World Journal of AIDS, 2013, 3, 305-312
Published Online December 2013 (http://www.scirp.org/journal/wja)
http://dx.doi.org/10.4236/wja.2013.34039
Open Access WJA
305
HIV/AIDS Related Stigma among Male Labor
Migrants in Nepal
Sushma Dahal1*, Paras Kumar Pokharel2, Birendra Kumar Yadav2
1Department of Public Health, Central Institute of Science and Technology Baneshwor, Kathmandu, Nepal; 2School of Public Health
& Community Medicine, BP Koirala Institute of Health Sciences, Dharan, Nepal.
Received August 22nd, 2013; revised September 21st, 2013; accepted September 26th, 2013
Copyright © 2013 Sushma Dahal et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Labor migrants are those of the at-risk g roups for HIV. Thi s c r os s - se c t i o na l s t u dy ha s t ri e d t o e x a m i n e H I V/ A I D S- r e l at e d
stigma among Nepalese returnee male labor migrants. Migrant workers who have worked at least six months abroad
were asked different questions related to sexual behavior, knowledge on HIV/AIDS & condom and HIV/AIDS-related
stigma. Stigma was measured on a three-point rating scale as high, average and low stigma. About 58% of migrants had
the view “I would rather not know if I have HIV” followed by “I don’t want to be friends with people living with HIV”
(53.6% migrants) and “people with HIV are cursed” (35.5% migrants). High stigma was present among 15.5% of the
total respondents with high proportion among those with higher age, lower education, rural residence, and no knowl-
edge on Voluntary Counseling and Testing (VCT) service. About a quarter of respondents were of the view that mi-
grants infected with HIV while abro ad should not be allowed to return Nepal. So me level of stigma on HIV/AIDS exists
among male labor migrants in Nepal. Interventio ns aiming at reducing stigma should consider the factor s like migrants’
age, education, place of residence and knowledge on VCT services.
Keywords: HIV/AIDS; Labor Migrants; Nepal; Stigma; VCT
1. Introduction
Migration is as an essential and inevitable component of
the economic and social life of every state [1]. Nepalese
government is promoting overseas employment opportu-
nities for its citizens because of poor absorption of
growing labor force in the country [2]. Political instabil-
ity, especially since the onset of armed conflict has also
increased the number of labor migrants [3]. Nepal today
is well recognized as the country of origin for labor mi-
grants mainly to the Gulf Cooperation Council and Ma-
laysia. Most popular countries of destination include
Qatar, Saudi Arabia, South Korea, Lebanon, Japan, Israel,
Malaysia, Kuwait and United Arab Emirate [4].
Ministry of Labor and Transport management in Nepal
estimates that at current there are 3 million Nepali people
under foreign employment and approximately 900 mi-
grant workers leave the country for overseas employment
everyday [4]. Different factors like socio-cultural pat-
terns of host country, economic transition of migrants,
reduced availability and accessibility of health services
and difficulty of host country health care system to cope
with the tradition and practices of immigrants caused
migrant population at increased risk of poor health and
other conditions like HIV and STIs [5]. Among different
Most At Risk Population (MARP) for HIV in Nepal [6],
male labor migrants and the clients of FSW are the im-
portant bridging population that transmits HIV from high
risk group to the general population. According to Na-
tional Centre for AIDS and STD Control [7] 2011 in
Nepal, male labor migrants accounted for 27% of the
total HIV infections [7]. However the data represent the
migrants goi ng to India.
In Nepal there exist strong traditional norms and be-
liefs related to sex and sexuality related top ics [8]. These
topics are rarely discussed in Nepalese families where
sexual activities outside marriage are also not accepted
[9]. In school curriculum though sex education has been
included, adolescen ts in school g et very little information
about sex education, and the major reasons behind in-
clude teachers’ lack of desire and skill to deliver the sen-
*Corresponding author.

HIV/AIDS Related Stigma among Male Labor Migrants in Nepal 306
sitive contents and poor enviro n ment for stud ents to learn
about the topics enthu siastically [10]. Similarly, for those
who want to obtain relevant information and services
related to sexual health, there is very inadequate provi-
sion of those services in Nepal [11]. These results in the
lack of knowledge about sex, sexuality, hygienic sexual
behaviors, and sexually transmitted infections like AIDS
etc. In case of HIV/AIDS, HIV which is infectious and
potentially terminable in nature leads to fear of contract-
ing it, its relation to sexual activity especially promiscu-
ity & homosexuality and immoral or irresponsible be-
haviors, concern of uninfected towards their own mate-
rial wellbeing, underestimation of their own risk by un-
infected etc. play important roles in making it a stigma-
tized disease. This stigma has also been found to be used
as a device to maintain social order [12]. However, these
reasons are not sufficient to explain the HIV/AIDS-re-
lated stigma. So, HIV/AIDS-related stigma is considered
as being multi-faceted and it is expected to differ from
other forms of prejudice [13].
HIV/AIDS-related stigma creates barrier to effective
HIV prevention and care programs. People fear discrimi-
nation and thus avoid the testing services. People Living
with HIV/AIDS (PLHA) may receive substandard treat-
ment, may refuse to disclose their status to partners or
change their behavior to avoid negative reactions. Since
they neither seek care and sup port nor disclose it to their
partners/families and thus contribute to further transmis-
sion of the disease in future [14]. People at risk of HIV
are less likely to access the quality treatment and care as
a result of shame associated with HIV/AIDS. The situa-
tion is likely to b e more severe when the targeted serv ice
users are migrant workers who are considered as MARP.
These ultimately lead to increased transmission, morbid-
ity and mortality [15]. Thus, as a consequence of stigma,
on the one hand migrant workers are likely to discrimi-
nate PLHA and on the other hand, they themselves are
less likely to utilize preventive and curative services p ar-
ticularly related to HIV/AIDS. Similarly, those migrant
workers contracting HIV are also more likely to conceal
their disease status [16,17], which results in low or even
no use of h ea lth servic es.
2. Methods
2.1. Study Design, Setting and Data Collection
A cross-sectional study was done from September 2009
to February 2010 among 110 Nepalese male labor mi-
grants returning after at least 6 months of work experi-
ence from any of the countries or areas: Qatar, Saudi
Arabia, UAE, Oman, Kuwait, Bahrain, Iraq, Israel, Mal-
dives, Malaysia, Singapore, Hong Kong, Brunei, Macao,
Saipan, South Korea, Kosovo, Latvia, the Seychelles and
South Africa within 3 months to 2 years from date of
interview were included. The data were collected from
three different cities of three regions (Eastern, Central
and Western) of Nepal. Respondents were identified and
taken purposively from the recruitment agencies where
migrants returned from overseas had visited either for
going abroad again or for some other reasons. Besides,
returnee migrants were also traced in the community to
increase the sample size. Major variables included in the
interviewer-administered questionnaire were socio-de-
mographic characteristics, sexual behaviors, knowledge
regarding HIV/AIDS & condom use and HIV/AIDS re-
lated stigma.
2.2. Data Processing and Analysis
Fourteen statements about HIV and PLHA were desi gned
with the help of available literatures [18-21] to measure
constructs related to 1) negative attitudes and beliefs
about PLHAs, 2) responden ts’ percep tion of po ssible dis-
crimination faced by PLHA and 3) positive statement
regardin g HIV/AIDS. It included both correct statements
(“yes” coded as 0, “no” coded as 1) and incorrect state-
ments (reversely coded) that were added to find out total
score for each respondent. Those respondents with (0 - 4)
scores were classified as having low stigma, (5 - 9) as
average stigma and (10 - 14) as high stigma.
Data was analyzed using SPSS 17 software. Descrip-
tive statistics such as frequency, percentage, table, ch arts
were described wherever appropriate. No any inferential
statistics was applied to the data as the respondents were
chosen purposively.
3. Results
3.1. Level of Stigma
Among total respondents, 66.4% (73) had low stigma,
18.2% (20) had average stigma and 15.5% (17) had high
stigma. About 58% of the respondents were of view, “I
would rather not know if I have HIV”, followed by about
54% with the view “I don’t want to be friends with peo-
ple living with HIV”, 43.6% with view “people with HIV
cannot be trusted” and 35.5% with the view “people with
HIV are cursed”. However, around 81% of the respon-
dents were of view that people with HIV should not hide
it (Table 1).
3.2. Socio-Demographic Information
Table 2 presents the cross tabulation between socio-de-
mographic characteristics of the respondents and the
level of AIDS related stigma. About 23% of respond ents
aged 20 - 29 years had average or high stigma which was
about 43% in 30 - 39 years and about 67% in 39 years
and above. Three out of four respondents who were illit-
erate had high stigma. About 38% of the respondents
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Table 1. Respondents view on statements related to HIV/AIDS (to measure level of stigma).
Statements Agree Disagree
1) AIDS attacks homosexuals or bisexuals 19 (17.3) 91 (82.7)
2) People around would leave if I have HIV 32 (29.1) 78 (70.9)
3) I would rather not know if I have HIV 64 (58.2) 46 (41.8)
4) People who have HIV/AIDS are dirty 28 (25.5) 82 (74.5)
5) People with HIV/AIDS are cursed 39 (35.5) 71 (64.5)
6) People with HIV/AIDS cannot be trusted 48 (43.6) 62 (56.4)
7) People with HIV/AIDS should be ashamed 35 (31.8) 75 (68.2)
8) People with HIV/AIDS are punished because they have done something wrong 38 (34.5) 72 (65.5)
9) People wit h HIV should be isolated 24 (21.8) 86 (78.2)
10) I don’t want to be friends with people living with HIV 59 (53.6) 51 (46.4)
11) I am afraid of people living with HIV 25 (22.7) 85 (77.3)
12) People wi th HIV should not be allowed to wor k 26 (23.6) 84 (76.4)
13) People with HIV are like everybody else 72 (65.5) 38 (34.5)
14) People with HIV should not hide it 89 (80.9) 21 (19.1)
Numbers in p arenthesi s i ndicate p ercentage of row total.
Table 2. Socio-demographic characteristics and level of stigma.
Number of respondents
Socio-demographic characteristics (n = 110) Low stigma Average stigma High stigma
Age category of the respondent
20 - 29 years 41 (77.3) 4 (7.5) 8 (15.1)
30 - 39 years 31 (57.4) 15 (27.7) 8 (14.8)
More than 39 years 1 (33.3) 1 (33.3) 1 (33.3)
Education category of the respondent
Illiterate 0 (0) 1 (25) 3 (75)
Primary education 0 (0) 6 (31.6) 13 (68.4)
Lower secondary and secondary 51 (81.0) 11 (17.4) 1 (1.6)
Higher secondary and above 22 (91.6) 2 (8.3) 0 (0)
Place of origin
VDC 40 (61.5) 14 (21.5) 11 (16.9)
Municipality 33 (73.3) 6 (13.3) 6 (13.3)
Years spent in overseas
Less than or equal to 2 years 16 (84.2) 3 (15.8) 0 (0)
2 - 4 years 42 (67.7) 9 (14.5) 11 (17.7)
More than 4 years 15 (51.7) 8 (27.6) 6 (20.7)
Numbers in p arenthesi s i ndicate p ercentage of row total.
from VDC residence had average or high stigma com-
pared to about 27% of those from municip ality. With the increase in the years of overseas employment, the level of stigma was high. About 16% of migrants who had

HIV/AIDS Related Stigma among Male Labor Migrants in Nepal 308
worked on average up to 2 years or less abroad had high
stigma compared to about 32% who worked for 2 - 4
years and about 48% of those who worked more than 4
years.
3.3. Sexual Behavior, Risk Perception and VCT
Service Use
Table 3 presents the cross tab ulation of stigma with sex-
ual behavior, condom use, HIV test, STI diagnosis and
respondents’ self rated risk of contracting HIV (low risk,
average risk and high risk). Respondents having and not
having any sexual intercourse in the overseas did not
have much difference in the level of high stigma (14.8%
vs. 16.1%). However, in relation to the type of sexual
partner, high difference was present; 43.5% of those
having sex with girlfriend and 26% of those having sex
with FSW had average or high level of stigma. Relatively
higher percent of those ever diagnosed with STI had high
average or high stigma (42.9%) than those who were
never diagnosed (33%). Respondents who perceived
themselves at low risk of contracting HIV/AIDS had
higher stigmatizing attitude than those who perceived
Table 3. Factors related to sexual behavior, risk perception and VCT service use.
Number of respondents
Factors related to sexual behavior, risk perception and VCT service useLow stigma Average stigma High stigma
Had any sexual intercourse in the overseas (n = 110)
Yes 36 (66.7) 10 (18.5) 8 (14.8)
No 37 (66.1) 10 (17.8) 9 (16.1)
If yes, with whom? (n = 54)
Girlfriend 13 (56.5) 8 (34.8) 2 (8.7)
Female Sex Worker (FSW) 22 (74.1) 2 (7.4) 5 (18.5)
Both girlfriend and FSW 3 (75) 0 (0) 1 (25)
Frequency of sex in a month
Less than or equal to 1 time 15 (75) 2 (10) 3 (15)
2 - 5 times 15 (60) 6 (24) 4 (16)
6 times and above 6 (66.7) 2 (22.2) 1 (11 .1)
Use of condom during sexual intercourse
Always 22 (66.7) 5 (15.1) 6 (18.2)
Sometimes 14 (70) 4 (20) 2 (10)
Never 0 (0) 1 (100) 0 (0)
Diagnosed with STIs before
Yes 4 (57.1) 2 (28.6) 1 (14.3)
No 69 (67.0) 18 (17.5) 16 (15.5)
Risk perceived of contracting HIV for oneself
Low risk 64 (64.6) 19 (19.2) 16 (16.2)
Average risk 7 (77.8) 1 (11.1) 1 (11.1)
High risk 2 (100) 0 (0) 0 (0)
Ever test for HIV by oneself
Yes 49 (65.3) 16 (21.3) 10 (13.3)
No 24 (68.6) 4 (11.4) 7 (20.0)
Use of VCT service
Yes 7 (87.5) 1 (12.5) 0 (0)
No 66 (64.7) 19 (18.6) 17 (16.7)
Numbers in p arenthesi s i ndicate p ercentage of row total.
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HIV/AIDS Related Stigma among Male Labor Migrants in Nepal 309
themselves at average or high risk. Among the respon-
dents who ever tested themselves for HIV, 13.3% had
high stigma compared to 20% of those who never tested
for HIV. 12.5% of respondents who ever used VCT ser-
vice had low stigma compared to around 35% who had
never used the service. A total of 99 (90%) respondents
categorized themselves at low risk, 9 (8.2%) at average
risk and 2 (1.8%) at hig h ri sk of cont ract ing HIV/AID S.
3.4. Knowledge about HIV/AIDS and Condom
Use
As knowledge related to HIV/AIDS and condom use can
also determine the level of HIV/AIDS related stigma, a
cross tabulation of knowledge related factors was done
with the stigma category. Table 4 shows that, out of 79
respondents who said women can give AIDS to men
8.8% had high stigma compared to 32.2% respondents
who said women can’t give AIDS to men. Similarly,
66.67% respondents who agreed that condoms are not
safe to use had average or high stigma compared to 28%
respondents who had the view they are safe. About 20%
of those who disagreed condom should be used with
FSW only had average or high stigma.
3.5. View on Return of PLHA in Nepal
Out of the total respondents, only 23.4% had known
someone with AIDS. In response to a question “Any
Nepalese who suffer from HIV/AIDS while in abroad,
should they be permitted to return Nepal?” about 74%
said they should be permitted, 23.6% said they should
not be permitted and 2.7% had no idea on this regard.
Respondents’ reasons behind the idea of permitting and
not permitting the return of migrants suffering from
HIV/AIDS were based on different themes which are
presented here separately for clarity.
Nepal is their country too
A total of forty one respondents believed that every
Nepalese has right to stay in Nepal. One of the respon-
dents’ comment reflecting this perspective, “Nepal is
their (migrants suffering from AIDS) country too and
they have right to live here with their family”. Migrants
said that disease status should not determine whether
they stay in Nepal. As one of the respondent stated,
“Though he has suffered from dangerous disease like
AIDS, the door to his own country should not be closed”.
One of the respondents also stated that “They have right
to die in their own country”.
They need love and care
Twelve respondents believed that migrants suffering
from HIV/AIDS need love and care. “They should be
institutionalized , loved and cared, if so they can live 5 -
10 years more” as commented by one of the respondents.
Some were also aware about the need of providing men-
tal support. As one respondent said “They should be
psychologically supported so that further transmission
could be contr ol l ed ”.
There is no other ways out
A total of 23 respondents also mentioned than there
were no other ways out that permitting the return as the
company’s rule in overseas doesn’t allow staying if one
is found to have HIV. As one respondent commented on
this perspective, “They can’t live abroad if the company
knows that they have HIV, they can’t work, they suffer
and so need their family and country”. One of the re-
spondent also stated that “they have no other place to go
than their own coun try”. Since all the respondents are the
returnee migrants, they have awareness about the com-
pany’s rule. Nine respondents had a similar reason stat-
ing, “If they suffer from HIV in abroad, they are highly
likely to suffer more”.
Table 4. Knowledge related factors and level of stigma.
Number of respondents
Knowledge related factors Low stigma Average stigma High stigma
Women can give AIDS to men (n = 79) 58 (73.4) 14 (17.7) 7 (8.8)
Women cannot give AIDS to men (n = 31) 15 (48.4) 6 (19.3) 10 (32.2)
Agree that AIDS ca nnot be cured (n = 94) 68 (72.3) 15 (15.9) 11 (11.7)
Disagree that AIDS cannot be cured (n = 16) 5 (31.2) 5 (31.2) 6 (37.5)
Agree that condoms are not safe (n = 9) 3 (33.3) 6 (66.7) 0
Disagree that condoms are not safe (n = 96) 69 (71.9) 14 (14.6) 13 (13.5)
Agree on the view that condom should be used with only FSW (n = 49) 32 (65.3) 9 (18.4) 8 (16.3)
Disagree on the view that condom should be used with only FSW (n = 87) 70 (80.4) 9 (10.3) 8 (9.2)
Nubers in parent hesis indicate percentage of row total. m
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HIV/AIDS Related Stigma among Male Labor Migrants in Nepal 310
Practice risky behavior in abroad
Some respondents’ believed that if those who have
suffered from HIV in abroad stay there, they are more
likely to engage in other risk behavior. Some of the re-
spondents stated that, “In foreign they are alone, their
family is in Nepal. So they are free to do anything they
like e.g. indulge with more partners for sex”. Respondents
were also aware that there more people should not suffer
due to one person. As one of the respondents commented
that, “In Nepal they transmit HIV to only their wife and
children but in abroad they transmit it to many others”.
To use them for preventing HIV
Some respondents came up with the useful interven-
tions to prevent further transmission of HIV in Nepal
with the use of migrants suffering from HIV themselves.
As one of the respondents mentioned that, “they should
be permitted to return Nepal if they agree to be active in
spreading messages to community about prevention of
HIV”. Another respondent said, “they can inform people
(especially prospective migrants) more effectively about
how to prevent contracting HIV”.
They infect many people
A total of 25 respondents gave reason related to
chance of more HIV infection behind their view of no
permission to be given to those suffering from HIV in
abroad. Most of them had same reason stating, “If they
return Nepal, they are likely to hide their disease and
hence infect other innocent people in Nepal”.
Other reasons mentioned behind no permission were
highly stigmatizing reflected by some of the reasons
stated. As two of the respondent commented, “They are
doing sins by having HIV”. Some respondents were also
found to have felt insecure image of themselves because
of those people who suffer from HIV in abroad. As one
of the respondent stated, “These people with HIV create
wrong impression of foreign employment to families,
friends and other people who are staying in Nepal”. One
of the respondent mentioned “They have committed
crime. So they should not be given permission to return
Nepal”.
4. Discussion
The study has tried to reveal the level of stigma on HIV/
AIDS among migrant workers. About 63% of the re-
spondents had low stigma whereas 15.5% had high
stigma.
In this and in a pr evious study b y Wolfe et al. [17] one
of the important stigmatizing attitudes is related to view
that “I would rather no t k now if I h ave HIV”. In Wolfe et
al.’s study 94% of respondents reported keeping their
HIV positive status secret from the community. Forty
percent of these reported that they delayed getting tested
for HIV. More than half of these who delayed getting
tested, more than half cited fear of a positive test result as
the primary reason for delay in seeking treatment. The
most typical form of stigmatization as described by
Herek & Glunt is rejection and status loss [22]. In the
present study, this rejection was expressed by around
54% of resp ondents who agreed a statement that “I don’t
want to be friends with PLHA” and around 24% who
agreed that “PLHA should not be allowed to work”.
Study of expression of HIV related stigma among rural to
urban migrants done by Hong et al. [23] also suggests
Chinese rural-to-urban migrants’ attitudes toward HIV
infected individuals take forms of denial, indifference,
labeling, separation, rejection, status loss, shame, hope-
lessness, and fear.
According to a study done in China among migrant
women living in Shanghai; being older, having low lev-
els of education and longer duration of stay in Shanghai
were identified as important correlates for having stig-
matizing attitude while having multiple sex partners was
correlated with less stigma [18]. Similar findings were
found in present study also; higher percent of older re-
spondents had average or high stigma compared to those
of younger age that is about 67% in 39 years and older,
43% in 30 - 39 years and 23% in 20 - 29 years age. Three
out of four resp onden ts who were illiterate h ad h igh lev el
of stigma. Around 16% of re sponden ts who had stayed in
overseas for less than or equal to 2 years had average or
high stigma compared to 32% of those who had stayed
for 2 - 4 years and around 48% of those who had stayed
for more than 4 years. Higher proportion of tho se having
sex with multiple partner and those with higher fre-
quency of sex had low level of stigma. Present study
found that higher proportion of respondents from VDC
residence had high stigma compared to respondents from
municipality residence.
Previous studies [20,24-26] have shown that stigma is
inversely related to HIV testing. Similar to this, present
study has found that 20% of those who never tested for
HIV and who had never heard of VCT service had high
stigma compared to about 13% of those who had ever
done HIV test.
Timely testing for HIV infection is essential for effec-
tive management of HIV as it makes the infected person
informed about their serostatus and hence they can gain
access to care and benefit from the available treatment
options. HIV related stigma has impact on HIV testing
and care [27]. According to findings from a study done in
Southern borders in Brazil, higher stigmatizing attitudes
were correlated with less HIV service utilization as well
as unwillingness to tell anyone about an HIV-positive
diagnosis [21].
According to a study by Barth KR et al. [28] among
college students, social stigmas and negative conse-
quences appear to represent significant barrier to HIV
testing, which could increase the risk of spreading the
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HIV/AIDS Related Stigma among Male Labor Migrants in Nepal 311
infections to others.
The level of stigma on HIV/AIDS among migrants af-
fects the effectiveness of HIV/AIDS prevention program
by creating an environment that discourages individuals
(both PLHA and people at risk) from disclosing them-
selves and seeking care on promotive, preventive and
curative services on HIV. HIV/AIDS stigma directly or
indirectly violates the human right element of at-risk
group and PLHA making them suffer more.
5. Conclusions
Findings from this study have several implications for
preventing the HIV epidemic in the future. Firstly it has
tried to explore the level of stigmatizing attitude against
HIV/AIDS among the labor migrants and secondly these
respondents are themselves the population at risk for
HIV infection in Nepal. On the one hand, the insulting
attitude against HIV/AIDS presenting among the re-
spondents directly affects their behavior towards PLHAs
and on the other hand, this attitude can possibly affect
their health service seeking behavior like going to a VCT
center and Anti-Retroviral Therapy center etc.
Thus, programs that aim for HIV prevention should
target both the prospective and returnee migrants in
country of origin. Stigma reduction programs should be
also designed on multifaceted nature of HIV-related
stigma and focus should be among migrants with no or
low education, rural residence and with higher duration
of people stay overseas. To reduce the stigma and make
future AIDS intervention programs effective, country of
des tination can have important roles in cond ucti ng s tigma
reduction programs and making VCT services accessible
to them.
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List of Abbreviations
FSW: Female Sex Worker
MARPs: Most At Risk Population
NCASC: National Centre for AIDS and STD Control
PLHA: People Living with HIV/AIDS
UAE: United Arab Emirates
VCT: Voluntary Counseling and Testing
VDC: Village Development Committee