Background: HIV stigma involves interactions between (at least) PLHIV, community members (CMs), health workers (HWs) and members of key populations (KPs). HIV stigma may change in prevalence and form over time, as might its impact on HIV prevention and treatment. However, evaluations of stigma that include these multiple perspectives are rare. We set out to comprehensively describe the stigma landscape in 21 communities in South Africa and Zambia at baseline in the HPTN 071 (PopART) trial.
Methods: Synthesis of baseline HIV stigma data from a large, mixed-method, longitudinal study. Quantitative data came from a representative population cohort (3859 PLHIV, a subsample of 5088 CMs not living with HIV, and 1558 HWs). Stigma was categorised into three domains using 11 items: experienced in communities, in health settings and internalised stigma (self-stigma). Qualitative data came from observations and key informant interviews.
Results: 1371/3859 (35.5%) of PLHIV reported at least one of 11 types of stigma. Reported stigma was more frequent in the community (22.1%) than in health settings (7.3%). Internalised stigma was common (22.5%). There was more internalised but less experienced stigma in health settings in Zambia than in South Africa. Structures and client-flow patterns identifying HIV status in clinics sometimes made PLHIV uncomfortable. Among PLHIV on treatment before the start of the trial, experienced community stigma was more commonly reported by those who had been non-adherent (aOR:1.52 95% CI:1.12-2.07). Stigma was experienced most acutely close to time of diagnosis.
Few CMs reported stigmatising attitudes, but many perceived that stigma was present. HWs rarely reported they would be ashamed if a family member was living with HIV (76/1439, 5.2%). In contrast, high proportions reported they would be ashamed if a family member were a man having sex with men (1065/1366, 80.0%), a woman selling sex (1100/1408, 78.2%) or a young woman falling pregnant before marriage (653/1432, 45.6%), especially in Zambia. However, HWs supported the rights of these groups to access health services.
Conclusions: HIV stigma remains a commonly experienced phenomenon for PLHIV. Going forward, it may be particularly important to address any negative effects of HIV stigma on treatment success, and to reduce stigma toward KPs.

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