# Social Networks, HIV Stigma, and the HIV Care Cascade in Rural Uganda

> **NIH NIH R01** · MASSACHUSETTS GENERAL HOSPITAL · 2020 · $635,554

## Abstract

PROJECT SUMMARY
Of the 29 million persons living with HIV (PLHIV) in sub-Saharan Africa, only half are aware of their
seropositivity, and among these, less than half are on HIV antiretroviral therapy (ART). The average CD4+
T-lymphocyte cell count at ART initiation in sub-Saharan Africa was 140 cells/mm3 as of 2012, demonstrating
that late-stage disease at presentation to care and at ART initiation remain the norm. The stigma attached to
HIV has been identified as a critical barrier to improving these HIV prevention and treatment outcomes. HIV
remains heavily stigmatized throughout sub-Saharan Africa and has only been partially mitigated by current
interventions. The scientific objective of this R01 application is to apply social network methods to understand
the social production of HIV stigma, its propagation over time through the social network, and its causal effects
on HIV prevention and treatment outcomes. Our central hypothesis is that injunctive norms (i.e., the prevailing
attitude within the social network about what constitutes approved or disapproved conduct) have a causal
effect on one's own beliefs, and that the effect is mediated by anticipated stigma (i.e., what one perceives to be
the prevailing attitude). We further hypothesize that injunctive norms, anticipated stigma, and one's own beliefs
exert independent causal effects on HIV prevention among those at risk for HIV infection and on HIV treatment
outcomes among PLHIV. These hypotheses have been formulated on the basis of our strong preliminary data
from rural Uganda showing that injunctive norms are associated with one's own negative attitudes toward
PLHIV, and that HIV stigma is associated with a wide range of adverse HIV prevention and treatment
outcomes. We recently completed a population-based, sociocentric social network study of N=1,814 adults in
rural Uganda. This R01 application will extend our pilot study into a cohort, following these same participants
and any new in-migrants over time, so that we can accomplish the following specific aims: (1) Estimate the
causal effect of injunctive norms on negative attitudes toward PLHIV; (2) Estimate the causal effects of
injunctive norms, anticipated stigma, and negative attitudes toward PLHIV on uptake of voluntary counseling
and testing, condomless sexual intercourse, and HIV infection among HIV-negative persons and persons of
unknown serostatus; and (3) Estimate the causal effects of injunctive norms, anticipated stigma, and
internalized stigma on depression, linkage to care, ART adherence, viral suppression, retention in care, &
secondary transmission risk among PLHIV. Our key innovation is that we use photograph-based identity
verification to collect longitudinal, sociocentric social network data, and we apply analytic methods designed to
identify causal effects and causal mediation effects. The proposed study will have significant public health
impact by laying a foundation for developing more effective anti-stigma interv...

## Key facts

- **NIH application ID:** 9939704
- **Project number:** 5R01MH113494-04
- **Recipient organization:** MASSACHUSETTS GENERAL HOSPITAL
- **Principal Investigator:** ALEXANDER C TSAI
- **Activity code:** R01 (R01, R21, SBIR, etc.)
- **Funding institute:** NIH
- **Fiscal year:** 2020
- **Award amount:** $635,554
- **Award type:** 5
- **Project period:** 2017-07-01 → 2022-06-30

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/9939704

## Citation

> US National Institutes of Health, RePORTER application 9939704, Social Networks, HIV Stigma, and the HIV Care Cascade in Rural Uganda (5R01MH113494-04). Retrieved via AI Analytics 2026-05-23 from https://api.ai-analytics.org/grant/nih/9939704. Licensed CC0.

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