Another very serious issue is stigma and discrimination.

People known to be living with HIV are often shunned or abused by community members, employers and even health workers. As well as causing much personal suffering, this sort of prejudice discourages people from seeking HIV testing, treatment and care. AIDS education also helps to reduce stigma and discrimination, by dispelling false information that can lead to fear and blame. This is crucial for prevention, as stigma often makes people reluctant to be tested for HIV and individuals that are unaware of their HIV infection are more likely to pass the virus on to others.7

Emotional impact
Children whose parents are living with HIV often experience many negative changes in their lives and can start to suffer neglect, including emotional neglect, long before they are orphaned. Eventually, they may suffer the death of their parent(s) and the emotional trauma that results. In this case, they may then have to adjust to a new situation, with little or no support, and may suffer exploitation and abuse.8 9 In one study carried out in rural Uganda, high levels of psychological distress were found in children who had been orphaned by AIDS. Anxiety, depression and anger were more found to be more common among AIDS orphans than other children. 12% of AIDS orphans affirmed that they wished they were dead, compared to 3% of other children interviewed.10 These psychological problems can become more severe if a child is forced to separate from their siblings upon becoming orphaned. In some regions this occurs regularly: a 2002 survey in Zambia showed that more than half of orphaned children no longer lived with all of their siblings

Stigmatisation
Children grieving for dying or dead parents are often stigmatised by society through association with AIDS. The distress and social isolation experienced by these children, both before and after the death of their parent(s), is made worse by the shame, fear, and rejection that often surrounds people affected by HIV and AIDS. Because of this stigma, children may be denied access to schooling and health care. Once a parent dies children may also be denied their inheritance and property. Often children who have lost their parents to AIDS are assumed to be HIV positive themselves, adding to the likelihood that they will face discrimination and damaging their future prospects. In this situation children may also be denied access to healthcare that they need. Sometimes this occurs

because it is assumed that they are infected with HIV and their illnesses are untreatable.

AIDS-related stigma and discrimination refers to prejudice, negative attitudes, abuse and maltreatment directed at people living with HIV and AIDS. The consequences of stigma and discrimination are wide-ranging: being shunned by family, peers and the wider community, poor treatment in healthcare and education settings, an erosion of rights, psychological damage, and a negative effect on the success of HIV testing and treatment. Stigma not only makes it more difficult for people trying to come to terms with HIV and manage their illness on a personal level, but it also interferes with attempts to fight the AIDS epidemic as a whole.

Fear of contagion coupled with negative, value-based assumptions about people who are infected leads to high levels of stigma surrounding HIV and AIDS. 2 Factors that contribute to HIV/AIDS-related stigma include: HIV/AIDS is a life-threatening disease, and therefore people react to it in strong ways. HIV infection is associated with behaviours (such as homosexuality, drug addiction, prostitution or promiscuity) that are already stigmatised in many societies. Most people become infected with HIV through sex, which often carries moral baggage. There is a lot of inaccurate information about how HIV is transmitted, creating irrational behaviour and misperceptions of personal risk. HIV infection is often thought to be the result of personal irresponsibility. Religious or moral beliefs lead some people to believe that being infected with HIV is the result of moral fault (such as promiscuity or 'deviant sex') that deserves to be punished. The effects of antiretroviral therapy on peoples physical appearance can result in forced disclosure and discrimination based on appearance. The fact that HIV/AIDS is a relatively new disease also contributes to the stigma attached to it. The fear surrounding the emerging epidemic in the 1980s is still fresh in many peoples minds. At that time very little was known about the risk of HIV transmission, which made people scared of those infected due to fear of contagion. From early in the AIDS epidemic a series of powerful images were used that

reinforced and legitimised stigmatisation. HIV/AIDS as punishment (e.g. for immoral behaviour) HIV/AIDS as a crime (e.g. in relation to innocent and guilty victims) HIV/AIDS as war (e.g. in relation to a virus which must be fought) HIV/AIDS as horror (e.g. in which infected people are demonised and feared) HIV/AIDS as otherness (in which the disease is an affliction of those set apart)

"The epidemic of fear, stigmatization and discrimination has undermined the ability of individuals, families and societies to protect themselves and provide support and reassurance to those affected. This hinders, in no small way, efforts at stemming the epidemic. It complicates decisions about testing, disclosure of status, and ability to negotiate prevention behaviours, including use of family planning services."14 AIDS-related stigma has had a profound effect on the epidemics course. The WHO cites fear of stigma and discrimination as the main reason why people are reluctant to be tested, to disclose their HIV status or to take antiretroviral drugs.15 One study found that participants who reported high levels of stigma were more than four times more likely to report poor access to care.16 These factors all contribute to the expansion of the epidemic (as a reluctance to determine HIV status or to discuss or practice safe sex means that people are more likely to infect others) and a higher number of AIDS-related deaths. An unwillingness to take an HIV test means that more people are diagnosed late, when the virus has already progressed to AIDS, making treatment less effective and causing early death. Research by the International Centre for Research on Women (ICRW) 17 found the possible consequences of HIV-related stigma to be: Loss of income/livelihood Loss of marriage & childbearing options Poor care within the health sector Withdrawal of caregiving in the home Loss of hope & feelings of worthlessness Loss of reputation Some of these consequences refer to internal stigma or self-stigma. Internal stigma refers to how people living with HIV regard themselves, as well as how they see public perception of people living with HIV. Stigmatising beliefs and actions may be imposed by people living with HIV themselves: "I am afraid of giving my disease to my family membersespecially my youngest brother who is so small. It would be so pitiful if he got the disease. I am aware that I have the disease so I do not touch himI talk with him only. I dont hold

him in my arms now." Woman in Vietnam18 Self-stigma and fear of a negative community reaction can hinder efforts to address the AIDS epidemic by perpetuating the wall of silence and shame surrounding the epidemic. Stigma also worsens problems faced by children orphaned by AIDS. AIDS orphans may encounter hostility from their extended families and community, and may be rejected, denied access to schooling and health care, and left to fend for themselves.
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Community level stigma and discrimination towards people living with HIV is found all over the world. A communitys reaction to somebody living with HIV can have a huge effect on that persons life. If the reaction is hostile a person may be discriminated against and may be forced to leave their home, or change their daily activities such as shopping, socialising or schooling. "At first relations with the local school were wonderful and Michael thrived there. Only the head teacher and Michael's personal class assistant knew of his illness Then someone broke the confidentiality and told a parent that Michael had AIDS. That parent, of course, told all the others. This caused such panic and hostility that we were forced to move out of the area. Michael was no longer welcome at the school. Other children were not allowed to play with him - instead they jeered and taunted him cruelly. One day a local mother started screaming at us to keep him away from her children and shouting that he should have been put down at birth. Ignorance about HIV means that people are frightened. And frightened people do not behave rationally. We could well be driven out of our home yet again.British woman describing the experience of her foster son in a British school39 Community-level stigma and discrimination can manifest as ostracism, rejection and verbal and physical abuse. It has even extended to murder. AIDS related murders have been reported in countries as diverse as Brazil, Colombia, Ethiopia, India, South Africa and Thailand. In December 1998, Gugu Dhlamini was stoned and beaten to death by neighbours in her township near Durban, South Africa, after speaking openly on World AIDS Day about her HIV status.40 It is therefore not surprising that 79 percent of people living with HIV who participated in a global study, feared social discrimination following their status disclosure.41 Stigma and discrimination can also take particular forms within key populations at higher risk. For example, studies have shown that within some gay communities there is segregation between HIV-positive and HIV-negative men, where men associate predominately with those of the same status. Some people living with HIV have linked this rift within the community with depression, anxiety and loneliness. Other members of gay communities have reported stigma based on physical changes due to the side effects of treatment, which can lead people to

delay seeking and initiating treatment.42 "We can fight stigma. Enlightened laws and policies are key. But it begins with openness, the courage to speak out. Schools should teach respect and understanding. Religious leaders should preach tolerance. The media should condemn prejudice and use its influence to advance social change, from securing legal protections to ensuring access to health care."Ban Ki-moon, Secretary-General of the United Nations

However, no policy or law can alone combat HIV/AIDS related discrimination. Stigma and discrimination will continue to exist so long as societies as a whole have a poor understanding of HIV and AIDS and the pain and suffering caused by negative attitudes and discriminatory practices. The fear and prejudice that lie at the core of the HIV/AIDS-related discrimination need to be tackled at the community and national levels, with AIDS education playing a crucial role. A more enabling environment needs to be created to increase the visibility of people with HIV/AIDS as a 'normal' part of any society. The presence of treatment can make this task easier; where there is the opportunity to live a fulfilling and long life with HIV, people are less afraid of AIDS; they are more willing to be tested for HIV, to disclose their status, and to seek care if necessary. The task is to confront the fear-based messages and biased social attitudes, in order to reduce the discrimination and stigma of people living with HIV and AIDS.