Individual-level socioeconomic status and community-level inequality as determinants of stigma towards persons living with HIV who inject drugs in Thai Nguyen, Vietnam.
BACKGROUND
HIV infection may be affected by multiple complex socioeconomic status (SES) factors, especially individual socioeconomic disadvantage and community-level inequality. At the same time, stigma towards HIV and marginalized groups has exacerbated persistent concentrated epidemics among key populations, such as persons who inject drugs (PWID) in Vietnam. Stigma researchers argue that stigma fundamentally depends on the existence of economic power differences in a community. In rapidly growing economies like Vietnam, the increasing gap in income and education levels, as well as an individual's absolute income and education, may create social conditions that facilitate stigma related to injecting drug use and HIV.


METHODS
A cross-sectional baseline survey assessing different types of stigma and key socioeconomic characteristics was administered to 1674 PWID and 1349 community members living in physical proximity throughout the 32 communes in Thai Nguyen province, Vietnam. We created four stigma scales, including HIV-related and drug-related stigma reported by both PWID and community members. We then used ecologic Spearman's correlation, ordinary least-squares regression and multi-level generalized estimating equations to examine community-level inequality associations, individual-level SES associations and multi-level SES associations with different types of stigma, respectively.


RESULTS
There was little urban-rural difference in stigma among communes. Higher income inequality was marginally associated with drug-related stigma reported by community members (p=0.087), and higher education inequality was significantly associated with higher HIV-related stigma reported by both PWID and community members (p<0.05). For individuals, higher education was significantly associated with lower stigma (HIV and drug related) reported by both PWID and community members. Part-time employed PWID reported more experiences and perceptions of drug-related stigma, while conversely unemployed community members reported enacting lower drug-related stigma. Multi-level analysis revealed that the relationship between education inequality and HIV-related stigma is superseded by the effect of individual-level education.


CONCLUSIONS
The results of the study confirm that socioeconomic factors at both the individual level and community level affect different types of stigma in different ways. Attention should be paid to these differences when planning structural or educational interventions to reduce stigma, and additional research should investigate the mechanisms with which SES and inequality affect social relationships and, in turn, stigma.
Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; tlim@jhsph.edu.
Travis
T
Lim
Carla
C
Zelaya
Carl
C
Latkin
Vu Minh
VM
Quan
Constantine
C
Frangakis
Tran Viet
TV
Ha
Nguyen Le
NL
Minh
Vivian
V
Go
D003430:Cross-Sectional Studies; D004192:Discrimination, Psychological / Q000502:physiology*; D015658:HIV Infections / Q000175:diagnosis / Q000188:drug therapy / Q000523:psychology*; D006801:Humans; D012923:Social Class; D057545:Social Stigma; D012959:Socioeconomic Factors; D015819:Substance Abuse, Intravenous / Q000150:complications / Q000523:psychology*; D014744:Vietnam
GINI coefficient; HIV; income inequality; injection drug users; multi-level model; persons who inject drugs; social determinants of health; socioeconomic status; stigma