Perceived Stigma and Its Associated Factors Among People Living With Hiv/aids in Bharatpur Art Center, Chitwan District, Nepal

Perceived Stigma and Its Associated Factors Among People Living With Hiv/aids in Bharatpur Art Center, Chitwan District, Nepal | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Perceived Stigma and Its Associated Factors Among People Living With Hiv/aids in Bharatpur Art Center, Chitwan District, Nepal Amrit Lamichhane, Madhavi Gaire, Manisha Paudel, Luna Devkota, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8582580/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 22 Apr, 2026 Read the published version in BMC Public Health → Version 1 posted 10 You are reading this latest preprint version Abstract Background Stigma due to HIV is an attitude and belief that negatively affects people with HIV. This stigma and discrimination affect the emotional well-being and mental health of people living with HIV, acting as a significant barrier to HIV prevention, treatment, care, support, and social integration. The aim of this study was to identify the perceived stigma level of PLHIV and its associated factors in the Bharatpur ART center, Chitwan, Nepal. Objectives To determine the prevalence of perceived stigma and its associated factors among PLHIV of Bharatpur ART Center, Chitwan District, Nepal. Methodology: A descriptive cross-sectional study was conducted among 348 people from the Bharatpur ART center, Chitwan District, Nepal, using a systematic sampling procedure. A face-to-face interview was taken by using semi-structured tools for independent variables, and the Bunn standard HIV Stigma Scale tool was used to measure the dependent variables. Stigma was measured in terms of felt stigma, Public Attitudes Concern (PAC), Disclosure Concern (DC), Negative Self-Image (NSI), and Enacted Stigma (ES), as well as overall stigma. Result Overall stigma was found to be 58.9%, where the percentages of each individual domain, NSI, PAC, DC, and ES, were reported as 65.2%, 53.7%, 56.9%, and 49.7%, respectively. On bivariate analysis, age, place of residence, ethnicity, reason for testing, exclusion due to HIV, hopelessness due to HIV, and depressed due to HIV were significantly associated with the dependent variable. Conclusion The research findings reported a significant level of high stigma that may act as a major hindrance to achieving the goal of Nepal’s National HIV strategic plan (95-95-95) by the end of 2026, as stigma serves as a major barrier in confronting high-risk individuals towards HIV testing and counseling services. Moreover, negative self-image is substantially higher than the other domains, which shows a dreadful impact on their overall well-being. The result from this study highlights the urgency of its findings to be shared among concerned stakeholders so as to step up in reducing stigma and discrimination among PLHIV. Stigma AIDS Discrimination Human immunodeficiency virus (HIV) and People Living with HIV (PLHIV) 1.Background HIV is an infection that attacks the body’s immune system, specifically the white blood cells called CD4 cells. If HIV is not treated, it may change into AIDS which is a condition that weakens the immune system and make it difficult for the body to fight off infections and diseases ( 1 ). Stigma refers to the prejudice, discrimination, stereotyping, and exclusion experienced by individuals with devalued physical, behavioral or medical characteristics.( 2 ) HIV-related stigma encompasses unreasonable or negative attitudes, behaviors, and judgments aimed towards those living with or at risk of HIV. It includes prejudice and discriminatory acts that result from classifying somebody as belonging to a group that is socially unacceptable. ( 3 , 4 ) According to UNAIDS Global HIV Statistics 2024, 39.9 million people globally were living with HIV in 2023 where only 30.7 million were into ART which is less than 34 million target by 2025. ( 5 ) WHO has identified HIV related stigma and discrimination as one of the significant barriers affecting the key population’s ability to access and utilize health service throughout the HIV continuum.( 6 ) Because of this, many people are unwilling to get tested for HIV, reveal a positive test result, utilize PrEP or other HIV prevention strategies or receive life-saving HIV treatment.( 7 ) According to a recent global report by the People Living with HIV Stigma Index, 13.0% of PLHIV experienced stigmatization at least once in the previous 12 months, perpetrated by health facility staff while undergoing HIV treatment. This rate almost doubled to 24.9% when respondents sought care for non-HIV-related health conditions and 84.8% of PLHIV also suffered internalized stigma. Additionally, among PLHIV who had temporarily discontinued ART, 34.3% reported that they were reluctant on resuming the treatment because of the fear of being mistreated by health workers or having their status disclosed without their consent. A part from health facilities, around 23.6% of respondents experienced stigma and discrimination because of their HIV status within the last 12 months in community settings. The most frequently mentioned incidences were being aware of others making discriminatory remarks or gossiping about them, with 14.2% noting 'other' persons and 12.6% indicating family members. ( 8 ) Stigma is found to be associated with a variety of unfavorable consequences for PLHIV, including a lower quality of life, mental health issues and limited access to care.( 9 ) Several studies have found that HIV-related stigma has a negative influence on mental health, including increased anxiety ( 10 , 11 ), depression ( 12 , 13 ), emotional discomfort ( 14 ) and reduced life satisfaction ( 15 , 16 ). Turan et al. found that stigma within communities often leads PLHIV to internalize negative perceptions, which raises their expectation of stigmatizing interactions, thereby harming their health and mental well-being ( 17 ). Furthermore, a meta-analysis by Rueda et al. found that high levels of stigma are associated with risky sexual behaviors, lower medication adherence, depression and decreased utilization of health and social services.( 11 ) These data indicate that HIV-related stigma has a considerable and widespread negative impact on the physical, mental, and social health of HIV patients. As per national HIV factsheet 2022 Nepal, the estimated number of PLHIV were 30000, while 25336 (84.5%) PLHIV knew their HIV status, 22735 (89.7%) PLHIV were on ART and 15284 (67.2%) PLHIV had their viral load status suppressed ( 18 ) showcasing the major challenges in achieving the 95-95-95 goal of Nepal’s National HIV strategic plan by the end of 2026.( 19 ) Notable portion of this gap in case detection, access to ART and adherence to treatment is contributed by stigma and discrimination. Likewise, the different studies from Nepal reveals the significant prevalence of depression, suicidal ideation, anxiety, stress, substance use ( 20 – 22 ) among PLHIV. Notable portion of this gap in case detection, access to ART, adherence to treatment and mental health issues is contributed by stigma and discrimination. Thus, it is essential to urgently identify the prevalence of stigma and associated factors so as to generate evidence and facilitate the prompt action. 2. Materials and Methods 2.1. Study design, area and participants A cross-sectional quantitative study was conducted in Bharatpur ART Center, Chitwan, Nepal. According to the fact sheet of HIV epidemic update of Nepal 2020, Bagmati Province had the highest number of people enrolled in ART program.( 23 ) Meanwhile, Bharatpur being the medical city of Nepal and Bharatpur hospital being one of the largest hospitals in Nepal ( 24 ) where PLHIV from different districts find accessible in receiving ART services. Thus this study aims to find out the stigma and its associated factors among PLHIV in Bharatpur ART center, Chitwan District, Nepal. The study participants were clients who were on ART at Bharatpur ART center, Chitwan, Nepal. 2.2 Sample size and sampling method At first the total list of ever been enrolled on ART was obtained from Bharatpur ART center. The number of ever been enrolled on ART was 1810. The sample size for the study was calculated by using Cochran's formula for finite population.( 25 ) Considering the prevalence of perceived stigma as 46.1% from the study “Perceived stigma among People with HIV/AIDS in Pokhara, Nepal” ( 26 ), with an allowable error of 5%, confidence interval of 95% and non- response rate of 10%, the total sample size was calculated to be 348. Systematic sampling method was used to select the sampling unit. For this the k th item was calculated (1810/348 = 5.2th ). The first number was chosen using lottery method followed by every 5th individuals. If the participant of every 5th interval included client who were LTFU, missing, migrated, dead, had known mental illness and below 18 years, the consecutive one was taken as research participant. 2.3. Data Collection Tool The data collection tool consisted of four sections. Information on independent variables was collected using a semi-structured questionnaire developed by the researchers based on an extensive literature review and expert consultation, and this questionnaire has not been previously published. The independent variables included socio-demographic characteristics, HIV-related variables, and psychological variables. Content validity of the questionnaire was ensured through comprehensive literature review and expert opinion. Perceived stigma, the dependent variable, was measured using the HIV Stigma Scale (HSS), originally developed by Berger et al. and later refined by Bunn et al. The scale has been previously used and validated in the Nepalese context, including a study conducted by Subedi et al. in Pokhara, Nepal. The HSS is a 32-item, 4-point Likert scale (ranging from strongly disagree to strongly agree) comprising four domains: Negative Self-Image, Public Attitude Concern, Disclosure Concern, and Enacted Stigma. Subscale scores were calculated by summing responses to items within each domain. One item in the Negative Self-Image domain and one item in the Disclosure Concern domain were reverse-coded prior to analysis. The total stigma score ranged from 32 to 128. Domain-specific score ranges were 7–28 for Negative Self-Image, 6–24 for Public Attitude Concern, 8–32 for Disclosure Concern, and 11–44 for Enacted Stigma. The scale demonstrated high internal consistency, with a Cronbach’s alpha value greater than 0.9. ( 27 ) 2.4. Data collection techniques Participants were oriented about objective of the study and assured of confidentiality. The data was collected in a closed counseling room of Bharatpur ART center through face to face interview after taking the informed consent from each participant. 2.5. Statistical Methods SPSS version 16 was used to perform all statistical calculations. Firstly, descriptive figure of each variable was calculated which was followed by chi-square test to find out the association between perceived stigma and independent variables. Stigma score of each domain was calculated by adding the individual item score which was then followed by calculation of mean score for individual domains and overall mean score. 3. Results The study showed that the majority of respondents were male representing 50.9% of total respondents while female and transgender are 44.8% and 4.3% respectively. Nearly half (47.4%) of the respondents reported that they were currently residing in Municipality followed by Metropolitan City (33.6%), Rural Municipality (13.5%) and Sub metropolitan city (5.5%). Majority of the participants were Brahmin/Chhetri (39.3%) followed by Janajati (38.2%) while the least belonging to Muslim (0.9%). Majority of the respondents were Hindu (81.6%) followed by Buddha (14.9%), Christian (2.6%) and Muslim (0.9%). More than half (66.1%) of the respondents were Married/living together while (16.1%) of the respondents were never married followed by widowed (14.9%) and divorced/separated (2.9%). In regard to the educational status, nearly half (49.4%) of the respondents can only read and write followed by secondary education (23%), basic education (19.3%) and 8.3% of respondents had more than secondary education. Major occupation of respondents was reported to be agriculture (28.2%) followed by house wife (18.7%) while least involved in social works (0.3%). More over half (67.5%) of respondents had less than NRs 25000 as a monthly family income. While exploring the HIV related variables, more than half of respondents (58%) were diagnosed HIV positive for > = 5 years, resulting in a long term diagnosis followed by (25.3%) mid-term diagnosis i.e. diagnosed HIV positive for 1–5 years and (16.7%) had a short-term diagnosis i.e. diagnosed for less than 1 year. A majority (88.8%) of respondents tested their HIV status because of unsafe sexual contact while minorities tested because of STI, TB, pregnancy, surgery, HIV/AIDS symptoms, unsafe sexual contact, medical checkup for abroad, needle sharing and medical checkup in jail. 84.8% of respondents had disclosed their HIV status to others among which a majority (45.1%) had disclosed their status with intimate partner followed by family members (29.3%). Regarding the mode of transmission of HIV, 93.1% of respondents reported that the HIV was transmitted to their bodies through unsafe sexual contact, whereas 4.6% experienced vertical transmission, 2% through shared needles and blades and 0.3% through donated organs and blood. Regarding the physical intimacy, 86.5% of the respondents had physical relation after HIV diagnosis. A majority of respondents (72.4%) had multiple sex partners where only 3.7% respondents reported that they had no sex partner. 8.4% of respondents forgot whether they used a condom or not during their most recent sexual encounter, compared to 63.6% of respondents who said they had worn one. More than half of the respondents’ partner (57.8%) had HIV status positive. Likewise, delving into the psychological factors, 56% of respondent reported that have been excluded/discriminated due to HIV among which 93.3% of respondents had been excluded/discriminated in health service provide center followed by 17.9% and 14.35% in family and community settings respectively. 71.6% and 71.3% reported feeling hopeless and depressed due to HIV respectively. Table 1 Perceived stigma level of PLHIV (n = 348) Stigma domains Level of perceived stigma Frequency Percentage (%) Negative self-image Low 121 34.8 High 227 65.2 Public Attitude Concern Low 161 46.3 High 187 53.7 Disclosure Concern Low 150 43.1 High 198 56.9 Enacted Stigma Low 175 50.3 High 173 49.7 Overall Stigma Low 143 41.1 High 205 58.9 Table 1 shows the information on level of perceived stigma among the respondents with respect to different domains of stigma. The majority of respondents (65.2%) reported experiencing high level of negative self-image. A significant proportion of respondents (53.7%) expressed a high level of concern regarding public attitudes. Likewise, 56.9% of respondents reported having a high level of disclosure concern while 49.7% had high level of enacted stigma. Overall, a majority of respondents (58.9%) reported level of perceived stigma. Table 2 Association of overall perceived stigma with independent variables Variables Level of perceived stigma χ2 P-value Low High Age 18–40 71 (47) 80 (53) 3.872 0.049* > 40 72 (36.5) 125 (63.5) Place of origin Metropolitan city 55 (47) 62 (53) 8.363 0.039* Sub Metro 5 (26.3) 14 (73.7) Municipality 71 (43) 94 (57) Rural Municipality 12 (25.5) 35 (74.5) Ethnicity Brahmin/Chhetri 46 (34.1) 89 (65.9) 4.488 0.034* Other than Brahmin/Chhetri 97 (45.5) 116 (54.5) Education level Only Read and write 75 (43.6) 97 (56.4) 8.182 0.042* Basic 34 (50.7) 33 (49.3) Secondary 23 (28.7) 57 (71.3) More than Secondary 11 (37.9) 18 (62.1) Reason for Testing Unsafe sexual contact 133 (43) 176 (57) 4.332 0.037* Other than unsafe sexual contact 10 (25.6) 29 (74.4) Excluded due to HIV Yes 62 (32.1) 131 (67.9) 15.202 0.000* No 80 (53) 71 (47) Hopeless due to HIV Yes 88 (35.3) 161 (64.7) 11.957 0.001* No 55 (55.6) 44 (44.4) Depressed due to HIV Yes 87 (35.1) 161 (64.9) 12.884 < 0.000* No 56 (56) 44 (44) * denotes significant association by applying Pearson chi-square test at 5% level of Significance On bivariate analysis, independent variables such as age, place of residents, ethnicity, education level, Reason for Testing, excluded due to HIV, Hopeless due to HIV and Depressed due to HIV were found to be significantly associated with dependent variable i.e., Perceived Stigma (Table 2 ). 4. Discussions Perceived stigma is one of the major barriers in accessing care by PLHIV. The current study found significant level (58.9%) of perceived stigma among PLHIV in Bharatpur ART Center, Chitwan District. This finding is consistent with study conducted in Pokhara Nepal ( 26 ), Central China ( 28 ) and Southern Ethiopia ( 29 ). Current study highlight significant associations between perceived stigma levels and variables such as age, place of residence, ethnicity, education level, reason for testing, experiences of exclusion due to HIV, feelings of hopelessness and depression. A significant association was found between age and perceived stigma (χ² = 3.872, p = 0.049). Respondents over 40 years of age had a higher frequency of high perceived stigma compared to younger respondents (63.5% vs. 53%). This aligns with prior studies, suggesting that older PLHIV may face additional stigma due to longstanding societal attitudes and the cumulative effects of living with HIV over time. ( 30 , 31 ). However, this finding contrasts with prior literature, which often suggests that older adults experience lower levels of stigma due to factors such as greater life experience, emotional resilience, or a longer duration since HIV diagnosis, allowing for better psychological adaptation.( 32 ) The PLHIV Stigma Index 2.0, Nepal (2022) found that stigma disproportionately affected certain age groups, with youth under 25 reporting higher internalized stigma (38%). This emphasizes the need for age-sensitive interventions that address the unique challenges faced by younger and older PLHIV populations.( 33 ) Place of residence demonstrated a significant association with stigma (χ² = 8.363, p = 0.039). Higher stigma levels were observed among respondents from sub-metropolitan areas (73.7%) and rural municipalities (74.5%), compared to those from metropolitan cities (53%). This pattern may reflect limited access to HIV education and heightened stigma in less urbanized areas, as documented in other studies. ( 9 ) Furthermore, rural stigma has been linked to greater fear of disclosure due to closer-knit communities ( 11 ). According to the Stigma Index 2.0, Nepal urban-rural disparities persist, with rural PLHIV reporting more frequent instances of external stigma, including gossip, social exclusion and discrimination by healthcare workers.( 33 ) Ethnicity was significantly associated with perceived stigma (χ² = 4.488, p = 0.034). Brahmin/Chhetri respondents reported higher levels of stigma (65.9%) compared to other ethnic groups (54.5%). This finding is supported by the study conducted in Pokhara Nepal.( 26 ) According to literature, stigma toward particular ethnic groups can be made worse by cultural expectations and perceived transgressions of social norms. ( 5 ) The findings align with research by Pulerwitz, J., et al. (2010), which highlights the importance of addressing structural inequalities and cultural norms to combat stigma in low and middle income countries.( 34 ) Education level also showed a significant association with stigma (χ² = 8.182, p = 0.042). Respondents with secondary education reported the highest levels of stigma (71.3%), while those with basic education had the lowest (49.3%). This finding contrasts with several studies suggesting that higher education correlates with lower stigma levels. For instance, a study in Uganda found a statistically significant negative association between years of schooling and HIV stigma, indicating that increased education correlates with reduced stigma.( 35 ) Similarly, research among elderly men in China showed that higher HIV/AIDS knowledge scores, often associated with higher education, corresponded with lower stigma levels.( 36 ) However, other studies have reported contradictory findings. Research among college students in the U.S. revealed low levels of HIV transmission knowledge, with only 4% responding correctly to related questions, suggesting that higher education does not always equate to accurate HIV knowledge.( 37 ) The reason for HIV testing was significantly associated with stigma levels (χ² = 4.332, p = 0.037). Individuals tested for reasons other than unsafe sexual contact reported higher stigma (74.4%) compared to those tested due to unsafe sexual contact (57%). Research suggests that individuals tested for other reasons, such as illness or suspicion of partner infection, may perceive heightened stigma because these contexts often involve visible symptoms or disclosure of status to partners or family, which can attract judgment.( 38 ) A strong association was found between exclusion and stigma (χ² = 15.202, p < 0.001). Respondents who experienced exclusion reported significantly higher stigma levels (67.9%). Social exclusion has been widely recognized as a key driver of HIV-related stigma ( 39 ). This is consistent with studies by Link and Phelan ( 40 ), which identify exclusion as a key mechanism in the perpetuation of stigma. Hopelessness due to HIV was significantly linked to stigma (χ² = 11.957, p = 0.001). Respondents feeling hopeless reported higher stigma (64.7%). Depression was significantly associated with stigma (χ² = 12.884, p < 0.001). Respondents with depression reported higher stigma (64.9%), emphasizing the interplay between mental health and stigma ( 39 ). Depression, often a neuropsychiatric complication of HIV, can exacerbate feelings of isolation and hopelessness, which in turn heightens perceptions of stigma.( 41 ) As the virus attacks the central nervous system, it not only compromises physical health but also contributes to the emotional burden of PLWH, amplifying their sense of being socially marginalized. ( 42 ) Limitations and Future Directions This study is limited to bivariate analysis using chi-square, which identifies associations but does not establish causality or directionality. Future research should employ multivariate analysis and longitudinal studies to better understand the dynamics of HIV-related stigma. Additionally, qualitative research can provide deeper insights into the lived experiences of PLHIV. Conclusion This study highlights significant associations between HIV-related stigma and various factors among PLHIV in Bharatpur ART Center. Addressing these challenges requires a multifaceted approach that incorporates education, mental health support integrated with ART, and culturally sensitive stigma reduction programs. By tackling stigma at its roots, we can improve the quality of life for PLHIV and foster a more inclusive society. Abbreviations HIV Human Immunodeficiency Virus PLHIV People Living with HIV CD4 Cluster of Differentiation 4 AIDS Acquired Immunodeficiency Syndrome PrEP Pre Exposure Prophylaxis UNAIDS Joint United Nations Programme on HIV/AIDS ART Antiretroviral Therapy STI Sexually Transmitted Infections TB Tuberculosis Declarations Ethics approval and consent to participate Ethical approval for this study was obtained from the Institutional Review Committee (IRC) of Shree Medical and Technical College, Nepal. Permission to conduct the study was also obtained from the Bharatpur Hospital. The study was conducted in accordance with the Declaration for Helsinki. Written informed consent was obtained from all participants prior to data collection, and confidentiality and privacy were strictly maintained throughout the study. Consent for publication Not Applicable Competing interests The authors declare no potential conflict of interest. Funding This study received no any funding. Author Contribution AL, MG, MP, JKP, and LD conceptualized the study and were responsible for methodology and instrument development. AL was responsible for data collection. AL and MG contributed to data curation and data analysis. AL and MG were responsible for drafting the manuscript under the guidance and supervision of LD and JKP. All authors contributed to the reviewing, supervision, and final edition of this manuscript. All authors read and approved the final manuscript. Acknowledgement The authors express their sincere appreciation towards Bharatpur Hospital ART center and all the respondents, faculties, and colleagues without whom this endeavor would not have been accomplished. Data Availability The corresponding author can provide access to the dataset upon request that supports the findings of the current study. References HIV and AIDS [Internet]. [cited 2024 Dec 6]. Available from: https://www.who.int/news-room/fact-sheets/detail/hiv-aids Dovidio J, Major B, Stigma. 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Available from: https://www.ncasc.gov.np/uploads/frontend/publication/65cc592a1f61c.pdf Pulerwitz J, Michaelis A, Weiss E, Brown L, Mahendra V. Reducing HIV-related stigma: lessons learned from Horizons research and programs. Public Health Rep Wash DC 1974. 2010;125(2):272–81. Ncitakalo N, Mabaso M, Joska J, Simbayi L. Factors associated with external HIV-related stigma and psychological distress among people living with HIV in South Africa. SSM - Popul Health. 2021;14:100809. Knowledge HIVAIDS. Depression, and HIV-Related Stigma Among Elderly Men in Rural China: A Hierarchical Regression Analysis - Qinxi Liu, Huan He, Qinying He, Na Li, Wei Xiao, Jie Xiao, Bihui Yang, Yuan Li, Yi Yang, 2023 [Internet]. [cited 2025 Jan 3]. Available from: https://journals.sagepub.com/doi/10.1177/15579883231189622?icid=int.sj-full-text.similar-articles.9&utm_source=chatgpt.com Kingori C, Nkansah MA, Haile Z, Darlington KA, Basta T. Factors Associated with HIV Related Stigma among College Students in the Midwest. AIMS Public Health [Internet]. 2017 July 5 [cited 2025 Jan 3];4(4):347–63. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5690459/ Holzemer WL, Uys L, Makoae L, Stewart A, Phetlhu R, Dlamini PS, et al. A conceptual model of HIV/AIDS stigma from five African countries. J Adv Nurs. 2007 June;58(6):541–51. Earnshaw VA, Smith LR, Chaudoir SR, Amico KR, Copenhaver MM. HIV stigma mechanisms and well-being among PLWH: a test of the HIV stigma framework. AIDS Behav. 2013 June;17(5):1785–95. Link BG, Phelan JC. Conceptualizing Stigma. Annu Rev Sociol [Internet]. 2001 Aug [cited 2025 Jan 4];27(1):363–85. Available from: https://www.annualreviews.org/doi/ 10.1146/annurev.soc.27.1.363 Visser MJ, Makin JD, Vandormael A, Sikkema KJ, Forsyth BWC. HIV/AIDS stigma in a South African community. AIDS Care. 2009;21(2):197–206. Du X, Zhang Q, Hao J, Gong X, Liu J, Chen J. Global trends in depression among patients living with HIV: A bibliometric analysis. Front Psychol [Internet]. 2023 Mar 9 [cited 2025 Jan 4];14. Available from: https://www.frontiersin.org/journals/psychology/articles/ 10.3389/fpsyg.2023.1125300/full Additional Declarations No competing interests reported. Supplementary Files 100.SMTCIRC20230230100AmritLamichhane.pdf QuestionnaireforPerceivedStigmaandItsassociatedFactorsamongPLHIV.pdf Cite Share Download PDF Status: Published Journal Publication published 22 Apr, 2026 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 12 Feb, 2026 Reviews received at journal 08 Feb, 2026 Reviews received at journal 05 Feb, 2026 Reviewers agreed at journal 30 Jan, 2026 Reviewers agreed at journal 29 Jan, 2026 Reviewers agreed at journal 28 Jan, 2026 Reviewers invited by journal 27 Jan, 2026 Editor assigned by journal 21 Jan, 2026 Submission checks completed at journal 20 Jan, 2026 First submitted to journal 20 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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07:09:15","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":90421,"visible":true,"origin":"","legend":"","description":"","filename":"QuestionnaireforPerceivedStigmaandItsassociatedFactorsamongPLHIV.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8582580/v1/1e5802a9409e3f6c22bd1943.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003ePerceived Stigma and Its Associated Factors Among People Living With Hiv/aids in Bharatpur Art Center, Chitwan District, Nepal\u003c/p\u003e","fulltext":[{"header":"1.Background","content":"\u003cp\u003eHIV is an infection that attacks the body\u0026rsquo;s immune system, specifically the white blood cells called CD4 cells. If HIV is not treated, it may change into AIDS which is a condition that weakens the immune system and make it difficult for the body to fight off infections and diseases (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Stigma refers to the prejudice, discrimination, stereotyping, and exclusion experienced by individuals with devalued physical, behavioral or medical characteristics.(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) HIV-related stigma encompasses unreasonable or negative attitudes, behaviors, and judgments aimed towards those living with or at risk of HIV. It includes prejudice and discriminatory acts that result from classifying somebody as belonging to a group that is socially unacceptable. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eAccording to UNAIDS Global HIV Statistics 2024, 39.9\u0026nbsp;million people globally were living with HIV in 2023 where only 30.7\u0026nbsp;million were into ART which is less than 34\u0026nbsp;million target by 2025. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) WHO has identified HIV related stigma and discrimination as one of the significant barriers affecting the key population\u0026rsquo;s ability to access and utilize health service throughout the HIV continuum.(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) Because of this, many people are unwilling to get tested for HIV, reveal a positive test result, utilize PrEP or other HIV prevention strategies or receive life-saving HIV treatment.(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) According to a recent global report by the People Living with HIV Stigma Index, 13.0% of PLHIV experienced stigmatization at least once in the previous 12 months, perpetrated by health facility staff while undergoing HIV treatment. This rate almost doubled to 24.9% when respondents sought care for non-HIV-related health conditions and 84.8% of PLHIV also suffered internalized stigma. Additionally, among PLHIV who had temporarily discontinued ART, 34.3% reported that they were reluctant on resuming the treatment because of the fear of being mistreated by health workers or having their status disclosed without their consent. A part from health facilities, around 23.6% of respondents experienced stigma and discrimination because of their HIV status within the last 12 months in community settings. The most frequently mentioned incidences were being aware of others making discriminatory remarks or gossiping about them, with 14.2% noting 'other' persons and 12.6% indicating family members. (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eStigma is found to be associated with a variety of unfavorable consequences for PLHIV, including a lower quality of life, mental health issues and limited access to care.(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) Several studies have found that HIV-related stigma has a negative influence on mental health, including increased anxiety (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), depression (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), emotional discomfort (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) and reduced life satisfaction (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Turan et al. found that stigma within communities often leads PLHIV to internalize negative perceptions, which raises their expectation of stigmatizing interactions, thereby harming their health and mental well-being (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Furthermore, a meta-analysis by Rueda et al. found that high levels of stigma are associated with risky sexual behaviors, lower medication adherence, depression and decreased utilization of health and social services.(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e) These data indicate that HIV-related stigma has a considerable and widespread negative impact on the physical, mental, and social health of HIV patients.\u003c/p\u003e \u003cp\u003eAs per national HIV factsheet 2022 Nepal, the estimated number of PLHIV were 30000, while 25336 (84.5%) PLHIV knew their HIV status, 22735 (89.7%) PLHIV were on ART and 15284 (67.2%) PLHIV had their viral load status suppressed (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) showcasing the major challenges in achieving the 95-95-95 goal of Nepal\u0026rsquo;s National HIV strategic plan by the end of 2026.(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) Notable portion of this gap in case detection, access to ART and adherence to treatment is contributed by stigma and discrimination. Likewise, the different studies from Nepal reveals the significant prevalence of depression, suicidal ideation, anxiety, stress, substance use (\u003cspan additionalcitationids=\"CR21\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) among PLHIV. Notable portion of this gap in case detection, access to ART, adherence to treatment and mental health issues is contributed by stigma and discrimination. Thus, it is essential to urgently identify the prevalence of stigma and associated factors so as to generate evidence and facilitate the prompt action.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Study design, area and participants\u003c/h2\u003e \u003cp\u003eA cross-sectional quantitative study was conducted in Bharatpur ART Center, Chitwan, Nepal. According to the fact sheet of HIV epidemic update of Nepal 2020, Bagmati Province had the highest number of people enrolled in ART program.(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) Meanwhile, Bharatpur being the medical city of Nepal and Bharatpur hospital being one of the largest hospitals in Nepal (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) where PLHIV from different districts find accessible in receiving ART services. Thus this study aims to find out the stigma and its associated factors among PLHIV in Bharatpur ART center, Chitwan District, Nepal. The study participants were clients who were on ART at Bharatpur ART center, Chitwan, Nepal.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Sample size and sampling method\u003c/h2\u003e \u003cp\u003eAt first the total list of ever been enrolled on ART was obtained from Bharatpur ART center. The number of ever been enrolled on ART was 1810. The sample size for the study was calculated by using Cochran's formula for finite population.(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) Considering the prevalence of perceived stigma as 46.1% from the study \u0026ldquo;Perceived stigma among People with HIV/AIDS in Pokhara, Nepal\u0026rdquo; (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), with an allowable error of 5%, confidence interval of 95% and non- response rate of 10%, the total sample size was calculated to be 348. Systematic sampling method was used to select the sampling unit. For this the k\u003csup\u003eth\u003c/sup\u003e item was calculated (1810/348\u0026thinsp;=\u0026thinsp;5.2th ). The first number was chosen using lottery method followed by every 5th individuals. If the participant of every 5th interval included client who were LTFU, missing, migrated, dead, had known mental illness and below 18 years, the consecutive one was taken as research participant.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Data Collection Tool\u003c/h2\u003e \u003cp\u003eThe data collection tool consisted of four sections. Information on independent variables was collected using a semi-structured questionnaire developed by the researchers based on an extensive literature review and expert consultation, and this questionnaire has not been previously published. The independent variables included socio-demographic characteristics, HIV-related variables, and psychological variables. Content validity of the questionnaire was ensured through comprehensive literature review and expert opinion.\u003c/p\u003e \u003cp\u003ePerceived stigma, the dependent variable, was measured using the HIV Stigma Scale (HSS), originally developed by Berger et al. and later refined by Bunn et al. The scale has been previously used and validated in the Nepalese context, including a study conducted by Subedi et al. in Pokhara, Nepal. The HSS is a 32-item, 4-point Likert scale (ranging from strongly disagree to strongly agree) comprising four domains: Negative Self-Image, Public Attitude Concern, Disclosure Concern, and Enacted Stigma. Subscale scores were calculated by summing responses to items within each domain. One item in the Negative Self-Image domain and one item in the Disclosure Concern domain were reverse-coded prior to analysis. The total stigma score ranged from 32 to 128. Domain-specific score ranges were 7\u0026ndash;28 for Negative Self-Image, 6\u0026ndash;24 for Public Attitude Concern, 8\u0026ndash;32 for Disclosure Concern, and 11\u0026ndash;44 for Enacted Stigma. The scale demonstrated high internal consistency, with a Cronbach\u0026rsquo;s alpha value greater than 0.9. (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Data collection techniques\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eParticipants were oriented about objective of the study and assured of confidentiality. The data was collected in a closed counseling room of Bharatpur ART center through face to face interview after taking the informed consent from each participant.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5. Statistical Methods\u003c/h2\u003e \u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eSPSS version 16 was used to perform all statistical calculations. Firstly, descriptive figure of each variable was calculated which was followed by chi-square test to find out the association between perceived stigma and independent variables. Stigma score of each domain was calculated by adding the individual item score which was then followed by calculation of mean score for individual domains and overall mean score.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eThe study showed that the majority of respondents were male representing 50.9% of total respondents while female and transgender are 44.8% and 4.3% respectively. Nearly half (47.4%) of the respondents reported that they were currently residing in Municipality followed by Metropolitan City (33.6%), Rural Municipality (13.5%) and Sub metropolitan city (5.5%). Majority of the participants were Brahmin/Chhetri (39.3%) followed by Janajati (38.2%) while the least belonging to Muslim (0.9%). Majority of the respondents were Hindu (81.6%) followed by Buddha (14.9%), Christian (2.6%) and Muslim (0.9%). More than half (66.1%) of the respondents were Married/living together while (16.1%) of the respondents were never married followed by widowed (14.9%) and divorced/separated (2.9%). In regard to the educational status, nearly half (49.4%) of the respondents can only read and write followed by secondary education (23%), basic education (19.3%) and 8.3% of respondents had more than secondary education. Major occupation of respondents was reported to be agriculture (28.2%) followed by house wife (18.7%) while least involved in social works (0.3%). More over half (67.5%) of respondents had less than NRs 25000 as a monthly family income.\u003c/p\u003e \u003cp\u003eWhile exploring the HIV related variables, more than half of respondents (58%) were diagnosed HIV positive for \u0026gt;\u0026thinsp;=\u0026thinsp;5 years, resulting in a long term diagnosis followed by (25.3%) mid-term diagnosis i.e. diagnosed HIV positive for 1\u0026ndash;5 years and (16.7%) had a short-term diagnosis i.e. diagnosed for less than 1 year. A majority (88.8%) of respondents tested their HIV status because of unsafe sexual contact while minorities tested because of STI, TB, pregnancy, surgery, HIV/AIDS symptoms, unsafe sexual contact, medical checkup for abroad, needle sharing and medical checkup in jail. 84.8% of respondents had disclosed their HIV status to others among which a majority (45.1%) had disclosed their status with intimate partner followed by family members (29.3%). Regarding the mode of transmission of HIV, 93.1% of respondents reported that the HIV was transmitted to their bodies through unsafe sexual contact, whereas 4.6% experienced vertical transmission, 2% through shared needles and blades and 0.3% through donated organs and blood. Regarding the physical intimacy, 86.5% of the respondents had physical relation after HIV diagnosis. A majority of respondents (72.4%) had multiple sex partners where only 3.7% respondents reported that they had no sex partner. 8.4% of respondents forgot whether they used a condom or not during their most recent sexual encounter, compared to 63.6% of respondents who said they had worn one. More than half of the respondents\u0026rsquo; partner (57.8%) had HIV status positive.\u003c/p\u003e \u003cp\u003eLikewise, delving into the psychological factors, 56% of respondent reported that have been excluded/discriminated due to HIV among which 93.3% of respondents had been excluded/discriminated in health service provide center followed by 17.9% and 14.35% in family and community settings respectively. 71.6% and 71.3% reported feeling hopeless and depressed due to HIV respectively.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePerceived stigma level of PLHIV (n\u0026thinsp;=\u0026thinsp;348)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStigma domains\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLevel of perceived stigma\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegative self-image\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e121\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e34.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e227\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e65.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePublic Attitude Concern\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e161\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e46.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e187\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e53.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisclosure Concern\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e43.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e198\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e56.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnacted Stigma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e175\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e50.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e173\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e49.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall Stigma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e143\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e41.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e205\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e58.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the information on level of perceived stigma among the respondents with respect to different domains of stigma. The majority of respondents (65.2%) reported experiencing high level of negative self-image. A significant proportion of respondents (53.7%) expressed a high level of concern regarding public attitudes. Likewise, 56.9% of respondents reported having a high level of disclosure concern while 49.7% had high level of enacted stigma. Overall, a majority of respondents (58.9%) reported level of perceived stigma.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAssociation of overall perceived stigma with independent variables\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eLevel of perceived stigma\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eHigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e18\u0026ndash;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71 (47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e80 (53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.872\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.049*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72 (36.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e125 (63.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePlace of origin\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMetropolitan city\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55 (47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62 (53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.363\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.039*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSub Metro\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (26.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (73.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMunicipality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71 (43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94 (57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural Municipality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (25.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35 (74.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEthnicity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBrahmin/Chhetri\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46 (34.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e89 (65.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.488\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.034*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther than Brahmin/Chhetri\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e97 (45.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e116 (54.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOnly Read and write\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75 (43.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e97 (56.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.182\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.042*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBasic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (50.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e33 (49.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (28.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57 (71.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMore than Secondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (37.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (62.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eReason for Testing\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnsafe sexual contact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e133 (43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e176 (57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.332\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.037*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther than unsafe sexual contact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (25.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29 (74.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eExcluded due to HIV\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62 (32.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e131 (67.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e15.202\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.000*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80 (53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71 (47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHopeless due to HIV\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88 (35.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e161 (64.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e11.957\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e55 (55.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44 (44.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDepressed due to HIV\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e87 (35.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e161 (64.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.884\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.000*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56 (56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44 (44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e* denotes significant association by applying Pearson chi-square test at 5% level of Significance\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOn bivariate analysis, independent variables such as age, place of residents, ethnicity, education level, Reason for Testing, excluded due to HIV, Hopeless due to HIV and Depressed due to HIV were found to be significantly associated with dependent variable i.e., Perceived Stigma (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e"},{"header":"4. Discussions","content":"\u003cp\u003ePerceived stigma is one of the major barriers in accessing care by PLHIV. The current study found significant level (58.9%) of perceived stigma among PLHIV in Bharatpur ART Center, Chitwan District. This finding is consistent with study conducted in Pokhara Nepal (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), Central China (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e) and Southern Ethiopia (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Current study highlight significant associations between perceived stigma levels and variables such as age, place of residence, ethnicity, education level, reason for testing, experiences of exclusion due to HIV, feelings of hopelessness and depression.\u003c/p\u003e \u003cp\u003eA significant association was found between age and perceived stigma (χ\u0026sup2; = 3.872, p\u0026thinsp;=\u0026thinsp;0.049). Respondents over 40 years of age had a higher frequency of high perceived stigma compared to younger respondents (63.5% vs. 53%). This aligns with prior studies, suggesting that older PLHIV may face additional stigma due to longstanding societal attitudes and the cumulative effects of living with HIV over time. (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). However, this finding contrasts with prior literature, which often suggests that older adults experience lower levels of stigma due to factors such as greater life experience, emotional resilience, or a longer duration since HIV diagnosis, allowing for better psychological adaptation.(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) The PLHIV Stigma Index 2.0, Nepal (2022) found that stigma disproportionately affected certain age groups, with youth under 25 reporting higher internalized stigma (38%). This emphasizes the need for age-sensitive interventions that address the unique challenges faced by younger and older PLHIV populations.(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e)\u003c/p\u003e \u003cp\u003ePlace of residence demonstrated a significant association with stigma (χ\u0026sup2; = 8.363, p\u0026thinsp;=\u0026thinsp;0.039). Higher stigma levels were observed among respondents from sub-metropolitan areas (73.7%) and rural municipalities (74.5%), compared to those from metropolitan cities (53%). This pattern may reflect limited access to HIV education and heightened stigma in less urbanized areas, as documented in other studies. (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) Furthermore, rural stigma has been linked to greater fear of disclosure due to closer-knit communities (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). According to the Stigma Index 2.0, Nepal urban-rural disparities persist, with rural PLHIV reporting more frequent instances of external stigma, including gossip, social exclusion and discrimination by healthcare workers.(\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eEthnicity was significantly associated with perceived stigma (χ\u0026sup2; = 4.488, p\u0026thinsp;=\u0026thinsp;0.034). Brahmin/Chhetri respondents reported higher levels of stigma (65.9%) compared to other ethnic groups (54.5%). This finding is supported by the study conducted in Pokhara Nepal.(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) According to literature, stigma toward particular ethnic groups can be made worse by cultural expectations and perceived transgressions of social norms. (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) The findings align with research by Pulerwitz, J., et al. (2010), which highlights the importance of addressing structural inequalities and cultural norms to combat stigma in low and middle income countries.(\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eEducation level also showed a significant association with stigma (χ\u0026sup2; = 8.182, p\u0026thinsp;=\u0026thinsp;0.042). Respondents with secondary education reported the highest levels of stigma (71.3%), while those with basic education had the lowest (49.3%). This finding contrasts with several studies suggesting that higher education correlates with lower stigma levels. For instance, a study in Uganda found a statistically significant negative association between years of schooling and HIV stigma, indicating that increased education correlates with reduced stigma.(\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) Similarly, research among elderly men in China showed that higher HIV/AIDS knowledge scores, often associated with higher education, corresponded with lower stigma levels.(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) However, other studies have reported contradictory findings. Research among college students in the U.S. revealed low levels of HIV transmission knowledge, with only 4% responding correctly to related questions, suggesting that higher education does not always equate to accurate HIV knowledge.(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eThe reason for HIV testing was significantly associated with stigma levels (χ\u0026sup2; = 4.332, p\u0026thinsp;=\u0026thinsp;0.037). Individuals tested for reasons other than unsafe sexual contact reported higher stigma (74.4%) compared to those tested due to unsafe sexual contact (57%). Research suggests that individuals tested for other reasons, such as illness or suspicion of partner infection, may perceive heightened stigma because these contexts often involve visible symptoms or disclosure of status to partners or family, which can attract judgment.(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eA strong association was found between exclusion and stigma (χ\u0026sup2; = 15.202, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Respondents who experienced exclusion reported significantly higher stigma levels (67.9%). Social exclusion has been widely recognized as a key driver of HIV-related stigma (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). This is consistent with studies by Link and Phelan (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e), which identify exclusion as a key mechanism in the perpetuation of stigma. Hopelessness due to HIV was significantly linked to stigma (χ\u0026sup2; = 11.957, p\u0026thinsp;=\u0026thinsp;0.001). Respondents feeling hopeless reported higher stigma (64.7%). Depression was significantly associated with stigma (χ\u0026sup2; = 12.884, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Respondents with depression reported higher stigma (64.9%), emphasizing the interplay between mental health and stigma (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). Depression, often a neuropsychiatric complication of HIV, can exacerbate feelings of isolation and hopelessness, which in turn heightens perceptions of stigma.(\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e) As the virus attacks the central nervous system, it not only compromises physical health but also contributes to the emotional burden of PLWH, amplifying their sense of being socially marginalized. (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cb\u003eLimitations and Future Directions\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis study is limited to bivariate analysis using chi-square, which identifies associations but does not establish causality or directionality. Future research should employ multivariate analysis and longitudinal studies to better understand the dynamics of HIV-related stigma. Additionally, qualitative research can provide deeper insights into the lived experiences of PLHIV.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study highlights significant associations between HIV-related stigma and various factors among PLHIV in Bharatpur ART Center. Addressing these challenges requires a multifaceted approach that incorporates education, mental health support integrated with ART, and culturally sensitive stigma reduction programs. By tackling stigma at its roots, we can improve the quality of life for PLHIV and foster a more inclusive society.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHIV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHuman Immunodeficiency Virus\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePLHIV\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePeople Living with HIV\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCD4\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCluster of Differentiation 4\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAIDS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAcquired Immunodeficiency Syndrome\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePrEP\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePre Exposure Prophylaxis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eUNAIDS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eJoint United Nations Programme on HIV/AIDS\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eART\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAntiretroviral Therapy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSTI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSexually Transmitted Infections\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTuberculosis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e Ethical approval for this study was obtained from the Institutional Review Committee (IRC) of Shree Medical and Technical College, Nepal. Permission to conduct the study was also obtained from the Bharatpur Hospital. The study was conducted in accordance with the Declaration for Helsinki. Written informed consent was obtained from all participants prior to data collection, and confidentiality and privacy were strictly maintained throughout the study.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot Applicable\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare no potential conflict of interest.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThis study received no any funding.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAL, MG, MP, JKP, and LD conceptualized the study and were responsible for methodology and instrument development. AL was responsible for data collection. AL and MG contributed to data curation and data analysis. AL and MG were responsible for drafting the manuscript under the guidance and supervision of LD and JKP. All authors contributed to the reviewing, supervision, and final edition of this manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors express their sincere appreciation towards Bharatpur Hospital ART center and all the respondents, faculties, and colleagues without whom this endeavor would not have been accomplished.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe corresponding author can provide access to the dataset upon request that supports the findings of the current study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHIV and AIDS [Internet]. [cited 2024 Dec 6]. 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.frontiersin.org/journals/psychology/articles/\u003c/span\u003e\u003cspan address=\"https://www.frontiersin.org/journals/psychology/articles/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fpsyg.2023.1125300/full\u003c/span\u003e\u003cspan address=\"10.3389/fpsyg.2023.1125300/full\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Stigma, AIDS, Discrimination, Human immunodeficiency virus (HIV) and People Living with HIV (PLHIV)","lastPublishedDoi":"10.21203/rs.3.rs-8582580/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8582580/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eStigma due to HIV is an attitude and belief that negatively affects people with HIV. This stigma and discrimination affect the emotional well-being and mental health of people living with HIV, acting as a significant barrier to HIV prevention, treatment, care, support, and social integration. The aim of this study was to identify the perceived stigma level of PLHIV and its associated factors in the Bharatpur ART center, Chitwan, Nepal.\u003c/p\u003e\u003ch2\u003eObjectives\u003c/h2\u003e \u003cp\u003eTo determine the prevalence of perceived stigma and its associated factors among PLHIV of Bharatpur ART Center, Chitwan District, Nepal. Methodology: A descriptive cross-sectional study was conducted among 348 people from the Bharatpur ART center, Chitwan District, Nepal, using a systematic sampling procedure. A face-to-face interview was taken by using semi-structured tools for independent variables, and the Bunn standard HIV Stigma Scale tool was used to measure the dependent variables. Stigma was measured in terms of felt stigma, Public Attitudes Concern (PAC), Disclosure Concern (DC), Negative Self-Image (NSI), and Enacted Stigma (ES), as well as overall stigma.\u003c/p\u003e\u003ch2\u003eResult\u003c/h2\u003e \u003cp\u003eOverall stigma was found to be 58.9%, where the percentages of each individual domain, NSI, PAC, DC, and ES, were reported as 65.2%, 53.7%, 56.9%, and 49.7%, respectively. On bivariate analysis, age, place of residence, ethnicity, reason for testing, exclusion due to HIV, hopelessness due to HIV, and depressed due to HIV were significantly associated with the dependent variable.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe research findings reported a significant level of high stigma that may act as a major hindrance to achieving the goal of Nepal\u0026rsquo;s National HIV strategic plan (95-95-95) by the end of 2026, as stigma serves as a major barrier in confronting high-risk individuals towards HIV testing and counseling services. Moreover, negative self-image is substantially higher than the other domains, which shows a dreadful impact on their overall well-being. The result from this study highlights the urgency of its findings to be shared among concerned stakeholders so as to step up in reducing stigma and discrimination among PLHIV.\u003c/p\u003e","manuscriptTitle":"Perceived Stigma and Its Associated Factors Among People Living With Hiv/aids in Bharatpur Art Center, Chitwan District, Nepal","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-22 13:45:48","doi":"10.21203/rs.3.rs-8582580/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-12T06:47:22+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-08T05:49:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-05T05:22:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"49745432747947937861258809009318492486","date":"2026-01-30T12:27:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"281998184387165224645285515102743895457","date":"2026-01-29T15:02:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"58517507708856531722186845185773658728","date":"2026-01-28T05:14:27+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-27T13:43:21+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-21T10:57:33+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-20T17:18:40+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2026-01-20T17:11:32+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"700b51cc-a776-47aa-8086-59c74caa8994","owner":[],"postedDate":"January 22nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-27T16:06:28+00:00","versionOfRecord":{"articleIdentity":"rs-8582580","link":"https://doi.org/10.1186/s12889-026-27535-6","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2026-04-22 15:59:30","publishedOnDateReadable":"April 22nd, 2026"},"versionCreatedAt":"2026-01-22 13:45:48","video":"","vorDoi":"10.1186/s12889-026-27535-6","vorDoiUrl":"https://doi.org/10.1186/s12889-026-27535-6","workflowStages":[]},"version":"v1","identity":"rs-8582580","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8582580","identity":"rs-8582580","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}