Persistent HIV-related stigma and rights gaps in Cabo Verde: national evidence from people living with HIV

Abstract

Background

Despite significant biomedical progress in human immunodeficiency virus (HIV) treatment and prevention, stigma and discrimination remain major barriers to epidemic control. Cabo Verde, a small island developing state, achieved near-universal coverage of antiretroviral therapy and an effective prevention of mother-to-child transmission. Yet, evidence on the lived experiences of people living with HIV has been scarce. This study provides the first nationally representative data on HIV-related stigma and discrimination in the country.

Methods

We conducted a cross-sectional, mixed-methods survey using the people living with HIV stigma index across all 22 municipalities of Cabo Verde. A stratified random sample of 543 people living with HIV was recruited in 2015, of whom 496 provided valid responses. Data collection included structured questionnaires, focus group discussions, and semi-structured interviews with healthcare providers and policymakers. Quantitative data were analysed descriptively, and Chi-square tests were used for statistical analysis. Qualitative data underwent thematic analysis.

Results

Participants were predominantly women (66.9%), with a mean age of 38.7 years. Antiretroviral therapy coverage was nearly universal (97.2%), and prevention of mother-to-child transmission outcomes were strong, with less than 1% of respondents reporting an HIV-positive child. However, only 25% disclosed their HIV status to family members, primarily due to fear of stigma. Reported external discrimination was low (10.3%), yet internalized stigma was widespread: 52.3% reported low self-esteem and more than half avoided childbearing or intimate relationships. Chi-square analysis revealed significant associations between fear of stigma and non-disclosure (P < 0.001), gender and external discrimination (P = 0.04), and education level and awareness of legal rights (P < 0.001).

Conclusions

The study demonstrates a paradox of high biomedical achievements but persistent hidden stigma. Interventions must address psychosocial support, socioeconomic empowerment, gender inequities, and legal literacy to reduce stigma and consolidate epidemic control. Cabo Verde’s experience highlights the urgent need to integrate stigma reduction into HIV responses globally, particularly in small island and low-prevalence contexts.