HIV/AIDS Related Stigma among Male Labor Migrants in Nepal

doi:10.4236/wja.2013.34039

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World Journal of AIDS, 2013, 3, 305-312

Published Online December 2013 (http://www.scirp.org/journal/wja)

http://dx.doi.org/10.4236/wja.2013.34039

Open Access WJA

305

HIV/AIDS Related Stigma among Male Labor

Migrants in Nepal

Sushma Dahal1*, Paras Kumar Pokharel2, Birendra Kumar Yadav2

1Department of Public Health, Central Institute of Science and Technology Baneshwor, Kathmandu, Nepal; 2School of Public Health

& Community Medicine, BP Koirala Institute of Health Sciences, Dharan, Nepal.

Email: *[email protected]

Received August 22nd, 2013; revised September 21st, 2013; accepted September 26th, 2013

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Labor migrants are those of the at-risk g roups for HIV. Thi s c r os s - se c t i o na l s t u dy ha s t ri e d t o e x a m i n e H I V/ A I D S- r e l at e d

stigma among Nepalese returnee male labor migrants. Migrant workers who have worked at least six months abroad

were asked different questions related to sexual behavior, knowledge on HIV/AIDS & condom and HIV/AIDS-related

stigma. Stigma was measured on a three-point rating scale as high, average and low stigma. About 58% of migrants had

the view “I would rather not know if I have HIV” followed by “I don’t want to be friends with people living with HIV”

(53.6% migrants) and “people with HIV are cursed” (35.5% migrants). High stigma was present among 15.5% of the

total respondents with high proportion among those with higher age, lower education, rural residence, and no knowl-

edge on Voluntary Counseling and Testing (VCT) service. About a quarter of respondents were of the view that mi-

grants infected with HIV while abro ad should not be allowed to return Nepal. So me level of stigma on HIV/AIDS exists

among male labor migrants in Nepal. Interventio ns aiming at reducing stigma should consider the factor s like migrants’

age, education, place of residence and knowledge on VCT services.

Keywords: HIV/AIDS; Labor Migrants; Nepal; Stigma; VCT

1. Introduction

Migration is as an essential and inevitable component of

the economic and social life of every state [1]. Nepalese

government is promoting overseas employment opportu-

nities for its citizens because of poor absorption of

growing labor force in the country [2]. Political instabil-

ity, especially since the onset of armed conflict has also

increased the number of labor migrants [3]. Nepal today

is well recognized as the country of origin for labor mi-

grants mainly to the Gulf Cooperation Council and Ma-

laysia. Most popular countries of destination include

Qatar, Saudi Arabia, South Korea, Lebanon, Japan, Israel,

Malaysia, Kuwait and United Arab Emirate [4].

Ministry of Labor and Transport management in Nepal

estimates that at current there are 3 million Nepali people

under foreign employment and approximately 900 mi-

grant workers leave the country for overseas employment

everyday [4]. Different factors like socio-cultural pat-

terns of host country, economic transition of migrants,

reduced availability and accessibility of health services

and difficulty of host country health care system to cope

with the tradition and practices of immigrants caused

migrant population at increased risk of poor health and

other conditions like HIV and STIs [5]. Among different

Most At Risk Population (MARP) for HIV in Nepal [6],

male labor migrants and the clients of FSW are the im-

portant bridging population that transmits HIV from high

risk group to the general population. According to Na-

tional Centre for AIDS and STD Control [7] 2011 in

Nepal, male labor migrants accounted for 27% of the

total HIV infections [7]. However the data represent the

migrants goi ng to India.

In Nepal there exist strong traditional norms and be-

liefs related to sex and sexuality related top ics [8]. These

topics are rarely discussed in Nepalese families where

sexual activities outside marriage are also not accepted

[9]. In school curriculum though sex education has been

included, adolescen ts in school g et very little information

about sex education, and the major reasons behind in-

clude teachers’ lack of desire and skill to deliver the sen-

*Corresponding author.

HIV/AIDS Related Stigma among Male Labor Migrants in Nepal

306

sitive contents and poor enviro n ment for stud ents to learn

about the topics enthu siastically [10]. Similarly, for those

who want to obtain relevant information and services

related to sexual health, there is very inadequate provi-

sion of those services in Nepal [11]. These results in the

lack of knowledge about sex, sexuality, hygienic sexual

behaviors, and sexually transmitted infections like AIDS

etc. In case of HIV/AIDS, HIV which is infectious and

potentially terminable in nature leads to fear of contract-

ing it, its relation to sexual activity especially promiscu-

ity & homosexuality and immoral or irresponsible be-

haviors, concern of uninfected towards their own mate-

rial wellbeing, underestimation of their own risk by un-

infected etc. play important roles in making it a stigma-

tized disease. This stigma has also been found to be used

as a device to maintain social order [12]. However, these

reasons are not sufficient to explain the HIV/AIDS-re-

lated stigma. So, HIV/AIDS-related stigma is considered

as being multi-faceted and it is expected to differ from

other forms of prejudice [13].

HIV/AIDS-related stigma creates barrier to effective

HIV prevention and care programs. People fear discrimi-

nation and thus avoid the testing services. People Living

with HIV/AIDS (PLHA) may receive substandard treat-

ment, may refuse to disclose their status to partners or

change their behavior to avoid negative reactions. Since

they neither seek care and sup port nor disclose it to their

partners/families and thus contribute to further transmis-

sion of the disease in future [14]. People at risk of HIV

are less likely to access the quality treatment and care as

a result of shame associated with HIV/AIDS. The situa-

tion is likely to b e more severe when the targeted serv ice

users are migrant workers who are considered as MARP.

These ultimately lead to increased transmission, morbid-

ity and mortality [15]. Thus, as a consequence of stigma,

on the one hand migrant workers are likely to discrimi-

nate PLHA and on the other hand, they themselves are

less likely to utilize preventive and curative services p ar-

ticularly related to HIV/AIDS. Similarly, those migrant

workers contracting HIV are also more likely to conceal

their disease status [16,17], which results in low or even

no use of h ea lth servic es.

2. Methods

2.1. Study Design, Setting and Data Collection

A cross-sectional study was done from September 2009

to February 2010 among 110 Nepalese male labor mi-

grants returning after at least 6 months of work experi-

ence from any of the countries or areas: Qatar, Saudi

Arabia, UAE, Oman, Kuwait, Bahrain, Iraq, Israel, Mal-

dives, Malaysia, Singapore, Hong Kong, Brunei, Macao,

Saipan, South Korea, Kosovo, Latvia, the Seychelles and

South Africa within 3 months to 2 years from date of

interview were included. The data were collected from

three different cities of three regions (Eastern, Central

and Western) of Nepal. Respondents were identified and

taken purposively from the recruitment agencies where

migrants returned from overseas had visited either for

going abroad again or for some other reasons. Besides,

returnee migrants were also traced in the community to

increase the sample size. Major variables included in the

interviewer-administered questionnaire were socio-de-

mographic characteristics, sexual behaviors, knowledge

regarding HIV/AIDS & condom use and HIV/AIDS re-

lated stigma.

2.2. Data Processing and Analysis

Fourteen statements about HIV and PLHA were desi gned

with the help of available literatures [18-21] to measure

constructs related to 1) negative attitudes and beliefs

about PLHAs, 2) responden ts’ percep tion of po ssible dis-

crimination faced by PLHA and 3) positive statement

regardin g HIV/AIDS. It included both correct statements

(“yes” coded as 0, “no” coded as 1) and incorrect state-

ments (reversely coded) that were added to find out total

score for each respondent. Those respondents with (0 - 4)

scores were classified as having low stigma, (5 - 9) as

average stigma and (10 - 14) as high stigma.

Data was analyzed using SPSS 17 software. Descrip-

tive statistics such as frequency, percentage, table, ch arts

were described wherever appropriate. No any inferential

statistics was applied to the data as the respondents were

chosen purposively.

3. Results

3.1. Level of Stigma

Among total respondents, 66.4% (73) had low stigma,

18.2% (20) had average stigma and 15.5% (17) had high

stigma. About 58% of the respondents were of view, “I

would rather not know if I have HIV”, followed by about

54% with the view “I don’t want to be friends with peo-

ple living with HIV”, 43.6% with view “people with HIV

cannot be trusted” and 35.5% with the view “people with

HIV are cursed”. However, around 81% of the respon-

dents were of view that people with HIV should not hide

it (Table 1).

3.2. Socio-Demographic Information

Table 2 presents the cross tabulation between socio-de-

mographic characteristics of the respondents and the

level of AIDS related stigma. About 23% of respond ents

aged 20 - 29 years had average or high stigma which was

about 43% in 30 - 39 years and about 67% in 39 years

and above. Three out of four respondents who were illit-

erate had high stigma. About 38% of the respondents

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Table 1. Respondents view on statements related to HIV/AIDS (to measure level of stigma).

Statements Agree Disagree

1) AIDS attacks homosexuals or bisexuals 19 (17.3) 91 (82.7)

2) People around would leave if I have HIV 32 (29.1) 78 (70.9)

3) I would rather not know if I have HIV 64 (58.2) 46 (41.8)

4) People who have HIV/AIDS are dirty 28 (25.5) 82 (74.5)

5) People with HIV/AIDS are cursed 39 (35.5) 71 (64.5)

6) People with HIV/AIDS cannot be trusted 48 (43.6) 62 (56.4)

7) People with HIV/AIDS should be ashamed 35 (31.8) 75 (68.2)

8) People with HIV/AIDS are punished because they have done something wrong 38 (34.5) 72 (65.5)

9) People wit h HIV should be isolated 24 (21.8) 86 (78.2)

10) I don’t want to be friends with people living with HIV 59 (53.6) 51 (46.4)

11) I am afraid of people living with HIV 25 (22.7) 85 (77.3)

12) People wi th HIV should not be allowed to wor k 26 (23.6) 84 (76.4)

13) People with HIV are like everybody else 72 (65.5) 38 (34.5)

14) People with HIV should not hide it 89 (80.9) 21 (19.1)

Numbers in p arenthesi s i ndicate p ercentage of row total.

Table 2. Socio-demographic characteristics and level of stigma.

Number of respondents

Socio-demographic characteristics (n = 110) Low stigma Average stigma High stigma

Age category of the respondent

20 - 29 years 41 (77.3) 4 (7.5) 8 (15.1)

30 - 39 years 31 (57.4) 15 (27.7) 8 (14.8)

More than 39 years 1 (33.3) 1 (33.3) 1 (33.3)

Education category of the respondent

Illiterate 0 (0) 1 (25) 3 (75)

Primary education 0 (0) 6 (31.6) 13 (68.4)

Lower secondary and secondary 51 (81.0) 11 (17.4) 1 (1.6)

Higher secondary and above 22 (91.6) 2 (8.3) 0 (0)

Place of origin

VDC 40 (61.5) 14 (21.5) 11 (16.9)

Municipality 33 (73.3) 6 (13.3) 6 (13.3)

Years spent in overseas

Less than or equal to 2 years 16 (84.2) 3 (15.8) 0 (0)

2 - 4 years 42 (67.7) 9 (14.5) 11 (17.7)

More than 4 years 15 (51.7) 8 (27.6) 6 (20.7)

Numbers in p arenthesi s i ndicate p ercentage of row total.

from VDC residence had average or high stigma com-

pared to about 27% of those from municip ality. With the increase in the years of overseas employment, the level

of stigma was high. About 16% of migrants who had

HIV/AIDS Related Stigma among Male Labor Migrants in Nepal

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worked on average up to 2 years or less abroad had high

stigma compared to about 32% who worked for 2 - 4

years and about 48% of those who worked more than 4

years.

3.3. Sexual Behavior, Risk Perception and VCT

Service Use

Table 3 presents the cross tab ulation of stigma with sex-

ual behavior, condom use, HIV test, STI diagnosis and

respondents’ self rated risk of contracting HIV (low risk,

average risk and high risk). Respondents having and not

having any sexual intercourse in the overseas did not

have much difference in the level of high stigma (14.8%

vs. 16.1%). However, in relation to the type of sexual

partner, high difference was present; 43.5% of those

having sex with girlfriend and 26% of those having sex

with FSW had average or high level of stigma. Relatively

higher percent of those ever diagnosed with STI had high

average or high stigma (42.9%) than those who were

never diagnosed (33%). Respondents who perceived

themselves at low risk of contracting HIV/AIDS had

higher stigmatizing attitude than those who perceived

Table 3. Factors related to sexual behavior, risk perception and VCT service use.

Number of respondents

Factors related to sexual behavior, risk perception and VCT service useLow stigma Average stigma High stigma

Had any sexual intercourse in the overseas (n = 110)

Yes 36 (66.7) 10 (18.5) 8 (14.8)

No 37 (66.1) 10 (17.8) 9 (16.1)

If yes, with whom? (n = 54)

Girlfriend 13 (56.5) 8 (34.8) 2 (8.7)

Female Sex Worker (FSW) 22 (74.1) 2 (7.4) 5 (18.5)

Both girlfriend and FSW 3 (75) 0 (0) 1 (25)

Frequency of sex in a month

Less than or equal to 1 time 15 (75) 2 (10) 3 (15)

2 - 5 times 15 (60) 6 (24) 4 (16)

6 times and above 6 (66.7) 2 (22.2) 1 (11 .1)

Use of condom during sexual intercourse

Always 22 (66.7) 5 (15.1) 6 (18.2)

Sometimes 14 (70) 4 (20) 2 (10)

Never 0 (0) 1 (100) 0 (0)

Diagnosed with STIs before

Yes 4 (57.1) 2 (28.6) 1 (14.3)

No 69 (67.0) 18 (17.5) 16 (15.5)

Risk perceived of contracting HIV for oneself

Low risk 64 (64.6) 19 (19.2) 16 (16.2)

Average risk 7 (77.8) 1 (11.1) 1 (11.1)

High risk 2 (100) 0 (0) 0 (0)

Ever test for HIV by oneself

Yes 49 (65.3) 16 (21.3) 10 (13.3)

No 24 (68.6) 4 (11.4) 7 (20.0)

Use of VCT service

Yes 7 (87.5) 1 (12.5) 0 (0)

No 66 (64.7) 19 (18.6) 17 (16.7)

Numbers in p arenthesi s i ndicate p ercentage of row total.

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HIV/AIDS Related Stigma among Male Labor Migrants in Nepal 309

themselves at average or high risk. Among the respon-

dents who ever tested themselves for HIV, 13.3% had

high stigma compared to 20% of those who never tested

for HIV. 12.5% of respondents who ever used VCT ser-

vice had low stigma compared to around 35% who had

never used the service. A total of 99 (90%) respondents

categorized themselves at low risk, 9 (8.2%) at average

risk and 2 (1.8%) at hig h ri sk of cont ract ing HIV/AID S.

3.4. Knowledge about HIV/AIDS and Condom

Use

As knowledge related to HIV/AIDS and condom use can

also determine the level of HIV/AIDS related stigma, a

cross tabulation of knowledge related factors was done

with the stigma category. Table 4 shows that, out of 79

respondents who said women can give AIDS to men

8.8% had high stigma compared to 32.2% respondents

who said women can’t give AIDS to men. Similarly,

66.67% respondents who agreed that condoms are not

safe to use had average or high stigma compared to 28%

respondents who had the view they are safe. About 20%

of those who disagreed condom should be used with

FSW only had average or high stigma.

3.5. View on Return of PLHA in Nepal

Out of the total respondents, only 23.4% had known

someone with AIDS. In response to a question “Any

Nepalese who suffer from HIV/AIDS while in abroad,

should they be permitted to return Nepal?” about 74%

said they should be permitted, 23.6% said they should

not be permitted and 2.7% had no idea on this regard.

Respondents’ reasons behind the idea of permitting and

not permitting the return of migrants suffering from

HIV/AIDS were based on different themes which are

presented here separately for clarity.

Nepal is their country too

A total of forty one respondents believed that every

Nepalese has right to stay in Nepal. One of the respon-

dents’ comment reflecting this perspective, “Nepal is

their (migrants suffering from AIDS) country too and

they have right to live here with their family”. Migrants

said that disease status should not determine whether

they stay in Nepal. As one of the respondent stated,

“Though he has suffered from dangerous disease like

AIDS, the door to his own country should not be closed”.

One of the respondents also stated that “They have right

to die in their own country”.

They need love and care

Twelve respondents believed that migrants suffering

from HIV/AIDS need love and care. “They should be

institutionalized , loved and cared, if so they can live 5 -

10 years more” as commented by one of the respondents.

Some were also aware about the need of providing men-

tal support. As one respondent said “They should be

psychologically supported so that further transmission

could be contr ol l ed ”.

There is no other ways out

A total of 23 respondents also mentioned than there

were no other ways out that permitting the return as the

company’s rule in overseas doesn’t allow staying if one

is found to have HIV. As one respondent commented on

this perspective, “They can’t live abroad if the company

knows that they have HIV, they can’t work, they suffer

and so need their family and country”. One of the re-

spondent also stated that “they have no other place to go

than their own coun try”. Since all the respondents are the

returnee migrants, they have awareness about the com-

pany’s rule. Nine respondents had a similar reason stat-

ing, “If they suffer from HIV in abroad, they are highly

likely to suffer more”.

Table 4. Knowledge related factors and level of stigma.

Number of respondents

Knowledge related factors Low stigma Average stigma High stigma

Women can give AIDS to men (n = 79) 58 (73.4) 14 (17.7) 7 (8.8)

Women cannot give AIDS to men (n = 31) 15 (48.4) 6 (19.3) 10 (32.2)

Agree that AIDS ca nnot be cured (n = 94) 68 (72.3) 15 (15.9) 11 (11.7)

Disagree that AIDS cannot be cured (n = 16) 5 (31.2) 5 (31.2) 6 (37.5)

Agree that condoms are not safe (n = 9) 3 (33.3) 6 (66.7) 0

Disagree that condoms are not safe (n = 96) 69 (71.9) 14 (14.6) 13 (13.5)

Agree on the view that condom should be used with only FSW (n = 49) 32 (65.3) 9 (18.4) 8 (16.3)

Disagree on the view that condom should be used with only FSW (n = 87) 70 (80.4) 9 (10.3) 8 (9.2)

Nubers in parent hesis indicate percentage of row total. m

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Practice risky behavior in abroad

Some respondents’ believed that if those who have

suffered from HIV in abroad stay there, they are more

likely to engage in other risk behavior. Some of the re-

spondents stated that, “In foreign they are alone, their

family is in Nepal. So they are free to do anything they

like e.g. indulge with more partners for sex”. Respondents

were also aware that there more people should not suffer

due to one person. As one of the respondents commented

that, “In Nepal they transmit HIV to only their wife and

children but in abroad they transmit it to many others”.

To use them for preventing HIV

Some respondents came up with the useful interven-

tions to prevent further transmission of HIV in Nepal

with the use of migrants suffering from HIV themselves.

As one of the respondents mentioned that, “they should

be permitted to return Nepal if they agree to be active in

spreading messages to community about prevention of

HIV”. Another respondent said, “they can inform people

(especially prospective migrants) more effectively about

how to prevent contracting HIV”.

They infect many people

A total of 25 respondents gave reason related to

chance of more HIV infection behind their view of no

permission to be given to those suffering from HIV in

abroad. Most of them had same reason stating, “If they

return Nepal, they are likely to hide their disease and

hence infect other innocent people in Nepal”.

Other reasons mentioned behind no permission were

highly stigmatizing reflected by some of the reasons

stated. As two of the respondent commented, “They are

doing sins by having HIV”. Some respondents were also

found to have felt insecure image of themselves because

of those people who suffer from HIV in abroad. As one

of the respondent stated, “These people with HIV create

wrong impression of foreign employment to families,

friends and other people who are staying in Nepal”. One

of the respondent mentioned “They have committed

crime. So they should not be given permission to return

Nepal”.

4. Discussion

The study has tried to reveal the level of stigma on HIV/

AIDS among migrant workers. About 63% of the re-

spondents had low stigma whereas 15.5% had high

stigma.

In this and in a pr evious study b y Wolfe et al. [17] one

of the important stigmatizing attitudes is related to view

that “I would rather no t k now if I h ave HIV”. In Wolfe et

al.’s study 94% of respondents reported keeping their

HIV positive status secret from the community. Forty

percent of these reported that they delayed getting tested

for HIV. More than half of these who delayed getting

tested, more than half cited fear of a positive test result as

the primary reason for delay in seeking treatment. The

most typical form of stigmatization as described by

Herek & Glunt is rejection and status loss [22]. In the

present study, this rejection was expressed by around

54% of resp ondents who agreed a statement that “I don’t

want to be friends with PLHA” and around 24% who

agreed that “PLHA should not be allowed to work”.

Study of expression of HIV related stigma among rural to

urban migrants done by Hong et al. [23] also suggests

Chinese rural-to-urban migrants’ attitudes toward HIV

infected individuals take forms of denial, indifference,

labeling, separation, rejection, status loss, shame, hope-

lessness, and fear.

According to a study done in China among migrant

women living in Shanghai; being older, having low lev-

els of education and longer duration of stay in Shanghai

were identified as important correlates for having stig-

matizing attitude while having multiple sex partners was

correlated with less stigma [18]. Similar findings were

found in present study also; higher percent of older re-

spondents had average or high stigma compared to those

of younger age that is about 67% in 39 years and older,

43% in 30 - 39 years and 23% in 20 - 29 years age. Three

out of four resp onden ts who were illiterate h ad h igh lev el

of stigma. Around 16% of re sponden ts who had stayed in

overseas for less than or equal to 2 years had average or

high stigma compared to 32% of those who had stayed

for 2 - 4 years and around 48% of those who had stayed

for more than 4 years. Higher proportion of tho se having

sex with multiple partner and those with higher fre-

quency of sex had low level of stigma. Present study

found that higher proportion of respondents from VDC

residence had high stigma compared to respondents from

municipality residence.

Previous studies [20,24-26] have shown that stigma is

inversely related to HIV testing. Similar to this, present

study has found that 20% of those who never tested for

HIV and who had never heard of VCT service had high

stigma compared to about 13% of those who had ever

done HIV test.

Timely testing for HIV infection is essential for effec-

tive management of HIV as it makes the infected person

informed about their serostatus and hence they can gain

access to care and benefit from the available treatment

options. HIV related stigma has impact on HIV testing

and care [27]. According to findings from a study done in

Southern borders in Brazil, higher stigmatizing attitudes

were correlated with less HIV service utilization as well

as unwillingness to tell anyone about an HIV-positive

diagnosis [21].

According to a study by Barth KR et al. [28] among

college students, social stigmas and negative conse-

quences appear to represent significant barrier to HIV

testing, which could increase the risk of spreading the

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HIV/AIDS Related Stigma among Male Labor Migrants in Nepal 311

infections to others.

The level of stigma on HIV/AIDS among migrants af-

fects the effectiveness of HIV/AIDS prevention program

by creating an environment that discourages individuals

(both PLHA and people at risk) from disclosing them-

selves and seeking care on promotive, preventive and

curative services on HIV. HIV/AIDS stigma directly or

indirectly violates the human right element of at-risk

group and PLHA making them suffer more.

5. Conclusions

Findings from this study have several implications for

preventing the HIV epidemic in the future. Firstly it has

tried to explore the level of stigmatizing attitude against

HIV/AIDS among the labor migrants and secondly these

respondents are themselves the population at risk for

HIV infection in Nepal. On the one hand, the insulting

attitude against HIV/AIDS presenting among the re-

spondents directly affects their behavior towards PLHAs

and on the other hand, this attitude can possibly affect

their health service seeking behavior like going to a VCT

center and Anti-Retroviral Therapy center etc.

Thus, programs that aim for HIV prevention should

target both the prospective and returnee migrants in

country of origin. Stigma reduction programs should be

also designed on multifaceted nature of HIV-related

stigma and focus should be among migrants with no or

low education, rural residence and with higher duration

of people stay overseas. To reduce the stigma and make

future AIDS intervention programs effective, country of

des tination can have important roles in cond ucti ng s tigma

reduction programs and making VCT services accessible

to them.

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List of Abbreviations

FSW: Female Sex Worker

MARPs: Most At Risk Population

NCASC: National Centre for AIDS and STD Control

PLHA: People Living with HIV/AIDS

UAE: United Arab Emirates

VCT: Voluntary Counseling and Testing

VDC: Village Development Committee