Discrimination among people living with HIV attending an antiretroviral therapy Centre in Gwalior: a cross-sectional study

INTRODUCTION

The Joint United Nations Programme on HIV/AIDS (UNAIDS) proposed the global “getting to zero” strategy, which emphasizes three major targets: zero new HIV infections, zero AIDS-related deaths, and zero discrimination.¹ However, the objective of eliminating discrimination, as highlighted in the UNAIDS 2011-2015 strategic framework, has not yet been fully achieved. Consequently, the target of zero discrimination was continued in the subsequent UNAIDS 2016-2021 strategy.² Therefore, assessing the magnitude of stigma and discrimination at the country level is essential to generate baseline evidence and to monitor progress toward achieving the goal of zero discrimination as part of ending the HIV epidemic.

In India, HIV/AIDS remains an important public health concern, although the prevalence is relatively low compared to many countries. Recent estimates indicate that adult HIV prevalence in India is approximately 0.2%, with more than 2.5 million people currently living with HIV.³ Despite significant advances in prevention and treatment, HIV infection in some Indian communities is still perceived as a consequence of “sinful” or immoral behavior, which contributes to persistent stigma and discrimination against people living with HIV and adversely affects their access to care and quality of life.

When stigma and discrimination are prevalent, individuals often fear social rejection and negative attitudes more than the disease itself. As a result, many prefer to remain unaware of their actual or suspected HIV status, which may lead to delayed diagnosis, faster disease progression, and an increased risk of transmission to others. However, the role of HIV-related stigma and discrimination as important factors contributing to the spread of the epidemic has not been fully explored. In light of the foregoing context, the present study was undertaken at the antiretroviral therapy (ART) Centre JAH, Gwalior to assess the sociodemographic determinants of people living with HIV and to assess the Stigma and Discrimination of people living with HIV attending ART centre.

Objectives

The objectives were to estimate the prevalence of the discrimination and sociodemographic determinants of people living with HIV and behavioral factors that contribute to mental health challenges among patients at anti-retroviral therapy facility in Gwalior.

METHODS

Study type

It was a hospital based cross-sectional study.

Place of study

The study was conducted at the ART Centre of the Jaya Arogya Group of Hospitals in Gwalior, Madhya Pradesh.

Period of study

The present study was carried from 1^st May 2024-30^th April 2025.

Sample size determination

The sample size was estimated by document analysis of Sahu et al.⁸

Using the formula:

Assuming a 5% level of significance and 5% absolute error and p=43.45, the minimum sample size was 378, rounding in total of 380 subjects.

Inclusion criteria

All registered participants who are HIV positive and in between 25 to 35 years of age irrespective of gender attending ART Centre, JAH, G.R.M.C, Gwalior, all HIV positive patients registered at ART Centre, JAH, Gwalior willing to give consent for his/ her participation to study were included.

Exclusion criteria

Participants below 25 years of age and above 35 years of age, severely ill patients, patients diagnosed with AIDS and participants not willing to participate in the study were excluded from the study.

Ethical consideration

The study received ethical clearance from the Institutional Ethical Committee, Approval no.-1449/IEC-GRMC/2024; Dated: 01/05/2024 of Gajra Raja Medical College, Gwalior (M.P.).

Discrimination scoring

The scoring of discrimination was carried out by combining the variables from Tables 3 and 4. Each variable was assigned a score based on the discriminatory attitude experienced by people living with HIV. A score of 2 was given for a discriminatory attitude, whereas a score of 1 was assigned for a non-discriminatory attitude. For example, in Table 3, “supportive” responses were scored as 1, while responses such as “ashamed” or “loss of status and honour” were scored as 2. Similarly, in Table 4, responses such as “unknown to family” were scored as 1, whereas “expelled from home” was scored as 2. The scores from both tables were then summed to obtain a composite value. A total score of ≤2 was considered as absence of discrimination, while a score ≥2 was considered as presence of discrimination. Based on this classification, the prevalence of discrimination was calculated.

Data were analysed using SPSS version 27.0. Chi-square test was used to assess the factors associated with discrimination, with p<0.05 considered statistically significant.

RESULTS

Table 1 illustrates a total of 380 participants were included in the study. The study population was predominantly male (74.7%), with females constituting about one-fourth (24.5%). Slightly more than half of the participants were aged 31 years or above (53.9%), indicating a relatively mature study population.

With respect to educational status, the majority had attained at least middle school education, and one-fifth of the participants were graduates or post-graduates (20.3%). Illiteracy was observed in a relatively small proportion (7.6%). Occupationally, unskilled workers formed the largest group (31.0%), followed by semi-skilled (23.7%) and skilled workers (10.3%), reflecting a predominantly lower to middle occupational profile.

According to the revised BG Prasad socio-economic classification (January 2025), most participants belonged to the upper-middle (32.9%) and middle (29.7%) classes, while a smaller proportion belonged to the lower-middle (16.6%) and lower (3.7%) classes. More than half of the participants were from the general caste category (52.0%), followed by other backward classes (31.1%) and scheduled castes (15.3%).

Majority of participants were Hindu (91.3%). Most participants resided in urban areas (61.0%), followed by rural areas (31.6%), indicating predominantly urban study population. In terms of marital status, about half of participants married (51.2%), while substantial proportion unmarried (40.3%). With regard to family structure, more than half of participants belonged to nuclear families (55.3%), followed by joint families (36.8%).

Table 2 depicts that most participants were adherent to ART (77.9%). Nearly half had received counselling within the past 1-3 months (48.4%), while 30.0% reported a gap of more than three months. About two-fifths had been on treatment for 1-4 years (41.6%). Alcohol and smoking before sexual intercourse were reported by 13.9% and 24.5% participants, respectively. Condom use was reported by 67.9%, while 32.1% did not use condoms. Most participants had a single sexual partner (58.4%), whereas 12.9% reported multiple partners.

The Table 3 presents the responses of partners and family members toward the HIV status of the study participants. Among the 380 participants, the majority 310 (81.5%) reported that their family members and partners were supportive after learning of their HIV status. However, 8 (2.1%) experienced shame or perceived loss of status, and 17 (4.5%) were disowned by their families. Furthermore, 40 (10.5%) participants chose not to disclose their HIV status, possibly due to fear of discrimination or rejection, while 5 (1.4%) reported being deserted by their spouse.

The Table 4 presents the attitude of spouses and family members toward study participants after learning their HIV status. A large majority 273 (72.0%), reported receiving a supportive and caring attitude from their family or spouse, indicating a generally positive and empathetic response within the domestic environment. However, 37 (9.7%) participants had not disclosed their status to their families, while 26 (6.8%) reported initial hesitation that eventually turned supportive. On the other hand, smaller proportions experienced discrimination 7 (1.8%) were expelled from home, 7 (1.8%) faced neglect or segregation, and 6 (1.6%) were verbally assaulted or faced negative behaviour. Overall, while the majority experienced family acceptance, a subset still faced discriminatory or stigmatizing responses, suggesting that social stigma persists, even within intimate family settings.

The Table 5 illustrates the prevalence of discrimination experienced by people living with HIV. Out of 380 participants, 85 (22.4%) reported having faced discrimination, while the majority, 295 (77.6%), did not report any discriminatory experiences.

Table 6 illustrates the association between socio-demographic characteristics and discrimination among people living with HIV (n=380). The overall prevalence of perceived discrimination was 22.4%. No significant association was observed with gender, age group, education, occupation, socio-economic status, or place of residence (p>0.05).

However, caste and religion were significantly associated with discrimination. A higher prevalence of discrimination was observed among Scheduled tribe participants (83.3%) and among Muslim (36.4%) and Christian (66.7%) participants compared to Hindus (21.6%). Marital status also showed a statistically significant association, with higher discrimination among separated (77.8%) and unmarried individuals (26.8%) compared to married participants (16.4%) (p<0.001).

Family type was significantly associated with discrimination, with higher prevalence among individuals living alone (60%) compared to nuclear (20%) and joint families (17.9%) (p<0.001).

Table 7 shows the association between high-risk sexual behavior and discrimination among people living with HIV. No significant association was observed with adherence to ART, time since last counselling, or smoking before sexual intercourse (p>0.05). However, duration of treatment was significantly associated with discrimination, with higher prevalence among those on treatment for less than one year (35.5%) compared to those on longer treatment (p=0.008). Alcohol intake before sexual intercourse was also significantly associated, with higher discrimination among those consuming alcohol (37.7%) (p=0.004).

Use of condoms showed a significant association, with higher discrimination among those reporting condom use (27.9%) compared to non-users (p<0.001). In addition, participants with multiple sexual partners reported significantly higher discrimination (46.9%) compared to those with a single or no partner (p<0.001).

DISCUSSION

In our present study the prevalence of discrimination experienced by people living with HIV. Out of 380 participants, 85 (22.4%) reported having faced discrimination, while the majority, 295 (77.6%), did not report any discriminatory experiences. According to Mehta et al among 135 women living with HIV (WLHIV), 41.5% (95% CI: 33.2%-49.8%) reported feeling discriminated against. The most common forms of discrimination included family rejection (17.3%), shifting of residence (8.5%), and divorce from spouse (5.4%).⁴ In a study by Patankar et al the majority of participants (88.17%; n=164) had disclosed their HIV status to family members and consequently experienced discrimination.⁵ Similarly, Nursalam et al in Indonesia found that more than 70% of respondents reported experiencing discriminatory attitudes within their families.⁶ In another study conducted by Corona et al in Virginia, it was observed that 79% of people living with HIV/AIDS (PLWHA) had experienced discrimination.⁷

In this study the majority of the participants (53.9%) were aged ≥31 years, while 46.1% were aged ≤30 years. In a study carried out by Sahu et al the participants had a mean age of 36.42 years with a standard deviation of 10.29 years.⁸ Similarly, Oke et al in their research conducted at Abeokuta, Nigeria, observed that the overall mean age of the respondents was 41.20±9.12 years.⁹

In this study the majority were male (74.7%), followed by female participants (24.5%), while 0.8% identified as transgender. Similarly, findings from Dutta et al in West Bengal revealed that males constituted 59.3% of the study participants.¹¹

In our present study 20.2% were graduates, 20.2% had completed middle school, 19.2% had education up to primary school, 16.8% had studied up to the intermediate level, and 16.1% had completed high school, while 7.6% of the participants were illiterate. According to Sahu et al about 21.73% of the participants were illiterate.⁸ In a study conducted by Charles et al in South India, it was reported that 11.2% of men and 17.5% of women were non-literate.¹⁰

In this study the majority of participants (32.9%) belonged to the upper middle class, followed closely by lower middle class (29.7%). Around 17.1% of participants were from the upper class, indicating that nearly one-fifth of the respondents had relatively higher socio-economic status. The upper lower class constituted 16.6%, while only 3.7% of participants were from the lower class. Similarly, Adhikari et al at Kolkata, using the BG Prasad socio- demographic scale (modified in 2018), classified 25.2%, 34.0%, 25.9%, 14.2%, and 0.7% of respondents into classes I, II, III, IV, and V, respectively. Furthermore, 50.7% of participants reported a personal income below ₹5000 per month, 6.5% were non-income earners, and 2.0% identified their occupation as sex work. Additionally, 6.5% of respondents reported tobacco and/or alcohol use at the time of the study.¹⁵

In this study, the majority of participants were Hindu (91.3%), followed by Muslim (5.8%), Sikh (2.1%), and Christian (0.8%). This distribution reflects the predominant religious composition of the population in the study region of Gwalior. According to Dutta et al in West Bengal, the study revealed that the majority of participants (79.1%) were Hindus, while 10% were Muslims and 11.9% were 158 Christians.¹¹ In a study from Kolkata by Sarkar et al it was observed that most participants were Hindus (80%), followed by Muslims (17.3%). Among the Hindu respondents, 51.1% belonged to the general category, while 22.2% were from the scheduled caste.¹²

In this study 258 (67.9%) reported using condoms during sexual intercourse, while 122 (32.1%) admitted to engaging in unprotected sexual intercourse. In a study conducted in Nepal, Bhatta et al observed that approximately one-fourth of individuals living with HIV (26.0%,95% CI=17.2-34.7) reported having sexual intercourse without using a condom.¹³

Similarly, in Botswana, Weiser et al found that 38% of respondents had engaged in unprotected sex within the past year, while only 12%-13% of both men and women reported having unprotected sexual intercourse with a non-monogamous partner during the previous month.¹⁴

In this study only 53 (13.9%) reported consuming alcohol before sexual intercourse, while the vast majority 327 (86.1%) denied such behavior and 93 (24.5%) reported smoking prior to sexual intercourse, while 287 (75.5%) denied such behavior. A study conducted by Bhatta et al reported that among individuals living with HIV, approximately 26.5% were current tobacco users (95% CI=18.9-34.1), whereas 22.7% (95% CI=15.5 30.0) consumed alcohol.¹³

Similarly, in Botswana, Weiser et al found that 38% of respondents had engaged in unprotected sex within the past year, while only 12-13% of both men and women reported having unprotected sexual intercourse with a non-monogamous partner during the previous month.¹⁴

Limitations

The study strictly included participants only between the ages of 25 and 35 years. This narrow focus limits the generalizability of the findings to younger adolescents or older adults living with HIV. As a hospital-based study focused on an ART centre, it may underestimate the true burden of stigma, as it excludes undiagnosed individuals or those avoiding treatment due to extreme fear of discrimination.

CONCLUSION

The study reveals that while discrimination is absent for 77.6% of PLHIV, it remains a barrier for 22.4%, particularly marginalized groups. Key drivers include caste (Scheduled Tribes 83.3%), religion, and lack of domestic support (60% among those living alone). The first year of treatment is critical, with higher discrimination rates (35.5%) observed.

Furthermore, high-risk behaviours like alcohol use (37.7%) or multiple partners (46.9%) increase vulnerability. To achieve UNAIDS "zero discrimination" goals, targeted interventions are essential for the newly diagnosed and socially isolated to improve mental health.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee1449/IEC-GRMC/2024; Dated: 01/05/2024

REFERENCES

1. 1. UNAIDS. 2011-2015 Strategy: Getting to Zero. Vol. 127. UNAIDS. 2013;1-64. Available at: https://files.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2010/20101221_JC2034E_UNAIDS-Strategy_en.pdf. Accessed on 17 October 2025.
2. 2. The Joint United Nations Programme on HIV/AIDS (UNAIDS). UNAIDS 2016-2021 Strategy -On the Fast-Track to End AIDS. Geneva: The Joint United Nations Programme on HIV/AIDS (UNAIDS); 2016. Available at: http://www.unaids.org/sites/default/files/mediaasset/20151027_UNAIDS_PCB37_15_18_EN_rev1.pdf. Accessed on 21 February 2026.
3. 3. National AIDS Control Organization. India HIV Estimations 2015 Technical Report. National Institute of Medical Statistics, ICMR, Ministry of Health and Family Welfare, Government of India; 2016. Available at: http://naco.gov.in/sites/default/files/India%20HIV%20 Estimations%202015.pdf. Accessed on 21 February 2026.
4. 4. Mehta K, Baxi R, Patel S, Chavda P, Mazumdar V. Stigma, discrimination, and domestic violence experienced by women living with HIV: A cross-sectional study from western India. Indian J Community Med. 2019;44(4):373.
5. 5. N P, D P. Study of HIV/AIDS related stigma and discrimination in people living with HIV AIDS. J Res Med Dent Sci. 2014;2(4):53.
6. 6. Nursalam N, Sukartini T, Kuswanto H, Setyowati S, Mediarti D, Rosnani R, et al. Investigation of discriminatory attitude toward people living with HIV in the family context using socio-economic factors and information sources: A nationwide study in Indonesia. PeerJ. 2022;10:e13841.
7. 7. Corona R, Cowgill BO, Bogart LM, Parra MT, Ryan G, Elliott MN, et al. Brief Report: A Qualitative Analysis of Discussions about HIV in Families of Parents with HIV. J Pediatr Psychol. 2009;34(6):677-80.
8. 8. Sahu AC, Akhade KS. A cross-sectional study on stigma and discrimination confronted by HIV positive patients in the economic capital of India. J Fam Med Prim Care. 2022;11(7):3622-7.
9. 9. Oke OO, Akinboro AO, Olanrewaju FO, Oke OA, Omololu AS. Assessment of HIV-related stigma and determinants among people living with HIV/AIDS in Abeokuta, Nigeria: A cross-sectional study. SAGE Open Med. 2019;7:2050312119869109.
10. 10. Charles B, Jeyaseelan L, Pandian AK, Sam AE, Thenmozhi M, Jayaseelan V. Association between stigma, depression and quality of life of people living with HIV/AIDS (PLHA) in South India-a community based cross sectional study. BMC Public Health. 2012;12(1):463.
11. 11. Datta S, Bhattacherjee S, Sherpa PL, Banik S. Perceived HIV Related Stigma among Patients Attending ART Center of a Tertiary Care Center in Rural West Bengal, India. J Clin Diagnost Res. 2016;10(10):VC09-12.
12. 12. Sarkar T, Karmakar N, Dasgupta A, Saha B. Stigmatization and discrimination towards people living with HIV/AIDS attending antiretroviral clinic in a centre of excellence in HIV care in India. Int J Community Med Public Health. 2019;6(3):1241.
13. 13. Bhatta DN, Subedi A, Sharma N. Tobacco smoking and alcohol drinking among HIV infected people using antiretroviral therapy. Tobacco Induced Dis. 2018;16(4):16.
14. 14. Weiser SD, Leiter K, Heisler M, McFarland W, Percy-de Korte F, DeMonner SM, et al. A Population Based Study on Alcohol and High-Risk Sexual Behaviors in Botswana. PLoS Med. 2006;3(10):e392.
15. 15. Adhikari K, Dutt D, Pal D, Hazra S. Stigma and its Associated Factors among People Living with HIV/AIDS (PLHA) Attending ART Centre in a Tertiary Care Institute in Kolkata. MAMC J Med Sci. 2022;8(1):62-9.