Stigma, depression and pillbox return among adults living with HIV in rural Tanzania: A prospective cohort study

Background: Stigma remains a major barrier to accessing HIV care. We analysed the association between stigma and failed pillbox return, and described factors associated with stigma among adults living with HIV in rural Tanzania. Methods: From the Kilombero and Ulanga Antiretroviral Cohort we included newly diagnosed adults ≥15 years enrolled between June 2019 and September 2022 with a stigma assessment at 6-12 months and a clinical visit within 7 days. We assessed stigma using the adapted 7-item Berger questionnaire. Logistic and linear regression models were used to identify factors associated with stigma and to determine the association between stigma and depression with failed pillbox return. Results: Among 241 participants (median age 37 years (IQR, 30-44) at enrolment), most were female (n = 170, 71%), WHO stage I (n = 132, 55%), had no pillbox at the clinical visit (n = 188, 78%), and remained in care at 2 years (n = 167, 69%). Participants with no pillbox had slightly higher stigma levels (9, IQR, 5-14) versus those who did (7, IQR, 4-13); this difference was not observed after adjustment (adjusted Odds Ratio 1.02 [95% CI 0.97, 1.07]; p = 0.38). Higher stigma was associated with higher depression (95% CI 0.48, 1.33, p < 0.01), HIV non-disclosure (95% CI 2.58, 8.33, p < 0.01) and higher education (p < 0.01). Higher Body Mass Index (p < 0.01) and advanced WHO stage (p < 0.01) were associated with lower stigma. Conclusion: Failed pillbox return was not associated with stigma. However, stigma was associated with depression, HIV non-disclosure and higher education. Stigma-reduction interventions focused on mental health and disclosure are urgently needed in rural areas.