like Calabar, women are allowed to inherit landed properties and it is a

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norm. This is unlike the patriarchy-dominated areas where the inheritance customs place women at unfavourable position, reproducing female subordination economically (NHD report, 2004). These inequalities are associated with inheritance laws that restrain the transfer of wealth and properties to females. Women do not inherit land not own farmlands in many cultures in Nigeria (Ugwu, 2009). Women are more vulnerable to HIV infection and its related stigma because the inheritance laws favour men and place women in economically disadvantaged positions. The feminization of the HIV/AIDS disease has due to cultural factors, resulted to the disempowerment of women. Women face socio- economic realities that place them at the receiving end (Jegede Ekpe, undated). Poverty as defined in chapter two shows deprivation even in the midst of resources based on domination or oppression. However, the effects of poverty could give an insight on how it affects the empowerment of women. That is the denial of the opportunities and choices most basic to human life the opportunity to lead a long, healthy, and creative life, and to enjoy a decent standard of living, dignity, liberty, self-esteem, and respect from others. (Human Development Report 2007) Both definitions are similar in highlighting the quality of life of an individual. The poverty status of women, who comprise fifty percent of the Nigerian population, is worse than that of men because Nigerian women since most are burdened with socio-cultural practices that strip the woman of her right to own property, treating her as property instead (Obilade and Mejiuni 2004). Also, the welfare of women in general including health and education had been ignored over the years. Among female PLWH, a negative report of experiences of women attests to this.

a woman who used to sell fish in a market in Nnewi. When people learnt that she is positive, they decided henceforth not to buy fish from her. Thus, her business collapsed. Her words Stigma creates poverty, by turning the individual into an outcast. The woman was completely abandoned when the community realised that she is HIV positive'. (Daily trust 14 October 2007) Nigeria: My Father wont eat My Food Ujorha Tadaferua- cited in )

Stigma in itself fuels poverty, which in turn has drives several women into sex work (Akinyemi et al, 2002). In urban cites, there is an estimation of between 350,000 and 2.1 million sex workers (Olayele et al, 2006), and among brothel based, an average of four clients 23

per one sex worker (Ladipo et al, 2001). Economic violence results in deepening poverty due to womens diminished access to independent means of livelihood (Falowe, 2008). Social discrimination as a result of HIV/AIDS also leads to economic exclusion and poverty among rural households and individuals (Ugwu, 2009).

3.4 Religion

Nigerians are very religious people and research has shown that 45% of Nigerians belong to the Christian faith and another 45% are Moslems, while the remaining 10% are either traditionalists or atheist (NPC, 2008). Religion plays a significant role in shaping the HIV/AIDS epidemic in Nigeria because fundamentally, Christians and Muslims in Nigeria share similar views on the reason HIV continues to spread: both groups see sexual misconduct as the root cause of the HIV crisis. Stigmatising attitudes of the church include, equating condom promotion with encouraging promiscuity. Condemning PLWH as sinners by saying, AIDS is Gods way of checking the immoral sexual behaviour (Smith 2004). Culture also shares the same moral views with the dominant religions. The Nigerian cultural tradition emphasized the importance of sexual discretion and believed that sex should be practiced within the marriage institution even before the advent of Christianity and Islam ( Aguwa ,2010). In the face of HIV, the response of the religious community can be negative as PLWHV have been stigmatized by religious leaders and communities of faith (UNAIDS, 2006). The priest do not bury anyone who dies of AIDS, they preach that other parishioners should alienate themselves from the sinners who have contracted HIV. On this, an individual reiterated, Many usually think it affects only people who are promiscuous. Because of their level of ignorance about the disease, many are not comfortable relating with PLWHV. Even in the religious circles, they are sometimes treated as outcast without much care and support (JAAIDS, 2004) In contrast, Nyblade et al (2004), in their study showed that religion or faith based institutions can encourage compassion and care for PLHA through a model of non-stigmatizing behaviour. Chikwendu, (2004) in her studies on FBOs in Nigeria, asserts that FBOs now see themselves as part of the solution to stigma reduction. They play a significant role in the global response to HIV, especially in providing a holistic ministry of care and support for 24

PLWHV and the community. This has encouraged some PLWHV obtain their locus of control from the agency of religion (Atuyambe, Otolok-Tanga, Murphy, Ringheim, and Woldehanna, 2007). In their study in Uganda, (Russell and Seeley, 2010) posit that religiosity or FBOs, provide a social life and spiritual support to PLWHV. Faith seemed to provide reassurance, encouragement and gave energy for peoples adaptive coping strategies. Though FBOs have been perceived as perpetuators of HIV stigma, for their moralistic, judgmental and socially conservative stances towards PLWHV and this attitude has adversely resulted to more denial and silence (DFID/Futures group 2005), their role in providing support to PLWHV is enormous. 3.5 Coping Strategies:

As mentioned previously that religion also helps PLWHV and their loved ones to cope with the consequence of the disease, It is important to note individuals adapt differently to diverse situations within their individual and societal context. Denial, shame and non-disclosure are also seen as strategies and forms of protection against stigma or discrimination (Adeyi et al 2006). Some of the coping mechanisms they employ include participation in support groups and religion as shown in previous section.

Denial and Shame. Before the advent of ART and increased knowledge, as a coping strategy, in defence against perceived stigma, the PLWHV denied their HIV status, to avoid stigma. I do not face stigma because I keep my status a secret. I do not discuss about it, so no none stigmatises me Female PLWHV, Ibadan (JAAIDS, 2004: pg 53).

However, when denial no longer protects their image because the disease has climaxed to the clinical stage where symptoms of disease have become evidentthen the next logical coping mechanism to be launched is shame. As their health conditions further deteriorate, they ascribed it to poison or witchcraft. Denial sometimes leads to non-disclosure of status. The consequence of this denial has led to poor health-seeking behaviour and serves as a barrier to access to SBC intervention (prevention, treatment and care services). Finally, it is believed that denial is based on faith invulnerability or low risk perception. For instance, in a study with FSWs, some said, 25

 If God says a person will die of AIDS, even if that person wears multiple condoms, they will all break and he will get infected and die of it( Akinyemi et al, 2002).

Support groups: Several female PLWH have relied on the support groups as a safety net and source of social capital where there have been ostracised from the society. Association of Women Living with HIV and AIDS in Nigeria (ASWHAN), a coordinating body for women living with HIV exists in eleven states in Nigeria with the aim of improving the quality of life of females living with HIV. Success has been recorded in advocating for improved access to PMTCT services and in distribution of Home Based care packages. However, the loophole in this achievement is that it is a momentarily aid provided by donors such as Christian aid and does not empower the women on a longer term to generate the financial resources needed for sustainable empowerment. ( www.aswhan.org/index.php?option=com_docman&task=doc)

3.6 Are there places stigma is predominant?

Having understood that stigma is still prevalent in Nigeria because HIV/AIDS as a disease is fused with stigma, this study highlights three levels where they are more prevalent, though it can be exercised everywhere (Foucault, 1980:98). There are the family, the institution (health care facilities) and the society. 3.6.1 The family

The family system is amongst the first spaces where women experience the impact HIV stigma. At this level, diverse forms of abuse exist, ranging from rejection of PLWHV, neglect, denial of access to toilet and household utensils and refusal to care for sick PLWHV (JAAIDS, 2004, Holzemer et al., 2007). Worse of the treatment directed at women in the family is economic violence. This may be defined when the abuser (male of family) has 26

absolute control over the females money and other economic resources. The abuser(s) determine without regard to women how the money is to be disbursed or banked, thereby debasing women to complete dependence for money to meet their personal needs (Falowe, 2008). Widows are more frequently blamed for the death of their spouse and discriminated against than widowers, when AIDS is suspected to have caused the death of the spouse. Widowers remarry relatively easily unlike widows, though they may have to search for a new spouse outside their community (Hilhorst et al 2006) while women are denied inheritance especially if they lost their spouses to AIDS (JAAIDS, 2004). Enwereji (2008) in a research carried out among women with HIV in Abia state illustrated that 86.7% of the women in the study were denied rights to family resources. These discriminatory acts of domination discourage women from disclosing HIV status (OConnell, 2002, Mbonu et al, 2009). As a result of stigma, it could be argued that though PLWHV suffers these feelings of guilt, shame, anger, depression, fear and mental strain, their family members also suffer similar challenges. (Vanable, Carey, Blair, & Littlewood, 2006).

3.6.2 The Institution The health care is amongst the sectors where PLWHV experience the impacts of the stigma epidemic. A PLWHV states, I was stigmatised when I was receiving medical care in the University College hospital, Ibadan. I developed ear and eye problems following my diagnosis...despite the fact that I kept complaining of deterioration, I was never slated for surgery to remove the cataract, even when others had surgery done for them. I kept using drugs, which are not working. I finally stopped attending the clinic (JAAIDS, 2004; p26).

Studies have shown the causes of HIV-related stigma in health institutions are lack of awareness among health workers of discriminating actions and its consequences; fear of casual contact based on inaccurate knowledge about HIV transmission; and the judgemental association of HIV with immoral behaviour (Nyblade et al 2004, Adebajo et al. 2003). In addition, variations of underfunding, insufficient medicines (ranging from antiretroviral treatment to basic medicines to treat opportunistic infections, non-practice of universal precautions), basic hospital equipment and post exposure prophylaxis prevention resources.

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Conversely, a significant number of health care workers are estimated to be HIV-positive because of lack of precautions regarding treatment.

Apart from this reason, stigma may limit the success of ARV programmes. Although a great number of women are in need of ARV to prevent mother to child transmission, only about one percent are receiving it (Adewole, Adeyi et al, 2006)

There is high dropout rate ... A number drop out because of stigma. We however do not have the statistics to corroborate this because follow-up of clients at home is a task the centre finds really hard to combine with our patients clinical management programme (JAAIDS,2004; p19). SBC might provide a long-term solution to this stigma challenge by addressing issues on modes of transmission, universal precautions, and the rights of PLWA .Previous studies assert HIV/AIDS education for HCP can reduce stigmatising attitudes and behaviour towards patients who are HIV-positive in Nigeria.

3.6.3 The society. Within this sphere of social interaction, stigma contributes to physical abuse, denial of PLWHV membership or active participation in community associations, social isolation, human rights violation of PLHIV including loss of employment and denial of employment, ( Klein et al., 2002; Kohi et al., 2006, JAIDS, 2004). A PLWHV recounts,

I worked with Pacific freightliners Ltd Ojota Lagos...before being laid off...after testing positive to HIV. The company got to know about my status because the hospital had to report back to the company on every staff that received medical treatment from the hospital. I presently find it difficult to get a new employment.... (JAAIDS, 2004:p26).

Although, The Nigerian Business Coalition Against AIDS (NIBUCCA) was established to address the workplace discriminatory behaviours by employing PLWHV, encouraging GIPA but much success has not been made yet. Unfortunately, PLWHV attract little sympathy as they were viewed as serving the punishment of their shameful behaviours and lifestyles (Adeokun,et al, 2006). Also, HIV-related stigma constitute a significant barrier to adoption of preventive, treatment and care behaviours, including, HIV test seeking behaviour and 28

condom use, (Adeokun et al., 2006; Babalola, 2007; Goldin, 1994) and to public health efforts (Valdiserri, 2002).

3.7 Interventions to reduce HIV stigma 3.7.1 National Governmental Response Nigeria has gone through diverse phases to address both the infection as well as the stigma associated with it. It dedicated a central body to lead and coordinate the response, while the various sectors, including civil society organisations, faith based organisations and networks of people living with HIV and AIDS support groups focus on packaging and implementing interventions based on a national action plan. The national action plan had guidelines on key interventions and monitoring of the epidemic. However, for effective national multi-sectoral response to HIV/AIDS, another national plan was developed in 2001, the HIV/AIDS Emergency Action Plan (HEAP) After the end of HEAP in 2004; this was not successful after an analysis findings showed insufficient nationwide awareness reflected by weak advocacy and information programs toward general populations and specifically at risk groupsyouth and women (NACA, 2001). A revised HIV/AIDS policy was then developed, the National Strategic framework (NSF) and a five-year (2004-2008) National HIV and AIDS Behaviour Change Communication Strategy (NBCC) in 2003 and 2004 respectively. This document is the blue print, which masterminds all SBC interventions to reduce HIV Stigma in Nigeria. (FMOH 2005a). Also, in response to the workplace discrimination, the Nigerian Business Coalition Against AIDS (NIBUCAA) was established in 2003 to coordinate the public and private sector response to HIV & AIDS in Nigeria. Though its aim is to assistance to members to set up workplace programmes (WPP)) through SBC and policy development, till date it has not effectively reduced workplace discrimination (Web forum NIBUCCA; http://www.nibucaa.org/act.php).

3.7.2 Non-Governmental (NGO) Response The role of NGOs as institutions in addressing behavioural change towards PLWHV is crucial in the reducing stigma and mitigating HIV/AIDS epidemic. Civil Society for HIV/AIDS in Nigeria (CiSHAN) which coordinates over 3,000 civil societies including

29

community based organizations, faith-based organizations and PLWHV groups all implement the NBCC, in the past had not made any impact partly because they lacked cohesion as an organisation and more importantly, skills in SBC.

In the past years, HIV intervention was geared towards awareness creation, campaigns, media jingles and poster information. But interventions were not research based neither was it tailored to specificity of relevant target group. However, implementation further evolved to adoption of health belief system models, risk perception and AIDS Risk reduction models. These models concentrated more on individuals and seemed to ignore other structural powers at play in producing and reproducing HIV related stigma. Until recently, the studies began to point towards research-based interventions in order to promote effective and tailored messages at targeted beneficiaries. This gave birth to strategic behavioural communication (SBC). Its activities include peer education, counselling, support groups, mass media, community mobilization and advocacy (FHI, 2005). The primary thrust of SBC is the use of communication and evidence based research to achieve desired health goals. It is believed that SBC can make positive inputs in diverse program areas targeting different population segments: such as influencing the adoption of positive health behaviours, increasing knowledge on HIV basic modes of transmission, promoting demand for HIV counselling and reduction of stigma (ibid).

While the strength of SBC lies when the activities are delivered through a mix of channels to reinforce the same key messages to the intended populations, only a few NGOs has utilised this process in fighting HIV epidemic and the stigma related to it. Consequently, communication programs aimed at improving knowledge of the infection potentially have roles to play in reducing stigma. Though some studies have demonstrated a negative relationship between stigma and communication exposure (e.g. Health Communication Partnerships, 2006 (Babalola et al, 2009). This study will not discuss the underlining theories, which the BCC and SBC comprise of; rather, it seeks to see its effectiveness in addressing HIV stigma and discrimination particularly among Nigerian women.

In summary, this chapter has shown the situation of HIV stigma in Nigeria, the categories of persons who are affected and why women are more vulnerable to HIV discrimination. It has also highlighted the three levels ( family, institution and society) where the impact of stigma

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may be felt as well as the efforts (interventions) so far to address the third phase of the AIDS epidemic( Maan, 1987).

CHAPTER FOUR Discussions

4. Overview This study reviewed HIV stigma reduction interventions (SBC) as it relates to mitigating the impact of HIV and its related stigma among vulnerable groups. The study also explored how the tripartite structural model of culture, gender and poverty as shown in Table 2.1 is addressed by SBC; it also address the issue of stigma and power dominance.

4.1. SBC and Culture: Impact of Economic empowerment on resistance. The levirate marriage as a cultural practice has been identified as one of the prime causes of the spread of HIV/AIDS in Nigeria especially in the rural communities (Bamgbose July 2002:13), cited in Immigration and Refugee Board of Canada. (2006). However, it is less likely that women in Nigeria who have greater economic independence would concede to levirate marriage (Ewelukwa, 2002). Studies show that womens economic independence is a determining variable, which influences her negotiating power in sexual marriage (Enwereji 2008); This concept can be explored to apply economic empowerment scheme in order to address poverty, consequently leading to resistance to harmful cultural norms. 4.2 SBC and Gender: Access of rural women to media intervention SBC programme appears to be all embracing (reaching women, men and adolescents). But in HIV/AIDS education, the medium of passing the information denies access to certain segments of the population. The most popular media for HIV/AIDS education in Nigeria are through the mass media, posters, seminars or rallies organized in the urban centres. Only few rural dwellers can access messages through this media because of illiteracy, lack of municipal facilities or lack of resources to purchase the necessary items. Available statistics show that 31

less than 13% of rural women read newspapers or watch the television (NARHS 2003). The implication is that the print and audiovisual campaigns do not reach the rural poor.

4.3 Interventions for Women, Addressing the Structure of Power 4.3.1 Advocacy to male stakeholders There is no specific intervention addressing the structure of power but because of the principal role men play in determining womens loss of status, SBC through advocacy, health education interventions focuses primarily on men but target women as secondary audience. Probably because studies have shown that educative health intervention could help achieve improved womens reproductive health, including reduction of HIV stigma because men are the custodians of culture. Therefore, men can be instrumental in correcting cultural ills that perpetuate stigma among women. Since the involvement of men in tackling unmet reproductive health issues among women has been successful (Adeyemi et al, 2005).

4.3.2 Greater involvement of women in policy making through education Tackling the issue of HIV related stigma and discrimination, goes beyond the scope of SBC interventions. As identified earlier, one of the key predictor of HIV stigma in Nigeria is poverty. Efforts to improve the girl child education to increase their earning power in formal employment will help to address poverty. Also, findings from the PSRHH gender mainstream showed improved participation of women especially PLWHV in decision making at the policy making level to ensure the interests of women were addressed adequately.1

4.4 Is SBC effective in HIV stigma reduction? Case study, PSRHH.

This section will answer the research question is SBC effective in HIV stigma reduction among women by exploring a successful HIV/AIDS program intervention the PSRHH project. The basis for selecting this project is as follows; a. The scale of project is broad to cover Nigeria or most states. b. Objective to work with vulnerable groups ( MOSY, FOSY, TWs, FSWs, USM)
1

A gender mainstreaming matrix in PSRHH program. This shows how PSRHH empowered women through HIV/AIDS policy development, planning and implementation.See Appendix 1

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c.

Clear objectives relating to SBC strategies for reducing HIV stigmatization and discrimination

d. Have indicators regarding access, coverage, impact or behavioural change; e. Duration of program should be a minimum of five years2

4.4.1 PSRHH: PSRHH a seven-year national behaviour change and condom social marketing from 2002-09 was managed by PSI (Population Services International) in partnership with Society for Family Health (SFH), Action Aid and Crown Agents. PRSHH contributed to the goal of improved sexual and reproductive health (SRH) among the poor and vulnerable populations in Nigeria. The success of the activities was measured by the following outputs: Reduced stigma and discrimination of People Living with HIV&AIDS among general population Reduced stigma and gender determinants driving the HIV&AIDS epidemic; Increased capacity of support groups to advocate for the rights of PLWHAs (Action Aid, 2008).

PSRHH project implemented all the components of SBC as shown in Table 1 and produced information, education and communication (IEC) print materials, and radio dramas aimed at increasing awareness of HIV/AIDS, and its causes and consequences. These radio dramas included One Thing at a Time, Odenjiji in Igbo, Garin Muna Fata in Hausa, and Abule Oloke Merin for Yoruba Audience. There were diverse billboard campaigns to promote awareness that a PLWHV may not display clinical symptoms of AIDS. In contrast, SBC messages could also be stigmatising; for instance, the media in Nigeria calls HIV/AIDS in local languages echieteka meaning death is imminent and STIs are called nsinwanyi which gives the impression that HIV is about women and totally incurable. 4.5 Family level. At the family level, the peer education process is used to impact knowledge, instil behaviour change and maintain the desired behaviours and this has proved to be effective (Ayanti et al, 2008). Success stories have shown how involvement of PLWHAs as IPC conductors has

The reason for this time frame is that stigma is a process and may take a long period of time for its impact to be measured.

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given hope to PLWHAs and improved inter-spousal communication which has resulted to gender appreciation and acceptance of PLWHV (SFH internal report, 2010).

4.6 Institutional level. In the health-care institutions, a program targeting improved patient-provider interaction and communication is inclusive such as training of health care providers. For instance, SFH has trained UNTH Enugu HCP staff of stigma and its implications for fuelling HIV epidemic. 4.7 Societal level PSRHH designed Interventions to reach different target groups at the societal level. For example, the youths were reached through school-based BCC interventions. The religious leaders were reached through advocacy and trainings and they were encouraged to form faith based initiatives such as Redeemed AIDS action Committees and the Islamic group, Nasrullahil-fathi society of Nigeria (NASFAT). This has been successful in improving acceptance of PLWHV but in the workplace, as stated in the chapter three, although NIBUCCA employed SBC activities such as peer education, to address stigma, it has not succeeded.

4.8 Success in stigma reduction? There at least five reasons why stigma seems to be less prevalent today than when HIV was discovered in Nigeria as a result of PSRHH and such similar projects . Correct and Increased knowledge. Accurate information has increased as a result of the diverse public campaigns and the presence of HIV organizations; support and faith based groups. More importantly, because the communication messages are targeted to address specific target groups. For instance, in the early days of HIV epidemic in Nigeria, people were classified as working corpse. Once you are infected [down with AIDS] people treat you as a dead person already (Alubo et al, 2006) However, presently, there is a hope shift to transition from the dead to the living due to ART drugs (Russell and Seeley, 2010).

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The Availability of Anti Retroviral Therapy. The ARV therapy has immensely restored self-esteem by restraining and mitigating the tangible consequences of HIV and AIDS, reversing the image of HIV as a deadly disease facilitating early death and restoring productivity. The Executive Summary of a Health Reform Foundation of Nigeria report states:

Currently, 124,572 PLWHV are accessing antiretroviral drugs in various centres across the country. This implies that the number of people on ART has multiplied ten folds.... (http://www.herfon.org/docs/HERFON_ART_Report.pdf)

Even with this level of success, yet stigma inhibits people from accessing the treatment. As someone said, I do not subscribe to the anti-retroviral programme of the organisation even though I can afford it because daily intake of the medical pills would make people suspicious of my HIV status. I still want to marry. (JAAIDS, 2004:p28) Self stigma as felt by this person has hindered her from accessing available ART. Public disclosure of HIV status. Increased number of PLWHV who are declaring their status publicly has led to societal acceptance, greater awareness, more accurate knowledge and public dialogue. By coming out and educating others, by openly disclosing my status, I reduce the tendency of people pointing fingers at me and stigmatising me. There is nothing new they have to say because I have said it.(JAAIDS, 2004:p41)

Increased number of support groups.

NEPWHAN presently consists of 250 support groups with 80,000 members spread across the 36 states. The organization is a member of all national AIDS committees and operates in more than 200 communities in Nigeria (FHI, 2006)

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Presence of Anti-Stigma bill.

NEPWHAN has contributed greatly to the articulation of the anti-discriminating bill presently before the National Assembly. Although this has not been successful, in Enugu and Lagos state, the anti-stigma bill has been passed into law and fully operational to protect the rights of PLWHV.

4.9 Limitations of SBC within PSRHH. Amaro and Raj (2000) state that assaulted women with low self-esteem and lower socioeconomic status have a lower likelihood of participating in an HIV intervention (Amaro and Raj, 2000). This implies that the process of reaching this vulnerable group through peer education was difficult. Though PSRHH used the existing structure of womens community meetings and support groups to reach women, challenges still exists on how the socially isolated women could be reached. In addition, SBC does not combine economic and stigma reduction interventions to help marginalized populations, specifically women to overcome internalized stigma and become empowered to advocate for their rights. Though its communication strategies through consistent exposure to correct information has helped them gain knowledge of their right to care, treatment and quality living.

4.9.1 Attempts to address poverty HIV programs acknowledge the import of addressing poverty in HIV programs (ENR, 2004). In an attempt to address the issue of poverty, the program links up with government established schemes such as Rural Infrastructure Development Scheme (RIDS), Social Welfare Services Scheme (SOWESS) and National Poverty Eradication Programme (NAPEP) (http://www.nigeriafirst.org/printer_263.shtml). The intent as argued is to allow the government to address this aspect while the program focuses on other issues. Paradoxically, the government in which the HIV program rely on has leadership and political problems and has not been successful in alleviating poverty as Nigeria s Human Development Index (HDI) ranks 158 in the world (HDR,2009).

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4.9.2 Justification for female economic empowerment. Having examined the impact SBC using the PSRHH as a case study, below are the justifications for poverty to be addressed. The first reason is the vulnerability of females with HIV/AIDS. Economic empowerment is crucial in any society because it provides a means for accessing basic needs for survival. However, it is more critical for females living with HIV because, there are vulnerable. Having been victims of numerous discriminatory acts such as physical and economic violence, abandonment by spouse, children or family, labelling, stereotyping and loss of status and employment, there is a need that the agency that subjects them to be susceptible to HIV infection seminally should be effectively addressed. Females are a lot more dependent. They depend on their husbands for money to buy drugs, so basically female patients are at a great disadvantage. Most of them are afraid of losing their husbands that are bringing in the money(Mbonu et al,2010). In health facilities, the poor have difficulties in accessing health care because of user fees, distance from facilities and male domination in restricting the movement of women especially for women in purdah.

Best practices from South Asia (World Bank, 2008) showed that capacity strengthening in the form of providing economic opportunities to PLWHV was shown to reduce stigma. This asserts, poverty alleviation will increase the resilience of communities, thus influencing the support available to affected households (Hilhorst et al, 2006). In conclusion, SBC has been appraised positively to reduce HIV related stigma especially with the combination of mass media though the limitation of the coverage of the intervention has conspired to constrain the rural poor from this success. This chapter addresses the research question: to what extent SBC mitigates the impact of HIV related stigma and discrimination among women in Nigeria.

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CHAPTER FIVE

Conclusion

This study explored the impact of HIV related stigma on Nigerian women and the effectiveness of SBC in addressing the determinants of stigma and discrimination. It described the forms and context stigma experienced by women in Nigeria, it also examined the factors which influence their experiences. In addition, it explored the extent which SBC mitigates the impact of HIV/AIDS related stigma in the context of understanding female vulnerability. Results of this study are consistent with previous research findings (Fakolade et al 2010, Babalola et al, 2009; Fatusi and Jimoh 2006) which argues that SBC has a great potential in reducing the severity of HIV related stigma and discrimination and or tailored educational and media intervention made significant reductions among the general populace. Furthermore, knowledge about HIV/AIDS has shown to reduce stigma (Oduroh, 2002), and communication based approaches for reducing stigma have demonstrated positive effects (Brown et al, 2001). Equitable SBC intervention mix can be strengthened to achieve gender equality and economic empowerment in HIV/AIDS prevention, treatment and care by poverty reduction strategies to empower the women economically. In Nigeria, SBCs contribution in addressing economic inequality to mitigate HIV stigma among PLWHV especially among women is insignificant. The possibility that poverty may erode the efforts of huge HIV programs because they do not focus on the tripartite power inequalities. Beyond the cultural and religious factors, there is also economic violence and domination which when its remedies are tactically infused into the SBC programs will provide a sustainable empowerment for women and reduce HIV stigma and discrimination.

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Finally, this study agrees with Ankrah, 1996: 99, that an effective strategy for addressing AIDS issue must include socio-economic development of women. Evidence points that SBC model alone cannot combat HIV-related stigma. Rather, SBC needs to tackle the poverty that lies at the core of HIV stigma at the tripartite levels and an economic enabling environment through integrating income generating or enterprise development as part of the SBC package for effective stigma reduction among women in Nigeria.

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