Developing a community-level anti-HIV/AIDS stigma and homophobia intervention in new York city: The project CHHANGE model

HIV/AIDS stigma and homophobia are associated with significant negative health and social outcomes among people living with HIV/AIDS (PLWHA) and those at risk of infection. Interventions to decrease HIV stigma have focused on providing information and education, changing attitudes and values, and increasing contact with people living with HIV/AIDS (PLWHA), activities that act to reduce stereotyped beliefs and prejudice, as well as acts of discrimination. Most anti-homophobia interventions have focused on bullying reduction and have been implemented at the secondary and post-secondary education levels. Few interventions address HIV stigma and homophobia and operate at the community level. Project CHHANGE, Challenge HIV Stigma and Homophobia and Gain Empowerment, was a community-level, multi-component anti-HIV/AIDS stigma and homophobia intervention designed to reduce HIV stigma and homophobia thus increasing access to HIV prevention and treatment access. The theory-based intervention included three primary components: workshops and trainings with local residents, businesses and community-based organizations (CBO); space-based events at a CBO-partner drop-in storefront and “pop-up” street-based events and outreach; and a bus shelter ad campaign. This paper describes the intervention design process, resultant intervention and the study team’s experiences working with the community. We conclude that CHHANGE was feasible and acceptable to the community. Promoting the labeling of gay and/or HIV-related “space” as a non-stigmatized, community resource, as well as providing opportunities for residents to have contact with targeted groups and to understand how HIV stigma and homophobia relate to HIV/AIDS prevalence in their neighborhood may be crucial components of successful anti-stigma and discrimination programming.     

Perceptions of HIV testing venues among men who have sex with men in London and the Midlands,United Kingdom

Undiagnosed HIV and late HIV diagnosis increase the risk of poor disease prognosis in infected individuals and of onward HIV transmission. It is vital to encourage regular HIV testing among men who have sex with men (MSM), a group disproportionately affected by HIV. A sample of 18 MSM from London and the East Midlands in England were interviewed regarding their perceptions of testing in the following three contexts: genitourinary medicine (GUM) clinics, community settings, and at home using a self-testing kit. The data were analyzed using qualitative content analysis. Perceived stigma from health care professionals, fear of being seen by significant others, and delays in being attended to were seen as barriers to testing in GUM clinics. While community settings were viewed as more accepting of sexual identity, concerns around homophobia and HIV stigma impeded access to testing for some individuals. HIV self-testing alleviated confidentiality concerns, but interviewees doubted the accuracy of the test results and worried about the lack of social support in the event of a reactive test result. Recommendations are offered for improving the acceptability of HIV testing in these contexts.     

‘Pain on Top of Pain,Hurtness on Top of Hurtness’: Social Discrimination,Psychological Well-Being,and Sexual Risk Among Women Living With HIV/AIDS

ABSTRACT

This qualitative study explored how a subsample (n = 26) of participants in Protect and Respect (N = 184), a safer-sex intervention for women living with HIV/AIDS (WLH/A), discussed their experiences of social discrimination and the impact of discrimination on their lives, psychological well-being, and risk behaviors during group intervention sessions. The majority of participants was Black (83%), earned less than $10,000 per year (80%), and acquired HIV through heterosexual sex (58%). Analyses demonstrated that social discrimination manifested in the women's lives as poverty, HIV/AIDS-related stigma, and gender inequality. These experiences caused intense psychological distress and limited WLH/A's ability to implement the safer-sex skills that they learned during the intervention. We discuss the applied and theoretical implications of our findings, advocating for HIV and sexual risk-reduction interventions that are based on an ecological framework that addresses holistically the individual, relational, and sociostructural factors that affect women's sexual risk behaviors.     

Stigma,AIDS, and HIV Prevention in Africa: Reports from Community Organizations Providing Prevention Services

ABSTRACT

The AIDS epidemic in Africa remains a serious health crisis. Nongovernmental organizations (NGOs) in Africa play a critical role in the delivery of HIV prevention services. An important barrier to their HIV prevention efforts is stigma directed at persons living with HIV/AIDS. In order to understand how stigma affects HIV prevention programming, we conducted in-depth qualitative interviews with NGO directors in 29 African countries. Qualitative analytic approaches were used to identify key themes. Substantial discrimination and stigmatization of HIV-positive persons was reported. HIV-positive women were particularly likely to suffer negative social and economic consequences. The stigma associated with HIV interfered with disclosure of HIV status, risk-reduction behaviors, and HIV testing, creating significant barriers to HIV prevention efforts.

Interventions to reduce AIDS-related stigma in Africa are urgently needed. Reducing the burden of stigma is critical to fighting the epidemic in Africa and could play an important role in global HIV reduction.     

Public Knowledge and Attitudes to HIV: Research From Three Decades in Sweden

The overarching objective of this article is to describe the Swedish public's knowledge about HIV and attitudes toward people living with HIV during the period 1987–2011. Within the framework of this objective, the article also directs a special focus at the association between knowledge about HIV transmission and attitudes toward people who are HIV positive. The study is based on the results of a questionnaire sent to a stratified random sample on eight occasions between 1987 and 2011. The study population comprises the Swedish general public aged 16–44 and is stratified on the basis of the respondents' age, with each of five age groups (16–17, 18–19, 20–24, 25–34, and 35–44) comprising 20% of the study respondents. A total of 21,027 individuals have completed the questionnaire in the eight surveys. The survey instrument is relatively short and comprises 27 questions on knowledge, attitudes and sexual behaviour relating to HIV. The eight surveys show that the public's knowledge about HIV and its different transmission routes is high and has increased over time. Above all there has been an increase in the level of knowledge about how HIV is not transmitted between people. However, the public's knowledge about the infectiousness of individuals receiving treatment for HIV infection is low. Public attitudes toward people with HIV have also undergone a clear shift over time, toward increased tolerance and a decline in the level of fear, especially in social situations. Despite this, a residual suspicion and stigmatisation can be seen in the public's attitudes to people who are HIV positive. This is most obvious from the questions that link HIV to sexuality and here the changes are very modest over time. Public knowledge about HIV and its transmission routes has increased between 1987 and 2011. Attitudes toward people who are HIV positive have generally become more tolerant and positive, not least in relation to different social situations. The fear of becoming infected has declined. At the same time there remains a stigma, which continues to direct suspicion at people who are living with HIV and to ascribe them negative characteristics and behaviors that are based on prejudice. The results show, however, that the public's attitudes toward same-sex relationships are clearly more accepting today than they were previously, and that the symbolic association between HIV and this group is tending to become weaker.     

Can social workers mitigate the existential implications of an HIV diagnosis in the era of HAART?

Whilst it is commonly recognised that highly active anti-retroviral therapy (HAART) has increased the life expectancy of people living with HIV (PLWH), it has also presented a number of new challenges that appear to have altered the experience of living with HIV considerably. This paper argues that significant advances and innovations in medical treatments has led to the marginalisation of a number of psychological, social and economic needs that stem from receiving a diagnosis of HIV. Rather than continuing to ignore both these difficulties and the existential implications of a diagnosis – such as restructuring one's sense of self, control and future orientation – a specific and tailored social work response is required to support PLWH in regaining their sense of control and self-determination. The study is based on findings from a focus group of 15 PLWH and a further 5 in-depth interviews; it thereby seeks to give a voice to a group frequently marginalised within social work research, and accurately capture the lived experiences of PLWH in the era of HAART.     

Issues Related to HIV Stigma in Nepal

ABSTRACT

We conducted a qualitative study to understand and describe experiences of people living with HIV and AIDS with regard to HIV-associated stigma in Nepal. The study has revealed four key themes associated with HIV stigma: a hierarchy of stigma (sexual transmission and women stigmatized more than injecting-drug transmission and men); exclusion and rejection (denial of care services, rejection from family); death as a form of punishment (untimely death is seen as a punishment for something done wrong in the past); and Mumbaiya disease (caught from working in “other places”). Cultural contexts are the best ways to understand HIV stigma in Nepal along with socially and culturally established gender roles. This study has confirmed that stigma manifests at different levels: individual, social, and structural, with denial and rejection being a key mechanism of stigma.     

Stigma, HIV/AIDS and prevention of mother-to-child transmission in Zambia

This report evaluates the extent of perceived and enacted HIV/AIDS-related stigma in a rural setting in Zambia. Stigmatisation is abundant, ranging from subtle actions to the most extreme degradation, rejection and abandonment. Women with HIV and pregnant women assumed to be HIV positive are repeatedly subjected to extensive forms of stigma, particularly once they become sick or if their child dies. Despite increasing access to prevention of mother to child transmission initiatives, including anti-retroviral drugs, the perceived disincentives of HIV testing, particularly for women, largely outweigh the potential gains from available treatments. HIV/AIDS related stigma drives the epidemic underground and is one of the main reasons that people do not wish to know their HIV status. Unless efforts to reduce stigma are, as one peer educator put it, “written in large letters in any HIV/AIDS campaign rather than small”, stigma will remain a major barrier to curbing the HIV/AIDS pandemic.     

Stigma Management Among Gay/Bisexual Men with HIV/AIDS

People with HIV infection are subjected to prejudice, discrimination and hostility related to the stigmatization of AIDS. To manage the stigma of their disease, they mount complex coping strategies. This paper reports results from a qualitative study that examined gay/bisexual men's experiences of living with HIV infection. Unstructured interviews from a diverse sample of 139 men were analyzed to examine how men coped with AIDS-related stigma. We discerned a variety of stigma management strategies that could be arranged along a continuum from reactive to proactive based on the extent to which they implicitly accepted or challenged the social norms and values that underlie the stigmatization of HIV/AIDS. Reactive strategies to cope with stigma involve defensive attempts to avoid or mitigate the impact of stigma, but imply acceptance of the underlying social norms and values that construct the stigma. Examples of reactive strategies include hiding one's HIV status, presenting one's illness as a less stigmatizing one (e.g., cancer), or distancing one's self from more damaging aspects of AIDS-stigma (e.g., attributing infection to blood transfusion). Proactive strategies challenge the validity of the stigma and imply disavowal and resistance of the social norms and values that underlie the stigma. Examples of proactive strategies include engaging in public educational efforts that address misperceptions about HIV transmission and social activism to change the social and political conditions that affect PWA/HIV.     

Measuring structural HIV stigma

Despite the progress in pharmaceutical and epidemiological tools for combating HIV spread, HIV stigma remains a significant social barrier impeding treatment and prevention efforts, potentially reducing the effectiveness of interventions to reduce HIV transmission. In this paper, we propose a novel approach to defining and estimating HIV stigmatization through the structure of sexual relations, as opposed to attitudes. We conceptualize structural stigma as arising from two mechanisms: (1) a reduced propensity towards HIV serodiscordant partnerships (exclusion); and (2) a reduced propensity towards partnerships with seroconcordant individuals who themselves have serodiscordant partnerships (ostracism). Both mechanisms can be assessed from observed partnership network data using exponential family random graph models (ERGMs). We demonstrate our approach on a sexual contact network of black men who have sex with men in the South Side of Chicago. We find a tendency for serodiscordant sexual relationships to be suppressed in the network ($\theta$ = −0.69, p $<$ .05), as well as a suppressive tendency for HIV negative YBMSM to have sex with other HIV negative people in serodiscordant relationships ($\theta$ = −0.96, p $<$ .05) suggesting that structural HIV stigma is present in this network. Potential relationships with attitudinal stigma and implications for epidemiological strategies for reducing HIV stigma are discussed.     

Women in India: The Context and Impact of HIV/AIDS

ABSTRACT

The response to the HIV/AIDS epidemic on the Indian subcontinent has been hampered by several factors, including societal stigma, lack of educational resources, lack of economic opportunities, and the competing priorities for a nation just growing and developing an infrastructure for education, industry, and health. In particular, Indian women are silent victims in this epidemic because they do not readily have a respected voice in decision making and priority setting for the government. The epidemic is increasingly affecting and infecting Indian women (e.g., female commercial sex workers, married women, and pregnant women). The status of Indian women has placed them at extreme disadvantage because India is a country with socially progressive laws but has been slow to change its social norms. The reported HIV prevalence is low although many researchers agree a large amount of underreporting occurs. For India to address this emerging epidemic among women appropriately, it should focus on three intervention areas: (1) short-term solutions such as treatment options for those already infected with HIV to prevent further infection to sexual partners and children; (2) intermediate solutions such as education for those who are uninfected but engaging in behaviors that may put them at risk, such as injection drug use, engaging in commercial sex work, engaging in extramarital sexual relations, and having sexual partners who are not monogamous; and 3) long-term solutions such as addressing the root causes of inequality (e.g., disparities in education and employment and unwillingness to change social norms).     

HIV/AIDS stigma manifestations during clinical interactions with MSM in Puerto Rico

HIV/AIDS stigma can have detrimental effects on physician/patient interactions when manifested by health professionals. Unfortunately, HIV/AIDS stigma is usually manifested in an intersectional manner with other preexisting stigmas, including stigma toward men who have sex with men (MSM). Therefore, our study aimed to examine the behavioral manifestations of HIV/AIDS stigma among physicians in training during simulated clinical interactions with MSM, and explore the interrelation between HIV/AIDS stigma attitudes and behaviors. We implemented an experimental design using Standardized Patient simulations with a sample of 100 physicians in training in Puerto Rico. Results show a significant difference in the two groups’ means (p?<?.001), with a higher number of stigma behaviors in the HIV MSM patient condition (M?=?6.39) than the common cold control condition (M?=?5.20). Results evidence that stigma manifestations toward MSM with HIV may continue to be an obstacle for public health in Puerto Rico, and that medical training to prevent stigma is still needed.     

The Second Closet: A Qualitative Study of HIV Stigma Among Seropositive Gay Men in a Southern U.S. City

ABSTRACT

Objectives: Stigma connected with HIV/AIDS has decreased considerably since the early epidemic yet affects those living with HIV in many ways. Little research, particularly qualitative research, concerning HIV stigma from the perspective of gay men has emerged. The present qualitative study aimed to fill this evidence gap by examining how HIV stigma is perceived and experienced by gay men who have become HIV-infected and how they respond to this stigma. Methods: Thematic analysis of 19 gay men's narratives identified six main themes. Results: Encountering HIV stigmatization was common and was linked to the physical stigmata identifying respondents as HIV-positive. Overwhelmingly, they found stigmatization to be most intensely felt within gay communities. One profound theme was internalized HIV stigma, referring to respondents’ internalized negative feelings about their HIV status. A related theme was the closeted nature of HIV. Lastly, regarding how the men dealt with the HIV diagnosis and experiences of HIV stigma, a theme of adaptation became clear. Conclusions: Although exploratory, the results can serve as a beginning framework for understanding and assisting seropositive gay men who experience HIV stigma. The findings are important because it is realistic to expect that in a climate in which HIV has become increasingly invisible and closeted and in which infections are on the rise, gay and bisexual men will be increasingly affected and infected by HIV.     

Gay Men's Perspectives on HIV Prevention and Treatment in Berlin,Germany: Lessons for Policy and Prevention

Qualitative data from interviews with gay men in Berlin, Germany were used to identify challenges facing HIV prevention and treatment as well as opportunities to improve them. In 2015, 20 self-identified gay men in Berlin—who had all received HIV prevention services and/or treatment (broadly defined)—participated in 1-on-1 qualitative interviews (30–75 min long). Ages ranged from 24 to 54, 35% self-identified as HIV-positive, and the remainder as HIV-negative. With regard to challenges to HIV prevention, participants highlighted (a) an already high HIV burden among gay men in Berlin and thus a need for doing prevention with positives (test-and-treat, and treatment as prevention); (b) the lack of a universal free condom distribution program; and (c) relaxed attitudes around the seriousness of HIV as a result of HIV treatment optimism. Participants highlighted that although condoms are an effective HIV prevention strategy (and thus certainly an area for focus), HIV prevention campaigns would benefit from updates with regard to embracing a diverse range of biological and behavioral prevention strategies, as well as expanded methods for making access to postexposure prophylaxis and free rapid HIV-antibody testing. This study informs HIV prevention approaches in Berlin, Germany as well as other urban centers where MSM are disproportionally affected by the HIV epidemic.     

State-Level HIV Criminalization Laws: Social Construction of Target Populations?

Applying Schneider and Ingram’s social constructionist framework that places people living with HIV (PLWH) in the intersection of both minimal power and negative social construction, this study investigates whether HIV criminalization laws are more likely to be present in states that have a relatively larger percentage of socially marginalized populations. A database was assembled of state-level variables related to HIV criminalization laws and indicators of social marginalization. Analyses show that states with HIV criminalization laws have relatively larger African American populations. Future research is needed to further clarify the racial component of HIV criminalization.     

HIV-Negative Seroconcordant Gay Male Couples' Attitudes,Intentions, and Perceived Behavioral Control for Planned Condom Use Within and Outside of Their Relationships

ABSTRACT

Despite high HIV rates among gay male couples, limited research exists about their attitudes, intentions, social norms, and perceived behavioral control for planned condom use within and outside of their relationships. Our cross-sectional study used multilevel modeling with dyadic data from 142 HIV-negative gay male couples to examine and identify which factors were statistically associated with planned condom use within and outside the relationship. Several differences for planned condom use were also noted based on the sample's prior history of unprotected anal intercourse and relationship type. Findings suggest additional prevention tools are needed for some HIV-negative gay male couples who are at risk for HIV.     

HIV knowledge mediates the relationship between HIV testing history and stigma in college students

ABSTRACT

Objective: HIV-related stigma is one of the strongest barriers to prevention and treatment. HIV prevalence in U.S. college students is estimated around 0.02%, but is thought to be drastically underreported. We examined the influence of HIV knowledge on the relationship between HIV testing history and stigma in college students. Participants: A random sample of 2343 students, over the age of 18, attending a large university in the southeastern United States completed the survey in January 2016. Methods: A mediation model was constructed in regression framework to explore the relationship between HIV testing history, knowledge, and stigma. Results: HIV testing history was associated with higher knowledge scores (a path: B = 4.08, p < .001) and higher knowledge scores were associated with lower stigma (b path: B = .01, p < .001). These results suggest that HIV knowledge partially mediates the relation between HIV testing history and stigma in college students. Conclusions: HIV testing history may decrease stigma by increasing knowledge. Results can be used to inform college health promotion practice on developing programs and services.     

Masturbation and Sexual Health

Abstract

In this study we applied research examining the hypothesized benefits of masturbation in dealing with sexual problems to the urgent health crisis posed by the HIV/AIDS pandemic. This is the first study to test the hypothesized relationship between masturbation and HIV risk as predicted by the Sexual Health Model, a sex-positive approach to sexual health developed in response to the need for a more explicit focus on sexuality and relationships in HIV prevention. This is also the first study to examine the relationship between several masturbation variables (i.e., masturbation guilt, lifetime masturbation, and current masturbation) and HIV-related sexual behaviors and attitudes in a sample of African American women (N =239). Data was collected using face-to-face structured interviews as part of the Women's Initiative for Sexual Health (WISH), a randomized, controlled trial of an HIV prevention intervention based on the Sexual Health Model, targeting low income, adult African American women. Contrary to expectations, results showed that participants who reported masturbating were more likely to report having multiple partners, being in a nonmonogamous relationship and engaging in high-risk sexual behaviors. There was no significant relationship between level of masturbation guilt and HIV risk nor between masturbation and consistent condom use or attitudes toward condoms. This study adds to the growing empirical support for associations between sexual health variables and safer sex and argues for a more explicit focus on sexuality in HIV prevention.     

East African Mothers with HIV: Testing,Talking, and Transmission to Children

ABSTRACT

Experiences of African mothers with HIV can inform the development of services to prevent HIV transmission to children. A small qualitative study was conducted in Tanzania with six openly HIV-positive women. They suggest that counseling and HIV testing additionally benefit the mother beyond reducing HIV transmission to her child. They recommend that testing of couples would allow them to make plans and informed choices together concerning sexual behavior, childbearing, and prevention of HIV transmission to children.