PERCEPTIONS AND ATTITUDES INFLUENCE ON THE LEVEL OF DISCRIMINATION AND STIGMATIZATION OF PEOPLE LIVING WITH HIV/ AIDS IN GARISSA COUNTY

Purpose: The purpose of the study was to establish the perceptions and attitudes influence on the level of discrimination and stigmatization of people living with HIV/ AIDS in Garissa County. Methodology: The target population of the study was all the patients with HIV and AIDS attending The Comprehensive care Centre at Garissa Provincial General Hospital in Garissa County. There are approximately 2000 people actively on ARVs attending the facility. A sample of 200 respondents was selected using random sampling from the listed list of all patients in the hospitals. The study used primary data. Data collection methods included: questionnaires and interview guide. Data was analyzed quantitatively and qualitatively. Information was sorted, coded and input into the statistical package for social sciences (SPSS) for production of graphs, tables, descriptive statistics and inferential statistics. Results were presented by use of tables and charts. Results: Based on the findings, the study concluded that perceived factors influenced stigmatization and discrimination levels. Specifically, the likelihood of females spreading HIV influenced levels of stigmatization and discrimination. Similarly, the likelihood of old people spreading HIV influenced levels of stigmatization and discrimination. Unique contribution to theory, practice and policy: Based on the findings, the study recommends that group therapy should be conducted regularly with an aim of encouraging members of the public to be tested and be aware of their HIV status.


INTRODUCTION 1.1 Background of the Study
Stigma is the identification that a social group creates of a person (or group of people) based on some physical, behavioral or social trait perceived as being divergent from group norm (Castro and Farmer, 2005).Also, as Deacon (2006) states, negative effects of stigma include status loss and discrimination.
Discrimination often includes harassment, violence, and the social tendency to blame the victim (Appleby et al., 2001).Also, according to Carr-Ruffino (1998) discrimination refers to actions, whereas prejudice refers to viewpoint.Although the UNAIDS Vision is zero new HIV infections, zero discrimination and zero AIDS -related deaths as per its global report of 2010, the epidemic of stigmatization against people living with HIV/AIDS remain a big challenge.According to Michel Sidibe, UNAIDS Executive Director, growth in investment for the AIDS response has flattened for the first time in 2009, Demand is outstripping supply.Stigma, discrimination, and bad laws continue to place roadblocks for people living with HIV and people on the margins.
The epidemic of HIV/AIDS has been accompanied by the epidemic of stigmatization against people living with HIV/AIDS (PLWHA) (Varas-Dı´az et al., 2005).Even though two decades have passed since the first five AIDS cases were reported in 1981 in the USA and HIV/AIDS cases have become more widespread, stigmatization against individuals with HIV/AIDS continues to persist in both overt and covert forms (Herek, 2002).HIV/AIDS stigma is a worldwide social phenomenon.PLWHA are often stigmatized partly because HIV/AIDS is a disease transmitted by modes and behaviors that are disapproved by society (e.g.homosexual behavior, drug use and commercial sex), and partly because people are afraid of contracting HIV/AIDS due to the fact that it is a degenerative and incurable disease with a high mortality rate.
Given that HIV/AIDS is a fatal contagion and prevalent in some social groups (e.g.gay and bisexual men and intravenous drug users among others), stigmatized reactions to PLWHA are thought to be a result of at least two types of attitudes: instrumental attitudes which derives mainly from fear of AIDS contagion, and symbolic attitudes which derives from the expression of hostility towards deviant behaviors of the risk groups (Herek and Capitanio, 1998).PLWHA are subjected to greater blame if they have been known to have contracted the infection through sexual behaviors (either heterosexually or homosexually) (Herek and Capitanio, 1999).
HIV-related stigma and discrimination have been acknowledged as an impediment to mitigating the HIV epidemic since its early days, yet programming and activities to reduce stigma and discrimination have been given much less attention than other aspects of the epidemic.Fortunately, in recent years there has been an increase in the literature on HIV stigma as the issue has gained visibility and greater conceptual clarity and as means to measure stigma have been refined (Nyblade and MacQuarrie, 2006;Genberg et al., 2008;Stein and Li, 2008;Visser et al., 2008).However, key gaps remain in the literature.

Problem Statement
Since the beginning of the AIDS epidemic, more than 60 million people have been infected with the HIV virus and approximately 30 million people have died of AIDS.In 2010, there were an estimated 34 million people living with HIV, 2.7 million new infections, and 1.8 million AIDS-related deaths (WHO).The WHO African Region is the most affected, where 1.9 million people acquired the virus in 2010.The estimated 1.2 million Africans who died of HIV-related illnesses in 2010 comprised 69% of the global total of 1.8 million deaths attributable to the epidemic.It is therefore, crystal clear that the HIV/AIDS epidemic poses the biggest challenge to Africa.
In its 26th Meeting, the UNAIDS Programme Coordinating Board Geneva, Switzerland defined HIV-related stigma as follows: HIV-related stigma refers to the negative beliefs, feelings and attitudes towards people living with HIV and/or associated with HIV.Thus, HIV-related stigma may affect those suspected of being infected by HIV; those who are related to someone living with HIV; or those most at risk of HIV infection, such as people who inject drugs, sex workers, men who have sex with men and transgender people.HIVrelated stigma exists worldwide and manifests itself in countries, communities, religious groups and individuals, though its basic elements are surprisingly common across cultures.It is expressed in stigmatizing language and behavior, such as ostracization and abandonment; shunning and avoiding everyday contact; verbal harassment; physical violence; verbal discrediting, blaming and gossip.Stigma often lies at the root of discriminatory actions.Stigma may also be internalized by stigmatized individuals in the form of feelings of shame, self-blame and worthlessness (UNAIDS, 2000).
HIV-related discrimination refers to the unfair and unjust treatment (act or omission) of an individual based on his or her real or perceived HIV status.Though HIV-related stigma often leads to discrimination, it is important to note that even if a person feels stigma towards another, s/he can decide to not to act in a way that is unfair or discriminatory.Conversely, a person may discriminate against another without personally holding stigmatizing beliefs, for example, where discrimination is mandated by law (UNAIDS, 2000).
Stigma not only makes it more difficult for people trying to come to terms with HIV/AIDS and manage their illness on a personal level, but also interferes with attempts to fight the AIDS epidemic as a whole.On a national level, the stigma associated with HIV can deter governments from taking fast, effective action against the epidemic, whilst on a personal level it can make individuals reluctant to access HIV testing, treatment and care.
UN Secretary-General Ban Ki Moon says: "Stigma remains the single most important barrier to public action.It is a main reason why too many people are afraid to see a doctor to Vol.1, Issue 1 No.1, pp81-105, 2016 www.ajpojournals.org85 determine whether they have the disease, or to seek treatment if so.It helps make AIDS the silent killer, because people fear the social disgrace of speaking about it, or taking easily available precautions.Stigma is a chief reason why the AIDS epidemic continues to devastate societies around the world." HIV/AIDS-related stigma has persisted world-wide for decades however, studies on the linkage between stigmatizing attitudes towards people living with HIV/AIDS (PLWHA) and misconceptions about HIV transmission routes in the general population, especially among the people of this region, are sparse; a research gap this study is intends to fill.The primary goal of this study was to establish whether perceptions and attitudes influences the level of discrimination and stigmatization of people living with HIV/ AIDS in Garissa County.

Research Objectives
To establish whether perceptions and attitudes influences the level of discrimination and stigmatization of people living with HIV/ AIDS in Garissa County.

Empirical Review
As per UNAIDS Global Report 2010, a sample of results from the People Living with Stigma show that stigma and discrimination are reportedly experienced by people living with HIV in diverse settings in all regions: In Myanmar, 11 per cent of respondents reported that they were often excluded from social events, and 15 percent reported that they were often excluded from family events in the last 12 months.Although 90 percent of respondents had not been denied health care in general due to their HIV-positive status in the last 12 months, 35 percent reported that they had been denied family planning services, and 20 percent had been denied other sexual and reproductive health services.
In the People"s Republic of China, a major concern for respondents was that they might become the subjects of gossip if their status was known with 87.3 percent of female respondents and 79.4 percent of respondents overall expressing this concern.More than half of respondents worried about being insulted or threatened, and almost one quarter worried about being physically attacked.In addition, 41.7 percent of respondents reported having faced some type of HIV related discrimination, and 12.1 percent of respondents had been refused medical care at least once since they were tested positive.Of those respondents with children, almost one tenth (9.1 percent) said that their children, who were not necessarily HIV positive themselves, had been forced to leave school because of the HIV status of their parents.
Although 87 percent of the respondents in Rwanda reported that they had never been denied health services, a large percentage (88 percent) of respondents reported being denied family planning services because of their HIV positive status in the last 12 months.HIV-positive status was also a major reason reported for denial or refusal of access to accommodation, work, and educational services.In the United Kingdom, 46 percent of respondents reported that their rights may have been violated in the last 12 months.Twenty-two percent of www.ajpojournals.org86 participants reported being physically harassed, and 40 percent reported being verbally harassed, with 54 percent of respondents saying that the harassment was at least partly due to their HIV status.Seventeen percent reported that they had been denied health services in the last 12 months.Human rights are no longer considered peripheral to the AIDS response.
Today, the vast majority of countries (89%) explicitly acknowledge or address human rights in their national AIDS strategies, with 92% of countries reporting that they have programmes in place to reduce HIV-related stigma and discrimination (UNAIDS, 2010).
At the same time, however, criminalization of people living with HIV still presents significant challenges to the AIDS response.More than 80 countries across the world have laws against same-sex behavior, and the free travel of people living with HIV is restricted in 51 countries, territories and areas.Such laws are not only discriminatory and unjust-they also drive HIV underground and inhibit efforts to expand access to life-saving HIV prevention, treatment, care and support (UNAIDS, 2010).

RESEARCH METHODOLOGY
This research utilized the survey design.The study focused on the population of Garrisa County of people living with AIDS.Those living with HIV/AIDS are approximately 2,000.In this regard, the men and women attending the HIV/AIDS Comprehensive Care Center (CCC) in Garissa County Hospital formed the sample frame of those living with HIV/AIDS since they are more accessible considering the nature of the study area and the topic in question.About 2,000 HIV/AIDS positive patients attend the clinic for collection of weekly ARV, testing, nutritional, pharmacy and laboratory, family planning, prevention of mother to child transmission and counseling services.The target sample was 10% of the population/patients.Therefore, the sample size of this study was 200 patients living with HIV and 12 key informants.Random sampling technique was used to select 200 individuals from the list provided by Garissa County Hospital.In order to collect primary data in appropriate form, detail and accuracy, questionnaires and in depth interview guide were used at the hospital and VCT center.Primary data was derived from questionnaires distributed to the patients.The questionnaire had closed-ended questions.Both quantitative and qualitative data was collected.Quantitative data analysis was done using descriptive statistics and inferential statistics.Specifically, descriptive statistics involved frequencies and means.Inferential statistics involved chi square and odd ratio regressions.The statistical package for social sciences (SPSS) was used to conduct the descriptive as well as the inferential statistics.Chi square and odd ratio regressions were used to achieve the objective.Content analysis was also used to address the qualitative information obtained from key informants and from open ended questions in the questionnaire.The study preferred qualitative content analysis since it addressed some of the weaknesses of the quantitative approach.The number of questionnaires that were administered was 200.A total of 200 questionnaires were properly filled and returned.This represented an overall successful response rate of 100% as shown on Table 1.According to Mugenda and Mugenda (2003) and also Kothari (2004) a response rate of 50% is adequate for a descriptive study.Babbie ( 2004) also asserted that return rates of 50% are acceptable to analyze and publish, 60% is good and 70% is very good.Based on these assertions from renowned scholars 80 % response rate is adequate for the study.

Demographic Characteristics
This section presents the descriptions of the respondents in terms of their gender, age, marital status, religion, level of education, employment type and level of income.

Gender
The respondents were asked to indicate their gender.Majority of the respondents were female who represented 81% of the sample while 19% were male.These results imply the population of Garissa County is female dominated.

Level of Education
The respondents were asked to indicate their level of education.Majority of the respondents had acquired up to primary level education as represented by 59%, 19% had post-secondary level education, 18% had no education, while only 4% had secondary school education.This implies that people in Garissa County are not very educated.

Age
The respondents were asked to indicate their age.Majority of the respondents were between 21-30 years as represented by 32.5%, 25.5%, were between 31-40 years 19% were between 41-50 years, 10.5% were less than 20 years while 12.5% were above 51 years.This implies that the majority of people in Garrisa County are in their middle age.

Marital Status
The respondents were asked to indicate their marital status.Majority of the respondents were single as represented by 41.0%, 23.5% were married, 22.5% were widowed while 13.0% were divorced.

Employment Type
The respondents were asked to indicate their employment type.Majority of the respondents are not employed as represented by 61.0%, 23.5% were self employed while only 15.5% were formally employed.This implies that a majority of the people in Garissa county are unemployed.The respondents were asked to indicate the income range that best described their level of income.Majority of the respondents earn between Kes 0-Kes 20,000 as represented by 75%, 16% earn between Kes 21,000-Kes 40,000, 6.5% Kes 41,000-Kes 60,000 while only 2.5% earn above Kes 60,000.This implies that majority of the people in Garissa County earned low income.

Descriptive Statistics
The objective was to determine the perceived factors affecting the spread of HIV.60.5% of the respondents indicated that males are likely to spread HIV.The results are presented in Table 4.3 below.Majority of the respondents believe females are most likely to spread HIV as represented by 80.5%, 79% of the respondents indicated that poor people are most likely to spread HIV.Further, results indicate that rich people are most likely to spread HIV as indicated by 84% of the respondents.Gay people are perceived as most likely to spread HIV as agreed by 94% of the respondents.Majority of the respondents indicated that prostitutes are most likely to spread HIV as represented 97%.Married people are perceived as likely to spread HIV as indicated by 63% of the respondents, 58% of the respondents indicated that unmarried people are likely to spread HIV, 77% indicated that divorced people are likely to spread HIV while 67% indicated that polygamous people are most likely to spread HIV.
Results also reveal that non polygamous are perceived as likely to spread HIV as represented by 69.5%, old people are perceived as least likely to spread HIV as agreed by 91.5% of the respondents while 48% of them perceived young people as likely to spread HIV.

Chi-Square Test for Perceived Factors
Table 3 presents results of likelihood of males spreading HIV and stigmatization and discrimination chi-square test.Results show that the relationship between likelihood of males spreading HIV and stigmatization and discrimination was significant (X 2 =28.251, p=0.000).This implies that likelihood of males spreading HIV significantly influenced stigmatization and discrimination levels.Results show that the relationship between likelihood of females spreading HIV and stigmatization and discrimination was significant (X 2 =25.316, p=0.000).This implies that likelihood of females spreading HIV significantly influenced stigmatization and discrimination levels.Table 5 presents results of likelihood of poor people spreading HIV and stigmatization and discrimination chi-square test.Results show that the relationship between likelihood of poor people spreading HIV and stigmatization and discrimination was significant (X 2 =22.390, p=0.000).This implies that likelihood of poor people spreading HIV significantly influenced stigmatization and discrimination levels.Table 6 presents results of likelihood of rich people spreading HIV and stigmatization and discrimination chi-square test.Results show that the relationship between likelihood of rich people spreading HIV and stigmatization and discrimination was significant (X 2 =33.873, p=0.000).This implies that likelihood of rich people spreading HIV significantly influenced stigmatization and discrimination levels.Table 7 presents results of likelihood of gay people spreading HIV and stigmatization and discrimination chi-square test.Results show that the relationship between likelihood of gay people spreading HIV and stigmatization and discrimination was significant (X 2 =14.815, p=0.000).This implies that likelihood of gay people spreading HIV significantly influenced stigmatization and discrimination levels.Table 8 presents results of likelihood of prostitutes spreading HIV and stigmatization and discrimination chi-square test.Results show that the relationship between likelihood of prostitutes spreading HIV and stigmatization and discrimination was significant (X 2 =3.884, p=0.049).This implies that likelihood of prostitutes spreading HIV significantly influenced stigmatization and discrimination levels.Table 9 presents results of likelihood of married people spreading HIV and stigmatization and discrimination chi-square test.Results show that the relationship between likelihood of married people spreading HIV and stigmatization and discrimination was significant (X 2 =27.971, p=0.000).This implies that likelihood of married people spreading HIV significantly influenced stigmatization and discrimination levels.Table 10 presents results of likelihood of unmarried people spreading HIV and stigmatization and discrimination chi-square test.Results show that the relationship between likelihood of unmarried people spreading HIV and stigmatization and discrimination was significant (X 2 =15.128, p=0.001).This implies that likelihood of unmarried people spreading HIV significantly influenced stigmatization and discrimination levels.Table 11 presents results of likelihood of divorced people spreading HIV and stigmatization and discrimination chi-square test.Results show that the relationship between likelihood of divorced people spreading HIV and stigmatization and discrimination was significant (X 2 =27.364, p=0.000).This implies that likelihood of divorced people spreading HIV significantly influenced stigmatization and discrimination levels.Results show that the relationship between likelihood of polygamous people spreading HIV and stigmatization and discrimination was significant (X 2 =16.203, p=0.000).This implies that likelihood of polygamous people spreading HIV significantly influenced stigmatization and discrimination levels.Table 13 presents results of likelihood of non polygamous people spreading HIV and stigmatization and discrimination chi-square test.Results show that the relationship between likelihood of non polygamous people spreading HIV and stigmatization and discrimination was significant (X 2 =42.920, p=0.000).This implies that likelihood of non polygamous people spreading HIV significantly influenced stigmatization and discrimination levels.Table 14 presents results of likelihood of old people spreading HIV and stigmatization and discrimination chi-square test.Results show that the relationship between likelihood of old people spreading HIV and stigmatization and discrimination was significant (X 2 =14.882, p=0.000).This implies that likelihood of old people spreading HIV significantly influenced stigmatization and discrimination levels.Table 15 presents results of likelihood of young people spreading HIV and stigmatization and discrimination chi-square test.Results show that the relationship between likelihood of young people spreading HIV and stigmatization and discrimination was not significant (X 2 =1.774, p=0.412).This implies that likelihood of young people spreading HIV did not significantly influence stigmatization and discrimination levels.Binary logistic regression was used to model relationship between perceived factors and stigmatization and discrimination levels.Table 16 shows that the likelihood of females spreading HIV is statistically associated to levels of stigmatization and discrimination (p<0.050).An increase in the likelihood of females spreading HIV increases the probability of stigmatization and discrimination by 3.551 times.Likelihood of unmarried people spreading HIV is statistically associated to levels of stigmatization and discrimination (p<0.027).An increase in the likelihood of unmarried people spreading HIV increases the probability of stigmatization and discrimination by 0.157 times.Likelihood of old people spreading HIV is statistically associated to levels of stigmatization and discrimination (p<0.002).An increase in the likelihood of old people spreading HIV increases the probability of stigmatization and discrimination by 0.057 times.

Content Analysis
From the interview guide responses all the respondents indicated yes to the question, "In your opinion, do people living with HI/AIDS experience stigmatization and discrimination."They cited verbal abuse, people living with HIV being perceived to die soon, people living with HIV being shunned by their families and friends, people avoiding physical contact with the infected persons and general fear from the public as some of the ways in which stigma and discrimination is expressed.When asked about factors that promote stigmatization and discrimination they mentioned illiteracy, ignorance and poverty.They recommended health drives and campaigns, civic education, guidance and counseling, group therapy, encouraging members of the public to be tested and holding regular village barazas to increase public awareness and openness about HIV/AIDS.

Discussion
The objective of the study was to establish whether perceptions and attitudes influences the level of discrimination and stigmatization of people living with HIV/ AIDS in Garissa County.Binary logistic regression results showed that the likelihood of females spreading HIV is statistically associated to levels of stigmatization and discrimination which implied that an increase in the likelihood of females spreading HIV increases the probability of stigmatization and discrimination.Similarly, the binary logistic regression results revealed that the likelihood of unmarried people spreading HIV is statistically associated to levels of stigmatization and discrimination which implied that an increase in the likelihood of unmarried people spreading HIV increases the probability of stigmatization and discrimination.Further, the binary logistic regression revealed that the likelihood of old people spreading HIV is statistically associated to levels of stigmatization and discrimination which implied that an increase in the likelihood of old people spreading HIV increases the probability of stigmatization and discrimination.

Conclusions
Perceived factors influenced stigmatization and discrimination levels.Specifically, the likelihood of females spreading HIV influenced levels of stigmatization and discrimination.
Similarly, the likelihood of old people spreading HIV influenced levels of stigmatization and discrimination.It was possible to conclude that the likelihood of females spreading HIV influenced and the likelihood of old people spreading HIV is statistically significant in explaining stigmatization and discrimination of people living with HIV in Garissa County.

Recommendations
Group therapy should be conducted regularly with an aim of encouraging members of the public to be tested and be aware of their HIV status.

Vol. 1 ,
Issue 1 No.1, pp81-105, 2016 www.ajpojournals.org84 Definitive studies demonstrating a causal link between the availability of treatment and lower stigma and discrimination, as well as the effect of stigma-reduction interventions on uptake of HIV prevention, care and treatment are lacking.Evaluation data on the potential range of stigma-reduction programmes is still limited, and documentation and evaluation of country programmes are non-existent.

Figure 2 :
Figure 2: Level of Education

Figure
Figure 3: Age Figure 4: Marital Status4.2.5 ReligionThe respondents were asked to indicate their religious affiliations.Majority of the respondents were Muslim as represented by 55.5%, while 44.5 were Christian.

Figure
Figure 5: Religion Figure 6: Employment Type 4.2.7 Level of Income

Figure 7 :
Figure 7: Level of Income

Table 12
presents results of likelihood of polygamous people spreading HIV and stigmatization and discrimination chi-square test.