HIV-Related Intersectional Stigma and Discrimination Measurement: State of the Science

A persona-based exploration of rabies post-exposure prophylaxis seeking behavior and its implication for communication strategic planning: Evidence from Thailand

Rabies is a lethal zoonotic illness that claims over 59,000 lives annually. However, this fatality can be avoided by postexposure prophylaxis (PEP). This study aimed to identify and characterize different personas of individuals regarding their PEP-seeking behavior and develop tailored communication strategies to encourage PEP adoption among these distinct groups effectively. We categorized our subjects, residing in two districts of Chonburi province, Thailand, into three groups: (i) individuals with a history of dog bites who underwent PEP; (ii) individuals bitten by dogs who did not receive PEP; and (iii) individuals who had never been bitten. Subsequently, we employed an empathy map, a visual method, and a customer journey map to better understand the participants' experiences and perceptions. A total of 38 individuals were interviewed. We categorized the participants into three distinct personas: positive, neutral, and negative trends. Individuals classified within the positive trend strongly advocate for seeking rabies vaccines in the event of a dog bite. Meanwhile, individuals who have a neutral inclination are more likely to contemplate getting vaccinated following a dog bite, particularly if the injury is substantial. Those with a negative trend demonstrate a notable lack of attention or concern toward preventing rabies. A lack of attention to the potential severity of the issue characterizes their attitude. Notably, nearly half (44.74 %; 17/38) of the individuals involved in the study indicated utilizing interpersonal communication, followed by digital platforms (42.11 %; 16/38) and traditional communication channels (10.52 %; 5/38). Tailoring communication modalities to suit each specific group is crucial for effective outreach.

Knowledge about biomedical HIV prevention among healthcare workers: A cross-sectional study in Europe and Central Asia

BACKGROUND

Knowledge of HIV prevention among healthcare workers, such as undetectable equals untransmittable (U=U), post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP) can hold implications for patient care and the HIV epidemic. Understanding the level of knowledge about HIV prevention among healthcare workers can provide information to enhance the effectiveness and equity of HIV prevention, treatment and care.

METHODS

An online survey was conducted to collect data on HIV knowledge among clinical and non-clinical healthcare workers in 54 countries in Europe and Central Asia between September and December of 2023. Knowledge was measured using questions asking respondents to agree or disagree with correct statements about HIV transmission and prevention. Four main outcome variables assessed knowledge among healthcare workers about U=U, PrEP, PEP and a combined outcome measuring overall knowledge level. Fixed-effects logistic and Poisson regression models assessed whether sociodemographic factors, professional characteristics and experiences with people living with HIV were associated with knowledge about these topics. Additionally, we assessed the impact of having ever received training on infection control and training on HIV stigma and discrimination on healthcare workers' knowledge of U=U, PEP and PrEP.

RESULTS

Among 18 348 healthcare workers, correct knowledge of U=U was reported by 61.25%, PEP by 55.70% and PrEP by 40.74%. A composite of correct knowledge across all topics was achieved by 31.29% of participants. Key sociodemographic and professional determinants influencing increased knowledge included being a man, of younger age and a medical doctor. Increased knowledge was also associated with having more experience caring for people with HIV, including working in an HIV care or infectious diseases department, and having cared for a higher number of people living with HIV in the past year. Having ever received training on infection control that included PEP and training on HIV stigma and discrimination was associated with increased knowledge in all areas. Across all determinants, respondents living in Western Europe reported higher knowledge about biomedical HIV prevention.

INTERPRETATION

Substantial knowledge gaps in HIV prevention were found among healthcare workers in Europe and Central Asia. Suboptimal knowledge and sociodemographic and professional differences warrant targeted training initiatives and interventions for improving healthcare workers' knowledge of HIV. The non-representative nature of the sample limits the generalizability of the findings.

Population-Level Trends and Determinants of HIV Testing Among U.S. Women Reporting HIV Risk Behavior From 2016 to 2020: A Repeated Cross-sectional Study

ABSTRACT

Racial and ethnic disparities in HIV among women in the United States persist. Testing is a key component of HIV prevention and treatment, yet national testing rates and demographic differences among women with increased vulnerability are unclear. A secondary repeated cross-sectional analysis of Behavioral Risk Factor Surveillance System data from female respondents spanning years 2016-2020 was performed to assess HIV testing among those reporting behaviors that increase the potential for acquiring HIV. Survey weighted logistic regression was used to model the predicted probability of an HIV test in the past 12 months. Among the weighted sample (N = 20,336), there was a 37.1% probability of an HIV test in the past 12 months. Non-Hispanic Black women had the highest probability (56.2%), and testing in the 25-34 and 35-44 years age groups was consistently below 50% in each year of the analysis. Overall, women with health care coverage (vs. without coverage) were more likely to be tested for HIV; however, no significant difference in testing by insurance status was observed for Non-Hispanic women of color in supplemental analysis. Our study underscores HIV testing gaps among U.S. women with increased HIV vulnerability, across all demographics, indicating missed opportunities and emphasizing the need for targeted, accessible, and engaging HIV prevention methods.

What Has Been Studied About Attitudes and Social Stigma Towards HIV/AIDS? A Global Bibliometric Study with Correlations on Global Health HIV-Related Indicators

Introduction: This study aimed to assess, through health metrics and bibliometric analysis, the global research on attitudes and social stigma of people living with HIV/AIDS and to identify research findings, gaps, and future directions. Methods: A cross-sectional bibliometric study was conducted through a structured search in different databases. Fifteen thousand four hundred and ninety-six documents were found between 1981 and 2024. Results: 83.5% were original articles, and international co-authorship was 30.66%. Since 2000, there has been an increase in research on HIV/AIDS attitudes and social stigma. The United States is the most prolific country worldwide (n = 7837 publications; 50.5%), with the highest number of prolific institutions (n = 4/5), as well as the greatest influence and relevance in research (h-index 170). The most studied topics worldwide are social support and social psychology concerning homosexuality, middle age, and youth in people living with HIV/AIDS. There was no significant correlation between the volume of publications, countries' income levels, and the most prolific geographic regions with adult HIV prevalence, overall HIV incidence and prevalence, or antiretroviral therapy coverage in people living with HIV (p > 0.05 for all cases). Conclusions: Over the past two decades, research has shifted from human rights, legal rights, and ethics to attitudes toward healthcare, with the recent interest in pre-exposure prophylaxis, gender minorities, and intersectional stigma. The absence of strong correlations between publications volume and global health HIV-related indicators underscores the necessity of translating evidence into actionable strategies to reduce stigma and improve health outcomes.

Intersectional forces of urban inequality and the global HIV pandemic: a retrospective analysis

To determine how the intersection of increased urban growth and poverty has impacted HIV incidence and prevalence, given growing HIV inequalities globally. Retrospective analysis using combined data from five publicly available, population-level datasets to determine city- and within-urban countrywide estimates of 95-95-95 treatment targets, prevalence and incidence rates from 2015 to 2019. For city-level estimates, we analysed combined data from: Fast-Track City (FTC), SINAN from Brazil and UNAIDS Naomi-Spectrum. Countrywide estimates of HIV prevalence in the urban slum versus non-slum since 2012 were compiled from Population-Based HIV Impact Assessment (PHIA) surveys in 12 countries and Demographic Health Surveys (DHS) in 28 countries. HIV prevalence is generally higher among the urban slum, compared to their non-slum counterparts, thus resulting in national HIV estimates masking nuances in HIV inequalities between the urban slum and non-slum. Specifically, national and city-level HIV estimates mask inequalities within and between cities, with secondary cities often having higher HIV prevalence and incidence rates than capital cities and large urban areas. The urban divide between slum and non-slum populations is a contributor to HIV inequality, often with poorer outcomes in smaller cities than their larger counterparts. Interventions tailored to cities, and particularly those considering local nuances in subpopulations (eg, different genders, ages, roles), are necessary to reduce HIV inequality. Focused HIV programming accounting for structural drivers of inequalities between urban slum and non-slum populations such as inequalities in wealth, education, employment and housing are crucial to closing gaps driving HIV inequalities globally.

Leveraging Bundled Interventions to Address Intersectional Barriers to Care for Black Women With HIV, the Black Women First Initiative, 2020

The 2020 initiative Improving Care and Treatment Coordination: Focusing on Black Women With HIV funded by the US Department of Health and Human Services Office of the Assistant Secretary for Health's Minority HIV/AIDS Fund and Health Resources and Services Administration's HIV/AIDS Bureau Ryan White HIV/AIDS Program aimed to enhance health and well-being for cisgender and transgender Black women with HIV through bundled interventions at 12 US sites. The initiative's intersectional approach involved Black women with HIV in program development and implementation. Quantitative data from 743 participants highlighted disparities in employment and housing, emphasizing the need for holistic, culturally sensitive care. In quantitative responses, participants, regardless of gender identity, reported HIV-related stigma and racial discrimination, with transgender women qualitatively reporting additional gender-based inequities that affect their HIV health outcomes and quality of life. We summarize findings from the initiative and provide recommendations to address intersectional barriers to care to improve health and well-being among Black women with HIV. Results of this initiative suggest that a flexible, responsive health care system that emphasizes a broad service delivery model reflecting the participants' diverse identities can improve health outcomes. (Am J Public Health. 2025;115(S1):S68-S74. https://doi.org/10.2105/AJPH.2025.308022).

HIV and hospitals between knowledge and stigma

The advent of effective antiretroviral treatments has led to the reclassification of HIV as a chronic disease for those on an effective treatment plan. However, the well-being of individuals with HIV is adversely affected by a number of factors, including stigma and discrimination, which hinder access to healthcare. To address this issue, it is first necessary to understand the current levels of knowledge and stigma surrounding HIV, and consequently, HIV Outcomes Italy has created a survey with the aim of assessing these levels.A total of 914 healthcare professionals, comprising clinicians, obstetricians, nurses and LPNs (licensed practical nurses) participated in an anonymous online survey with questions pertaining to knowledge on HIV, stigma, and training on STIs (sexually transmitted infections). The survey was conducted in Italy between August 2022 and February 2023.The results show a reasonable level of knowledge regarding HIV-related topics among healthcare workers. However, a notable minority exhibited deficiencies. The findings indicate the presence of stigma, both in the form of observed discriminatory practices and in the form of personal enactment of discriminatory behaviour.The results of the survey indicate an inverse relationship between knowledge and stigma, emphasising the need for ongoing and specific education on HIV.

Identifying Subgroups of Intersectional Stigma, Discrimination, and the Association with Mental Health Outcomes Among HIV-Positive Men Who Have Sex with Men: A Latent Class Analysis

This study aimed to (1) identify latent classes of stigma and discrimination experiences among men who have sex with men (MSM) living with HIV; (2) examine the associations between class membership and mental health outcomes, and (3) investigate the moderating effects of social support and resilience. The study used the baseline (N = 224) and six-month follow-up data (N = 118) from a longitudinal cohort study on HIV and hypertension among African American and Asian Pacific American MSM in Hawai'i and Philadelphia from 2019 to 2023. Latent class analysis was conducted to characterize the patterns of stigma and discrimination experience. Multivariable regression was conducted to examine the association between class membership and mental health outcomes. Interaction terms were added to examine the moderation effects of social support and resilience on the association between class memberships and mental health outcomes. A five-class model was identified: Class (1) high on internalized homophobia and low on all discrimination experiences; Class (2) high on racial discrimination; Class (3) high on sexual identity discrimination; Class (4) low on internalized homophobia and all discrimination experiences; Class (5) high on physical disability discrimination and internalized homophobia. Class 5 consistently predicted worse mental health outcomes, compared to Class 4. The association between Class 2 (high racial discrimination) and depression was moderated by perceived social support. The study reveals complex experiences of intersectional stigma and discrimination among MSM living with HIV, highlighting the need for further research on the intersecting effects of multiple disadvantages among aging sexual minorities.

An Incognito Standardized Patient Approach for Measuring and Reducing Intersectional Healthcare Stigma: A Pilot Cluster Randomized Control Trial

BACKGROUND

Consistent evidence shows stigma impedes healthcare access in people living with HIV (PLWH) and men who have sex with men (MSM). We evaluated the impact of stigma reduction training for providers whose design was informed by direct observation of their clinical behaviors obtained through visits by incognito standardized patients (SPs).

SETTING

We conducted this study in sexually transmitted disease clinics in Guangzhou, China.

METHODS

This pilot cluster randomized control trial assessed the feasibility, acceptability, and preliminary efficacy of an intervention whose design was informed by a baseline round of incognito visits in which SPs presented standardized cases to consenting doctors. By randomly varying the HIV status and sexual orientation of each case, we could quantify stigma as differences in care quality across scenarios. We then conducted a follow-up round of SP visits and assessed the impact using linear fixed effects regression.

RESULTS

Feasibility and acceptability among the 55 provider participants were high, with no adverse visit events. The provider training improved the offering of testing to HIV-negative MSM (0.05 percentage points, 95% confidence interval, -0.24 to 0.33) and diagnostic effort for HIV-positive MSM (0.23 SD improvement, 95% CI: -0.92 to 1.37). Patient-centered care only improved for HIV-positive straight cases (SD, 0.57; 95% CI: -0.39 to 1.53). All estimates lacked statistical precision, an expected outcome of a pilot randomized control trial.

CONCLUSIONS

Our training reduced stigma in several domains of care, but least of all for PLWH, suggesting that future trainings should include more clinical content to strengthen clinical skills in PLWH management.

Intersectional HIV stigma in Sub-Saharan Africa, Latin America and the Caribbean: Insights and pathways forward - A scoping review

Research has recently surged on intersectional HIV stigma, including how intersecting stigmatized identities and socio-structural conditions influence HIV prevention and treatment outcomes. However, most of this work has been concentrated in high-income settings. This scoping review aimed to provide an overview of research on intersectional HIV stigma in Sub-Saharan Africa, Latin America and the Caribbean. A search was conducted using five databases for articles published between January 2008 and April 2023. Two reviewers independently screened all identified studies, sorted the included studies, and conducted descriptive analyses. Of 1907 retrieved studies, 73 met inclusion criteria, of which 16% were intervention studies and 84% were non-intervention studies. Stigma was propagated through structural factors (e.g., anti-sexual and gender minority laws), institutional factors, and socio-demographic factors. Moreover, place-based differences emerged. Findings of the scoping review were discussed and interpreted by a community advisory board composed of activists and researchers from Sub-Saharan Africa, Latin America, and the Caribbean, which provided recommendations on the pathways forward in research for intersectional HIV stigma. Future research on intersectional stigma should encompass social marketing studies for promoting inclusive HIV services, strategies to transform the narrative in media, and investigations into the impact of laws against sexual and gender minority (SGM) individuals on HIV service participation, all approached from the perspective of those affected by the intersectional stigma.

Food insecurity and pediatric HIV: patient perspectives on clinical solutions

Food insecurity is a prevalent social determinant of health for people living with HIV and is associated with suboptimal treatment outcomes. While clinic-based efforts to address food insecurity have increased over the past decade, few studies have explored the perspectives of paitents and caregivers managing chronic illnesses such as HIV. Caregiver insights are particularly critical in pediatric HIV care, where caregivers often play a central role in screening and referral processes. This study examined the experiences of adolescents and young adults living with HIV and caregivers of children with HIV, to inform screening and referral practices within a pediatric palliative care clinic in Atlanta, GA. We conducted audio-recorded, in-depth interviews (n = 14) and focus groupswith 10 patients and caregivers living with food insecurity. Thematic analysis, guided by our interview topics, revealed five key themes: (1) trust in providers, (2) coping by "making it work", (3) barriers to healthy eating, (4) challenges to medication adherence, and (5) recommendations for cross-sector resource connection. Our findings underscore the need for partnerships between clinics and community-based organizations, bolstered by structural and systems-level interventions and policies, to promote food security and well-being for pediatric patients in complex care settings.

'Surviving and thriving': intersectional stigma and resilience of dual minority identities among Chinese gay and bisexual men living with HIV

Intersectionality has facilitated an understanding of the complexities of the adversities and challenges faced by individuals with multiple disadvantaged identities, including gay and bisexual men living with HIV. This study used deficiency- and empowerment-based perspectives together with an intersectionality lens to examine the intersections between sexuality minority and HIV-related stigma and resilience, as well as their compound effects on Chinese gay and bisexual men living with HIV. We conducted in-depth interviews with 21 gay and bisexual men living with HIV in Shenzhen, identifying two overarching themes and six subthemes in the provided accounts via thematic analysis. The theme of 'Interplay between Minority Identities' comprised aggravating effects and alleviating effects at the intrapersonal, interpersonal, community and structural levels. The theme of 'Compound Impact of Intersecting Identities' was contributed to by the subthemes 'the pressure to continue family lineage', 'persistent health concerns', 'financial concerns', and 'heightened psychological distress and resilience'. Integrating deficiency and empowerment perspectives, our findings highlight the importance of addressing intersectional stigma and identifying resilience resources to empower Chinese gay and bisexual men living with HIV to thrive amidst compounded adversities. Findings have implications for future intersectional research and intervention practice, especially in fostering resilience within the context of intersectional stigma.

Association of Intersectional Anticipated Discrimination with Mental Health Among Immigrant Latinos

Introduction

Anticipating discrimination can lead to increased vigilance, which acts as a potential stressor similar to actual discrimination experiences. However, there is limited understanding of how discrimination and anticipated discrimination affect Latinos with intersecting identities, particularly those who are immigrants. Using a cross-sectional survey, we examine the association between intersectional anticipated discrimination and mental health among immigrant Latinos.

Methods

We conducted a cross-sectional survey through the Rapid Acceleration of Diagnostics-Underserved Populations initiative (March 2022-May 2023). Participants were foreign-born adults who self-identified as Latino or Hispanic. The exposure measure used the Intersectional Anticipated Discrimination Scale, and outcomes measures included 2-item screens for anxiety (Generalized Anxiety Disorder screener [GAD-2]) and depression (Patient Health Questionnaire [PHQ-2]) and a 3-item screen for hazardous alcohol consumption (Alcohol Use Disorders Identification Test).

Results

A total of 810 participants completed the survey, of whom 66.7% were uninsured. Among them, 25.2% screened positive for anxiety, 18.1% for depression, and 20.2% for hazardous alcohol consumption. Positive screening for anxiety and depression was associated with higher levels of anticipated discrimination (GAD-2 adjusted odds ratio [AOR] = 1.05, 95% confidence interval [CI]: 1.03, 1.07; PHQ-2 AOR = 1.05, 95% CI: 1.03, 1.07). A dose-response relationship was observed with higher levels of anticipated discrimination and higher PHQ-2 and GAD-2 scores.

Conclusions

Anticipated intersectional discrimination was associated with symptoms of anxiety and depression in immigrant Latinos. Prioritizing culturally competent care that recognizes the heterogeneity of the Latino population, enhancing community support, and implementing targeted policy interventions are imperative steps toward promoting mental health equity among this population.

A Moderated Mediation Analysis of HIV and Intersectional Stigmas and Antiretroviral Adherence in People Living with HIV in the Dominican Republic

Experiencing HIV and intersectional stigmas in healthcare settings may affect antiretroviral treatment (ART) adherence among people with HIV (PWH), given their need for frequent interactions with clinical settings and healthcare providers. Considering the importance of reducing stigmas to promote well-being and the need to elucidate how stigma influences health across various settings, we examined how experienced HIV stigma in Dominican Republic healthcare settings impacts ART adherence through internalized HIV stigma and whether race or sexual orientation stigma moderates this relationship. Participants were 471 PWH (aged 17-71) who were recruited from two HIV clinics in the Dominican Republic in 2021-2022. Results revealed a significant mediation effect (B=-0.10, SE = 0.05, CI [-0.234, - 0.014]) after adjusting for effect of age and time since HIV diagnosis, suggesting that experienced HIV stigma in healthcare settings was associated with more internalized HIV stigma (B = 0.39, SE = 0.11, p = .001), subsequently linked to lower ART adherence (B=-0.26, SE = 0.11, p = .016). The indirect effect was significant at low levels of race stigma (B=-0.16, SE = 0.09, CI [-0.369, - 0.001]) but not at high levels of race stigma (B=-0.06, SE = 0.05, CI [-0.175, 0.038]). This indirect effect was also significant at low levels of sexual orientation stigma (B=-0.19, SE = 0.10, CI [-0.401, - 0.023]) but not at high levels of sexual orientation stigma (B=-0.04, SE = 0.06, CI [-0.160, 0.074]). These findings suggest that addressing experienced HIV stigma in Dominican Republic healthcare settings, along with various dimensions of HIV-related stigma (e.g., internalized stigma) and intersecting stigmas (e.g., race, sexual orientation), is vital for improving health outcomes, such as optimal ART adherence.

Associations between perceived discrimination experiences, treatment adherence self-efficacy, and depressive symptoms among people living with HIV in the Southern United States

This study examined associations between perceived discrimination, treatment adherence self-efficacy, and depressive symptoms among people living with HIV (PLHIV) in the Southern United States. Cross-sectional survey data were collected from 402 PLHIV who self-reported on interpersonal discrimination experiences based on HIV status, sexuality, gender, income, and living condition. Participants also reported on adherence self-efficacy and depressive symptoms. We employed K-means clustering to identify groups based on discrimination experiences, and logistic regressions to examine group differences on adherence self-efficacy and depressive symptoms. Results suggested three groups: a cluster with high perceived discrimination across all identities/conditions (n = 41; 11%; Cluster 1); a cluster with high perceived discrimination based on HIV status, income, and living condition (n = 49; 13%; Cluster 2); and a cluster with low perceived discrimination across all identities/conditions (n = 288; 76%; Cluster 3). Compared to Cluster 3, Cluster 1 and 2 had 2.22 times (p = .037) and 3.98 times (p<.001) greater odds of reporting depressive symptoms. Compared to Cluster 3, Cluster 2 had 3.40 times (p = .003) greater odds of reporting lower adherence self-efficacy. Findings demonstrate the need for individual-level support for PLHIV with discrimination histories, and broader efforts to end the stigma, discrimination, and marginalization of PLHIV based on HIV status and other characteristics.

Differences in internalized HIV stigma across subpopulations of people with HIV in care across the United States

BACKGROUND

Few studies have examined which subgroups of people with HIV (PWH) carry the greatest burden of internalized HIV stigma (IHS), which may be important to care provision and interventions.

METHODS

PWH in the CFAR Network of Integrated Clinical Systems (CNICS) longitudinal, US-based, multisite, clinical care cohort completed tablet-based assessments during clinic visits including a four-item, Likert scale (low 1-5 high), IHS instrument. Associations between sociodemographic characteristics and IHS scores were assessed in adjusted linear regression models.

RESULTS

Twelve thousand six hundred and fifty-six PWH completed the IHS assessment at least once from February 2016 to November 2022, providing 28 559 IHS assessments. At baseline IHS assessment, the mean age was 49 years, 41% reported White, 38% Black/African American, and 16% Latine race/ethnicity, and 80% were cisgender men. The mean IHS score was 2.04, with all subgroups represented among those endorsing IHS. In regression analyses, younger PWH and those in care fewer years had higher IHS scores. In addition, cisgender women vs. cisgender men, PWH residing in the West vs. the Southeast, and those with sexual identities other than gay/lesbian had higher IHS scores. Compared with White-identifying PWH, those who identified with Black/African American or Latine race/ethnicity had lower IHS scores. Age stratification revealed patterns related to age category, including specific age-related differences by gender, geographic region and race/ethnicity.

DISCUSSION

IHS is prevalent among PWH, with differential burden by subgroups of PWH. These findings highlight the benefits of routine screening for IHS and suggest the need for targeting/tailoring interventions to reduce IHS among PWH.

Stigma and fear of getting sick in the care of people living with HIV: an exploratory systematic review

The aim of the present study was to explore the stigma and fear of getting sick in health professionals who treat people living with HIV. An exploratory systematic review was conducted. The search was limited to the presence of stigma and fear of getting sick on the part of healthcare workers who treat people living with HIV, documented by the health workers or patients themselves. No language restriction was made and systematic reviews, comments or communications were excluded. The sources of information were Scopus, PubMed/MEDLINE, Science Direct, and the CENTRAL Registry, from the last 5 years. The quality of the evidence was assessed with an adapted tool and the synthesis of the results was carried out using a narrative synthesis approach. Twenty-three articles were included, which related structural stigma, stigma by health professionals and fear of getting sick. Among the findings, data stood out such as that more than 50% of patients reported having experienced discrimination due to HIV and even accumulated stigma for other additional causes. Stigma enacted in healthcare settings was related to suboptimal adherence to treatment (OR 1.38; 95% CI: 1.03-1.84; p=0.028). Stigma is a structural barrier in the care of people living with HIV and generates a psychological, physical, and social health impact for these people. Some limitations of the present study are that, despite searching the major databases, important manuscripts may have been left out. Additionally, there are regions that are not represented in this review because no manuscripts from those areas were found.

Measuring intersectional HIV, sexual diversity, and gender non-conformity stigma among healthcare workers in Ghana: scale validation and correlates of stigma

BACKGROUND

Men who have sex with men (MSM) are at heightened risk for HIV acquisition, yet they may delay or avoid HIV testing due to intersectional stigma experienced at the healthcare facility (HCF). Few validated scales exist to measure intersectional stigma, particularly amongst HCF staff. We developed the Healthcare Facility Staff Intersectional Stigma Scale (HCF-ISS) and assessed factors associated with stigma in Ghana.

METHODS

We analyzed baseline data from HCF staff involved in a study testing a multi-level intervention to reduce intersectional stigma experienced by MSM. Data are from eight HCFs in Ghana (HCF Staff n = 200). The HCF-ISS assesses attitudes and beliefs towards same-sex relationships, people living with HIV (PLWH) and gender non-conformity. Exploratory factor analysis assessed HCF-ISS construct validity and Cronbach's alphas assessed the reliability of the scale. Multivariable regression analyses assessed factors associated with intersectional stigma.

RESULTS

Factor analysis suggested an 18-item 3-factor scale including: Comfort with Intersectional Identities in the Workplace (6 items, Cronbach's alpha = 0.71); Beliefs about Gender and Sexuality Norms (7 items, Cronbach's alpha = 0.72); and Beliefs about PLWH (5 items, Cronbach's alpha = 0.68). Having recent clients who engage in same-gender sex was associated with greater comfort with intersectional identities but more stigmatizing beliefs about PLWH. Greater religiosity was associated with stigmatizing beliefs. Infection control training was associated with less stigma towards PLWH and greater comfort with intersectional identities.

CONCLUSIONS

Achieving the goal of ending AIDS by 2030 requires eliminating barriers that undermine access to HIV prevention and treatment for MSM, including HCF intersectional stigma. The HCF-ISS provides a measurement tool to support intersectional stigma-reduction interventions.

Prevalence of HIV-related stigma manifestations and their contributing factors among people living with HIV in Sweden - a nationwide study

BACKGROUND

With access to  antiretroviral therapy (ART) HIV infection is a chronic manageable condition and non-sexually transmissible. Yet, many people living with HIV still testify about experiencing HIV-related stigma and discrimination. It is well-documented that HIV-related stigma and discrimination continue to be critical barriers to prevention, treatment, care and quality of life. From an individual stigma-reduction intervention perspective, it is essential to identify individual and interpersonal factors associated with HIV-related stigma manifestations. To address this issue and to expand the literature, the aim of this study was to assess the prevalence of HIV-related stigma manifestations and their associated factors among a diverse sample of people living with HIV in Sweden.

METHOD

Data from 1 096 participants were derived from a nationally representative, anonymous cross-sectional survey "Living with HIV in Sweden". HIV-related stigma manifestations were assessed using the validated Swedish 12-item HIV Stigma Scale encompassing four HIV-related stigma manifestations: personalised stigma, concerns with public attitudes towards people living with HIV, concerns with sharing HIV status, and internalized stigma. Variables potentially associated with the HIV-related stigma manifestations were divided into four categories: demographic characteristics, clinical HIV factors, distress and ART adherence, and available emotional HIV-related support. Four multivariable hierarchical linear regression analyses were employed to explore the associations between multiple contributors and HIV-related stigma manifestations.

RESULTS

The most dominating stigma feature was anticipation of HIV-related stigma. It was manifested in high scores on concerns with sharing HIV status reported by 78% of the participants and high scores on concerns about public attitudes towards people living with HIV reported by 54% of the participants. High scores on personalised stigma and internalized stigma were reported by around one third of the participants respectively. Between 23 and 31% of the variance of the four reported HIV-related stigma manifestations were explained mainly by the same pattern of associated factors including female gender, shorter time since HIV diagnosis, feelings of hopelessness, non-sharing HIV status, and lack of available emotional HIV-related support.

CONCLUSION

The most dominating stigma feature was anticipation of stigma. Female gender, shorter time since HIV diagnosis, feelings of hopelessness, non-sharing HIV status, and lack of available emotional HIV-related support constituted potential vulnerability factors of the four HIV-related stigma manifestations. Our findings highlight the vital necessity to support people living with HIV to increase their resilience to stigma in its different forms. Exploring associated factors of HIV-related stigma manifestations may give an indication of what circumstances may increase the risk of stigma burden and factors amenable to targeted interventions. As individual stigma-reductions interventions cannot be performed isolated from HIV-related stigma and discrimination in society, a key challenge is to intensify anti-stigma interventions also on the societal level.

Association Between Clinical Encounter Frequency and HIV-Related Stigma Among Newly-Diagnosed People Living with HIV in Rwanda

HIV-related stigma in healthcare settings remains a key barrier to engaging people living with HIV (PLHIV) in care. This study investigated the association between clinical encounter frequency and HIV-related anticipated, enacted, and internalized stigma among newly-diagnosed PLHIV in Rwanda. From October 2020 to May 2022, we collected data from adult PLHIV on antiretroviral therapy (ART) in Kigali, Rwanda who were participating in a randomized, controlled trial testing early entry into differentiated care at 6 months after ART initiation. We measured anticipated HIV stigma with five-point Likert HIV Stigma Framework measures, enacted stigma with the four-point Likert HIV/AIDS Stigma Instrument, and internalized stigma with the four-point Likert HIV/AIDS Stigma Instrument. We used multivariable linear regression to test the associations between clinical encounter frequency (average inter-visit interval ≥ 50 days vs. < 50 days) and change in mean anticipated, enacted and internalized HIV stigma over the first 12 months in care. Among 93 individuals enrolled, 76 had complete data on encounter frequency and stigma measurements and were included in the present analysis. Mean internalized stigma scores of all participants decreased over the first 12 months in care. Anticipated and enacted stigma scores were low and did not change significantly over time. There was no association between encounter frequency and change in internalized stigma. In this pilot study of newly-diagnosed Rwandan PLHIV with relatively low levels of HIV-related stigma, clinical encounter frequency was not associated with change in stigma. Additional research in diverse settings and with larger samples is necessary to further explore this relationship.

Tackling late HIV diagnosis: Lessons from the UK in the COVID-19 era

INTRODUCTION

Late diagnosis of HIV is associated with increased morbidity and mortality, and an increased risk of non-infectious comorbidities. On a societal level, late diagnosis leads to higher treatment and healthcare costs and is a major driver of HIV transmission. Despite improvements in other areas of the HIV care pathway, late diagnosis remains an individual and public health concern globally.

OBJECTIVE

To examine the barriers to HIV testing and highlight successful strategies to improve prompt diagnosis. This review describes the prevalence of late diagnosis in the UK and discusses key factors that contribute to late diagnosis, including the effect of the COVID-19 pandemic. Late HIV diagnosis is lower in the UK than in most other European countries. In this review, pilot projects and ongoing initiatives that have reduced late diagnosis in the UK are highlighted; moreover, further strategies for improving prompt diagnosis are suggested.

CONCLUSIONS

Insufficient testing is the fundamental reason for late HIV diagnosis, with societal, systemic, and individual factors all contributing to inadequate testing. Improving access to testing, removing barriers to health-seeking behaviour, and ensuring all people with HIV indicator conditions are promptly tested are key to reducing the rates of late diagnosis globally.

Scoping review of HIV-related intersectional stigma among sexual and gender minorities in sub-Saharan Africa

OBJECTIVES

Sexual and gender minority (SGM) populations in sub-Saharan Africa (SSA) are disproportionately impacted by HIV and often face multiple HIV-related stigmas. Addressing these stigmas could reduce SGM HIV vulnerability but little is known about how the stigmas operate and intersect. Intersectional stigma offers a lens for understanding the experiences of stigmatised populations and refers to the synergistic negative health effects of various systems of oppression on individuals with multiple stigmatised identities, behaviours or conditions. This review aims to (1) assess how often and in what ways an intersectional lens is applied in HIV-related stigma research on SGM populations in SSA and (2) understand how intersectional stigma impacts HIV risk in these populations.

DESIGN

Scoping review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews.

DATA SOURCES

Public health and regional databases were searched in 2020 and 2022.

ELIGIBILITY CRITERIA

Articles in French and English on HIV-related stigma and HIV outcomes among men who have sex with men, women who have sex with women and/or transgender individuals in SSA.

DATA EXTRACTION AND SYNTHESIS

Articles were screened and extracted twice and categorised by use of an intersectional approach. Study designs and stigma types were described quantitatively and findings on intersectional stigma were thematically analysed.

RESULTS

Of 173 articles on HIV-related stigma among SGM in SSA included in this review, 21 articles (12%) applied an intersectional lens. The most common intersectional stigmas investigated were HIV and same-sex attraction/behaviour stigma and HIV, same-sex attraction/behaviour and gender non-conformity stigma. Intersectional stigma drivers, facilitators and manifestations were identified across individual, interpersonal, institutional and societal socioecological levels. Intersectional stigma impacts HIV vulnerability by reducing HIV prevention and treatment service uptake, worsening mental health and increasing exposure to HIV risk factors.

CONCLUSION

Intersectional approaches are gaining traction in stigma research among SGM in SSA. Future research should prioritise quantitative and mixed methods investigations, diverse populations and intervention evaluation.

Culturally Relevant Africultural Coping Moderates the Association Between Discrimination and Antiretroviral Adherence Among Sexual Minority Black Americans Living with HIV

Exposure to discrimination has been linked to lower HIV antiretroviral therapy (ART) adherence and poor HIV care outcomes among Black Americans. Coping has been shown to mitigate the harmful effects of discrimination on health behaviors, but the use of cultural relevant Africultural coping strategies is understudied as a moderator of the association between intersectional discrimination and ART adherence among Black Americans. We used adjusted logistic regression to test whether Africultural coping strategies (cognitive/emotional debriefing; collective; spiritual-centered; ritual-centered) moderated associations between multiple forms of discrimination (HIV, sexual orientation, race) and good ART adherence (minimum of 75% or 85% of prescribed doses taken, as measured by electronic monitoring in separate analyses) among 92 sexual minority Black Americans living with HIV. Mean adherence was 66.5% in month 8 after baseline (36% ≥ 85% adherence; 49% ≥ 75% adherence). Ritual-centered coping moderated the relationship between each of the three types of discrimination at baseline and good ART adherence in month 8 (regardless of the minimum threshold for good adherence); when use of ritual coping was low, the association between discrimination and adherence was statistically significant. The other three coping scales each moderated the association between racial discrimination and good ART adherence (defined by the 75% threshold); cognitive/emotional debriefing was also a moderator for both HIV- and race-related discrimination at the 85% adherence threshold. These findings support the benefits of Africultural coping, particularly ritual-centered coping, to help sexual minority Black Americans manage stressors associated with discrimination and to adhere well to ART.

Individual and Collective Forms of Stigma Resistance: Pathways Between HIV and Sex Work Stigma and Viral Suppression Among Female Sex Workers in the Dominican Republic

Intersecting forms of stigma including both HIV and sex work stigma have been known to impede HIV prevention and optimal treatment outcomes among FSW. Recent research has indicated that intersectional stigma can be resisted at the community and individual level. We assessed pathways between HIV stigma, sex work stigma, social cohesion and viral suppression among a cohort of 210 FSW living with HIV in the Dominican Republic. Through Poisson regression we explored the relationship between HIV outcomes and internalized, anticipated and enacted HIV and sex work stigma, and resisted sex work stigma. We employed structural equation modeling to explore the direct effect of various forms of stigma on HIV outcomes, and the mediating effects of multi-level stigma resistance including social cohesion at the community level and occupational dignity at the individual level. 76.2% of FSW were virally suppressed and 28.1% had stopped ART at least once in the last 6 months. ART interruption had a significant negative direct effect on viral suppression (OR = 0.26, p < 0.001, 95% CI: 0.13-0.51). Social cohesion had a significant positive direct effect on viral suppression (OR = 2.07, p = 0.046, 95% CI: 1.01-4.25). Anticipated HIV stigma had a significant negative effect on viral suppression (OR = 0.34, p = 0.055, 95% CI: 0.11-1.02). This effect was mediated by the interaction between cohesion and dignity which rendered the impact of HIV stigma on viral suppression not significant. Findings demonstrate that while HIV stigma has a negative impact on viral suppression among FSW, it can be resisted through individual and collective means. Results reinforce the importance of community-driven, multi-level interventions.

Looking through the lens of stigma: Understanding and anticipating concerns about the responsible development and use of psychiatric electroceutical interventions (PEIs)

Psychiatric electroceutical interventions (PEIs) show promise for treating depression, but few studies have examined stakeholders' views on them. Using interview data and survey data that analyzed the views of psychiatrists, patients, caregivers, and the general public, a conceptual map was created to represent stakeholders' views on four PEIs: electroconvulsive therapy (ECT), repetitive transcranial magnetic stimulation (TMS), deep brain stimulation (DBS), and adaptive brain implants (ABIs). Stigma emerged as a key theme connecting diverse views, revealing that it is a significant factor in the acceptance and usage of PEIs. Stigma not only discourages seeking mental health services for depression but also inhibits the acceptance of PEIs. Addressing the pervasive and complex effects of stigma highlights the need to change societal attitudes toward mental illnesses and their treatments and to provide support to patients who may benefit from these interventions. The map also demonstrates the value of conceptual mapping for anticipating and mitigating ethical considerations in the development and use of PEIs.

Association Between Age of Anal Sex Debut and Adult Health Behaviors Among Sexual Minoritized Men Living with HIV

Earlier age of anal sex debut (ASD) has been linked with contemporary and long-term health outcomes, including vulnerability to HIV acquisition. The goal of this study was to utilize a life course approach to examine associations between earlier ASD and recent health behaviors among sexual minoritized men (SMM) living with HIV. A total of 1156 U.S. SMM living with HIV recruited from social and sexual networking apps and websites completed online surveys as part of a longitudinal eHealth intervention. Data from baseline surveys were analyzed to determine associations between age of ASD and adult health outcomes, including mental health, HIV viral load, and substance use. The median age of ASD among these participants was 17 years old, consistent with other work. Earlier ASD was significantly associated with a greater likelihood of past 2-week anxiety (AOR = 1.45, 95% CI 1.07-1.97) and past 3-month opioid use (AOR = 1.60, 95% CI 1.13-2.26); no significant associations were found for recent depression, HIV viral load, or stimulant use. Earlier ASD may function as an important proxy measure for deleterious health outcomes in adulthood, particularly recent anxiety and opioid use. Expansion of comprehensive and affirming sexual health education is critical to early engagement of individuals with a higher risk of HIV acquisition, with plausible downstream health benefits lasting into adulthood among SMM living with HIV.

An Incognito Standardized Patient Approach for Measuring and Reducing Intersectional Healthcare Stigma

Background

Consistent evidence highlights the role of stigma in impairing healthcare access in people living with HIV (PLWH), men who have sex with men (MSM), and people with both identities. We developed an incognito standardized patient (SP) approach to obtain observations of providers to inform a tailored, relevant, and culturally appropriate stigma reduction training. Our pilot cluster randomized control trial assessed the feasibility, acceptability, and preliminary effects of an intervention to reduce HIV stigma, anti-gay stigma, and intersectional stigma.

Methods

Design of the intervention was informed by the results of a baseline round of incognito visits in which SPs presented standardized cases to consenting doctors. The HIV status and sexual orientation of each case was randomly varied, and stigma was quantified as differences in care across scenarios. Care quality was measured in terms of diagnostic testing, diagnostic effort, and patient-centered care. Impact of the training, which consisted of didactic, experiential, and discussion-based modules, was assessed by analyzing results of a follow-up round of SP visits using linear fixed effects regression models.

Results

Feasibility and acceptability among the 55 provider participants was high. We had a 87.3% recruitment rate and 74.5% completion rate of planned visits (N=238) with no adverse events. Every participant found the training content "highly useful" or "useful." Preliminary effects suggest that, relative to the referent case (HIV negative straight man), the intervention positively impacted testing for HIV negative MSM (0.05 percentage points [PP], 95% CI,-0.24, 0.33) and diagnostic effort in HIV positive MSM (0.23 standard deviation [SD] improvement, 95% CI, -0.92, 1.37). Patient-centered care only improved for HIV positive straight cases post-training relative to the referent group (SD, 0.57; 95% CI, -0.39, 1.53). All estimates lacked statistical precision, an expected outcome of a pilot RCT.

Conclusions

Our pilot RCT demonstrated high feasibility, acceptability, and several areas of impact for an intervention to reduce enacted healthcare stigma in a low-/middle-income country setting. The relatively lower impact of our intervention on care outcomes for PLWH suggests that future trainings should include more clinical content to boost provider confidence in the safe and respectful management of patients with HIV.

Multilevel Stigma and Its Associations with Medical Care Ratings Among Men Who Have Sex With Men in HPTN 078

INTRODUCTION

Our research assessed associations between stigma-related variables and medical care ratings among clients with HIV in HIV Prevention Trials Network (HPTN) 078 who were men who have sex with men (MSM).

METHODS

Logistic regression explored care ratings, stigma, socio-demographics (N = 637). Qualitative thematic coding and themes explored stigmatizing experiences in different settings (N = 111).

RESULTS

Whites were twice as likely as African-Americans to report high care ratings (P < .05). Clients who reported familial exclusion due to having sex with men were 40% less likely to report high medical care ratings (P < .05). Clients who agreed healthcare providers think people with HIV "sleep around" were half as likely to report high care ratings (P < .08). Stigmatization included "treating me like they'll catch HIV from my hand," and care avoidance so others didn't "know I was having sex with men".

CONCLUSIONS

Providers can promote African American MSM client retention with more affirming healthcare provision, namely minimizing assumptions and addressing identities and client needs beyond just HIV care.

Pathways Between Intersectional Stigma and HIV Treatment Engagement Among Men Who Have Sex with Men (MSM) in India

In India and other low-and-middle-income countries, little is known about how intersectional stigma affects MSM engagement in ART. Informed by the Health Stigma and Discrimination Framework, we qualitatively examined how multiple stigmas influence ART engagement among Indian MSM. We conducted 3 focus groups (N = 22) with MSM living with HIV, aged 21-58 years, in Delhi and Hyderabad to identify potential intervention targets and solutions to improve treatment outcomes. Framework analysis and techniques were used to code and analyze translated audio-recordings. Findings revealed enacted stigma, associated with HIV and MSM identity, manifested as familial shame and healthcare discrimination, inhibiting access to support, and decreasing HIV care engagement. Anticipated stigma led to worry about disclosure and societal repercussions. Community-Based-Organizations, ART centers, and family members were primary sources of support, leading to increased ART initiation and retention. Potential solutions included using MSM peer-counselors, increasing social support, and providing HIV education to the general community.

Public health services and intersectional stigma: a social sciences perspective with implications for HIV service design and delivery

PURPOSE OF REVIEW

Understanding stigma is important for improving HIV care services and gaps in HIV service delivery have been attributed to stigma. This review article synthesizes recent evidence on stigma and its implications for HIV service design and delivery. Given the intersectional nature of stigma, we will focus on HIV stigma as well as related forms of stigma based on one's race, sexual identity, gender identity and other identities.

RECENT FINDINGS

Stigma remains a barrier to achieving equity in HIV services. Individualistic measures of stigma remain influential and are associated with barriers to accessing HIV health services. Recent work also highlights stigma measured at a structural level and its impact on HIV services contexts. Individuals situated at intersections of marginalized identities continue to face greatest injustices, and although intersectional approaches have been adapted to design services at a micro level, few focus on structural change. Recent evidence for mitigating stigma indicates some success for psychosocial interventions that target internalized stigma. Furthermore, community-led approaches show promise in addressing stigma that manifests in HIV health services settings.

SUMMARY

Interventions that address individual-level stigma and structural stigma are needed. Theoretical and applied antistigma research is needed to make HIV services more equitable.

Measuring and Addressing Stigma Within HIV Interventions for People Who Use Drugs: a Scoping Review of Recent Research

PURPOSE OF REVIEW

Persistent stigma remains a crucial barrier to HIV prevention and treatment services among people who use drugs (PWUD), particularly for those living with or at-risk for HIV. This scoping review examines the current state of science with regard to approaches for measuring and addressing stigma within HIV interventions among PWUD.

RECENT FINDINGS

Sixteen studies fit the inclusion criteria for this review. Half the studies originated within the USA, and the remaining represented four different regions. Within these studies, stigma was measured using various quantitative, qualitative, and mixed methods. The studies primarily focused on HIV stigma, including value-based judgments, anticipated stigma, and perceived stigma domains. Information-based and skills building approaches at the individual level were the most common for the stigma reduction interventions. Adoption of systematic evaluations is needed for measuring stigma, including intersectional stigma, within HIV interventions among PWUD. Future studies should focus on developing multilevel intersectional stigma reduction interventions for PWUD with and at-risk for HIV globally.