The Problem With Intersectional Stigma and HIV Equity Research

Cancer, HIV, and stigma: a portfolio analysis of grants funded by the National Cancer Institute

PURPOSE

People with HIV (PWH) are at higher risk of cancer compared to the general population and experience worse cancer outcomes compared to cancer patients without HIV. One contributing factor to these outcomes is stigma, a social phenomenon that manifests across both HIV and cancer and compounds among those with a dual diagnosis. To assess the state of research, we conducted a portfolio analysis of National Cancer Institute (NCI)-funded extramural grants on this topic.

METHODS

A keyword search identified 47 potentially relevant awards funded between Fiscal Years 2014-2024. Sixteen awards (8 research awards; 8 grant supplements) met inclusion criteria and were further double-coded for key study characteristics.

RESULTS

Funded awards most frequently considered the prevention (n = 6) and treatment (n = 8) phases of the cancer control continuum, with few focusing on other phases of the continuum. Study samples were racially heterogeneous and often socioeconomically challenged, but no grants focused on other high-risk populations such as individuals with disabilities. Stigma was most often assessed as a predictor (n = 10) and measured at the individual level (n = 16). Seven awards assessed both HIV and cancer stigma, but these constructs were usually assessed independently. Only three grants included an intervention component addressing stigma.

CONCLUSION

NCI-supported research on stigma in the context of HIV and cancer has been limited over the past decade. Results point to opportunities for enhancing extramural research in this area, including developing and testing stigma reduction interventions, expanding research across the cancer control continuum, and focusing on all affected populations.

Interventions for stigma reduction in HIV treatment and prevention designed to enhance antiretroviral uptake and adherence: A systematic review

HIV remains a significant public health burden worldwide, especially in developing countries, despite the availability of effective prevention and treatment modalities, namely PrEP and ART, respectively. HIV-related stigma is a significant barrier to the optimal uptake or adherence to ART or PrEP in vulnerable populations. Therefore, there is a need for effective interventions that can address HIV-related stigma and improve adherence to ART or PrEP in vulnerable populations. This systematic review aimed to identify interventions that can effectively reduce HIV-related stigma and improve adherence to ART or PrEP in vulnerable individuals. A systematic review methodology following the PRISMA guidelines was used. The sources of information included MEDLINE (via PubMed search engine), Embase, Scopus, Web of Science, CINAHL, and PsycINFO. Studies were eligible if they were randomized controlled trials (RCTs) or quasi-experimental studies investigating the effectiveness of any intervention addressing HIV-related stigma among persons living with HIV and improving ART/PrEP adherence. We adopted a narrative synthesis approach to present our findings. For quality appraisal of included studies, we used Cochrane Risk of Bias (RoB 2) tool.Eight RCTs, but no quasi-experimental studies, met the eligibility criteria. Among the seven RCTs on ART adherence, four investigated the effectiveness of cognitive behavioral components (two studies showing positive impact on stigma reduction and ART adherence). Other effective interventions that improved ART adherence while reducing HIV-related stigma included empowerment program and youth peer-mentoring. Only one study focused on PrEP (comprising motivational interviewing, client-centered counseling), which showed stigma reduction and PrEP adherence. Although many interventions have the promise of HIV stigma reduction while simultaneously improving medication adherence, larger scale studies are needed for generalizability. The heterogeneity in measurement instruments for ART/PrEP adherence underscores the need for standardized scales. Cognitive behavioral therapy, empowerment interventions, youth peer-mentoring, motivational interviewing, and client-centered counseling all show effectiveness in reducing HIV self-stigma, while simultaneously improving medication adherence. Future studies should consider the inclusion of diverse populations and refining interventions to address HIV- stigma, especially about PrEP. It is critical to incorporate validated measurement tools to enhance comparability across research endeavors to address the complex interplay between stigma and adherence. PROSPERO number: CRD42023455610.

Pre-exposure Prophylaxis: Clinical Considerations for Overcoming Barriers to Uptake and Persistence

ABSTRACT

Pre-exposure prophylaxis (PrEP) is the administration of antiretroviral medications before HIV exposure to prevent HIV infection. PrEP or biomedical prevention is an essential part of the ending the HIV epidemic strategy. Currently, there are 4 guideline-approved dosing approaches to PrEP, which include 2 oral formulations and 1 long-acting injectable. Unfortunately, most individuals who would benefit from PrEP do not receive a prescription, and even fewer initiate and continue PrEP. Barriers to PrEP uptake and persistence are complex and extend along a socio-ecologic framework from individual through structural. In this article, we highlight the barriers to PrEP care among priority populations, discuss evidence-based solutions, and offer multilevel considerations for clinicians, researchers, and community members to increase access, uptake, and persistence in PrEP care for all.

'It's not a me thing': the role of transcendence and critical politics in Black LGBTQ wellness in Montreal

This study explores well-being strategies and challenges for Black LGBTQ individuals in Montreal, Canada. Semi-structured interviews were conducted between March and May 2023 with key informants, or advocates and service providers for LGBTQ communities in the Montreal metropolitan area. Thematic analysis was used and involved transcription, memo-writing and a multi-step, inductive coding process using MAXQDA. The findings highlight three areas of well-noted challenges for Black LGBTQ individuals: systemic barriers; lack of targeted support; and challenges to accessing services. Two strategic domains emerged as innovative approaches to support well-being: transcendental practices and intersectional sociopolitical awareness raising. Transcendental practices, ranging from fine arts and dance to reiki energy healing, offered avenues for healing and community-building. Intersectional sociopolitical awareness was described as crucial in informing and contributing to existing efforts to improve well-being such as therapeutic engagement with clients and facilitating mutual aid. The identified transcendental practices and political awareness offer promising avenues for holistic well-being and comprehensive approaches to challenges such as inequitable HIV burden. Recognising the convergence of identities and social power axes can inform future interventions to foster more inclusive and empowering health strategies for Black LGBTQ communities.

Discrimination and Mental Health Among Black and Latino People Living with HIV: Understanding the Role of Religion and Spirituality

Despite significant advances in HIV care and treatment, Black and Latino people living with HIV (PWH) still face substantial health disparities due to discrimination and systemic inequities, which adversely affect their mental health. Given the profound significance of religion and spirituality in Black and Latino communities, the effects of religiosity on the relationship between discrimination and mental health should be examined. This study examined religiosity as a moderator between discrimination and mental health among Black and Latino PWH. Using data from the All of Us Research Program collected from 2016 to 2022, we analyzed electronic health records and survey responses from 902 participants, employing descriptive statistics, Chi-squared test, principal component analysis, and binary logistic regression. Results showed significant associations between education, employment, income, discrimination, religiosity, and mental health. Compared with no or low religiosity, those with high religiosity had significant higher odds of good mental health (aOR:2.35, 95% CI:1.16-4.75). Those who experienced discrimination had 59% lower odds of good mental health compared to those who did not report experiences of discrimination (aOR:0.41, 95% CI:0.20-0.83). There was no significant interaction effect of religiosity on the relationship between discrimination and mental health. While religiosity positively influences mental health, it does not mitigate the detrimental effects of compounded discrimination that Black and Latino PWH face. Continued collaborations between religious and spiritual leaders, researchers, and community members is needed to understand better the relationship between these factors and to identify strategies to maximize the protective effect of religiosity.

Exploring HIV Risk Among Sexual Minority Women by Identity and Behavior in a Population-Based Sample of Low-Income Heterosexually Active Women

Purpose: Research suggests that sexual minority women (SMW) face elevated HIV risk compared with their heterosexual counterparts. This study examined the association between sexual minority status-defined by identity and behavior-and HIV-related vulnerabilities among heterosexually active low-income women. Methods: This analysis used National HIV Behavioral Surveillance data (n = 5542) collected in 2019 from heterosexually active low-income women in 23 U.S. urban areas. We examined sexual minority identity and behavior and a set of substance use, sexual behavior, health and health care, and social determinants of health indicators commonly associated with heightened HIV transmission risk. Log-linked Poisson regression models generated adjusted prevalence ratios and 95% confidence intervals. Results: Among women who reported sexual minority identity (22.2%; n = 1231), 34.6% (n = 426) reported past-year sex with only men. Of women who reported past-year sex with both women and men (17.8%; n = 985), 18.3% (n = 180) identified as heterosexual. In adjusted models, SMW had significantly higher prevalence of nearly every HIV risk-associated factor examined than their heterosexual counterparts. Risk profiles by identity and behavior were similar. Notably, SMW defined by behavior had similar or higher prevalence of nearly every risk factor than those defined by identity. Conclusions: This study demonstrates disproportionate HIV-related vulnerabilities among SMW compared with their heterosexual counterparts. The findings underscore the importance of measuring multiple dimensions of sexual orientation (identity and behavior), as SMW and their associated risks show important nuances. Implications include tailoring HIV prevention and health promotion interventions to meet the needs of low-income SMW.

Intersectional HIV Stigma Among Black Women: Regional Differences and Implications From the Black Women First Initiative

Objectives. To explore intersectional stigma and sociodemographic characteristics, with consideration of US regional differences, among Black women with HIV enrolled in the Black Women First (BWF) initiative. Methods. In this prospective, nonrandomized study, participants' stigma scale responses and sociodemographic data were collected between May 2021 and August 2023. Participants participated in bundled interventions tailored to Black women's needs and local contexts during this time. Repeated measure models, adjusted for site clustering, were conducted with consideration of regional differences. Results. There were significant sociodemographic and baseline stigma differences between Black women residing in the US South and other regions. By the 12-month follow-up timepoint, because of bundled interventions, stigma significantly reduced among Black women, especially women in the South and transgender women. Conclusions. Bundled interventions with stigma-reduction approaches that address intersectional stigma and consider geography may be an effective way to reduce and eliminate stigma for Black women with HIV. Public Health Implications. BWF aligns with the National HIV/AIDS Strategy (2022-2025), promoting the development and expansion of culturally sensitive, evidence-informed interventions to improve Black women's health outcomes. (Am J Public Health. 2025;115(S1):S75-S84. https://doi.org/10.2105/AJPH.2025.308037).

Racism, discrimination, medical mistrust, stigma, and lung cancer screening: a scoping review

OBJECTIVE

Lung cancer screening can reduce lung cancer-specific mortality, but it is widely underutilized, especially among minoritized populations that bear a disproportionate burden of lung cancer, such as Black Americans. Racism, discrimination, medical mistrust, and stigma contribute to lower uptake of preventive screenings in general, but the role these factors play in lung cancer screening is unclear. We therefore conducted a scoping review to synthesize the literature regarding how racism, discrimination, medical mistrust, and stigma relate to lung cancer screening.

DESIGN

Informed by PRISMA-ScR guidelines, we searched five databases for relevant literature, and two trained researchers independently reviewed articles for relevance. We conducted a narrative, descriptive analysis of included articles.

RESULTS

A total of 45 studies met our inclusion criteria. Most articles reported on medical mistrust or one of its cognates (e.g. trust and distrust, n = 37) and/or stigma (n = 25), with several articles focusing on multiple constructs. Few articles reported on racism (n = 3), and n = 1 article reported on discrimination. Results from empirical studies suggest that medical mistrust, distrust, and stigma may be barriers to lung cancer screening, whereas trust in health care providers may facilitate screening. The articles reporting on racism were commentaries calling attention to the impact of racism on lung cancer screening in Black populations.

CONCLUSIONS

Overall, novel interventions are needed to promote trust and reduce mistrust, distrust, and stigma in lung cancer screening initiatives. Dedicated efforts are especially needed to understand and address the roles that racism and discrimination may play in lung cancer screening.

Intersectional Microaggressions and Implications for Health Inequities and HIV Among Latino/x Sexual Minority Males in Puerto Rico

Latino/x sexual minority males (SMM) continue to be disproportionately impacted by health inequities. This study aims to understand the lived experience of Puerto Rican (PR) SMM related to how intersectional microaggressions influence health-related risk and protective factors. Young adult (ages 21-30) PR SMM from San Juan, Puerto Rico, completed a bilingual in-depth individual interview (14 in Spanish and 1 in English). A thematic analysis based on the original language of the interviews was conducted using NVivo. Six prominent themes were identified through the data analysis: (1) religious microaggressions, being gay is bad because God doesn't like it; (2) gender microaggressions, gay is not good because it's not for men; (3) sexuality microaggressions, this one is a homosexual, coming out as a sexual minority; (4) trans microaggressions, drag queens create an illusion; (5) internalized microaggressions, battling with internalized homophobia; and (6) mitigating microaggressions, establishing a supportive community. Findings suggest that multiple forms of microaggressions based on the intersectionality of sexuality and gender manifest from straight as well as gay communities. PR SMM demonstrated their resiliency by assessing interactions with others to mitigate risks and enhance supportive networks.

Qualitative analysis of patient and key informant interviews to inform integration of HIV pre-exposure prophylaxis services into gynecology care in Alabama

BACKGROUND

HIV pre-exposure prophylaxis (PrEP) use is low among Southern, Black cis-gender women (CGW). Gynecology clinics are well-positioned to integrate PrEP services as a component of sexual and reproductive healthcare for CGW.

OBJECTIVES

Identify key determinants to PrEP implementation into routine gynecologic care.

DESIGN

Qualitative, in-depth interviews (IDIs).

METHODS

We conducted IDIs with key informants (i.e., physicians, nurses, medical assistants) and focus group discussions (FGDs) with patients accessing care in a gynecology clinic serving under- and uninsured women in Alabama. IDIs explored individual-, setting-, and process-level factors that may impact PrEP care implementation in a clinic serving approximately 3000 women yearly, 64% of whom are Black women.

RESULTS

Ten key informants participated in individual IDIs (median age 33.5, range 24-58 years, 80% female); 20 women participated in either 1 of 4 FGDs (n = 8) or an individual IDI (n = 12); median age 32, range 19-44. The following themes emerged: (1) patient- and provider-level stigmas related to sexuality, sexually transmitted infections (STIs), and HIV limit discussions about sexual health and HIV prevention. (2) Providers report limited knowledge about prescribing and monitoring PrEP, which is reflected in patient's observations that providers do not routinely initiate discussions about HIV prevention or PrEP. (3) Providers utilize a more risk-based approach to PrEP counseling; patients expect non-targeted, comprehensive sexual health information. (4) Structural and social barriers will be challenges to implementing PrEP in routine gynecological care. (5) Patients and providers support a clinic-wide approach to integration of PrEP into gynecology clinics.

CONCLUSION

Discussions around sexual health and STIs are limited in routine gynecologic care, but patients expect comprehensive counseling from knowledgeable providers. Additional provider training may increase comfort discussing and providing PrEP. These findings will inform development of implementation strategies to integrate PrEP care into gynecologic services.

Exploring Effects of Race and Differential Item Functioning on PrEP Stigma Experiences: Implications for Latent Stigma Measurement in Racially and Sexually Diverse Populations

PrEP stigma measurement remains a challenge to the validity of studies and interventions addressing HIV prevention. It may lead to inaccurate assessment of the relationship between PrEP stigma and health outcomes such as PrEP persistence and care retention in groups experiencing HIV-related inequities. The present research explored the psychometric properties of a novel IV pre-exposure prophylaxis (PrEP) stigma scale in a cohort of racially diverse men who have sex with men (MSM). Using item response theory, analyses explored presence of differential item functioning (DIF) among Black and White respondents. Participants completed baseline surveys measuring psychosocial factors, sociodemographic factors, and PrEP stigma items. The primary analysis used a machine learning approach to assess (a) the presence of DIF; and (b) compare latent stigma between Black and White respondents, after correcting for any DIF. The model identified four out of 13 scale items as having a high probability of DIF for Black respondents, which is relatively good given that the original PrEP stigma scale was neither designed nor tested for validation comparing Black and White respondents. The DIF-adjusted latent PrEP stigma measure reveals statistically and substantially significantly higher levels of stigma for Black compared to White respondents (Diff.: 1.05 +/- 0.19). While most items performed well, findings demonstrate the importance of assessing measurement error in populations where stigma is rampant and being studied or intervened upon (and in this case, where multilevel and intersectional stigma may be present).

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.

Local Dynamics of Intersectional Stigma for Black LGBTQ People in Montreal, Quebec

Much academic literature on intersectional stigma is limited by a focus on relatively static and "universal" identity traits, such as ethnicity, gender, and sexuality. This paper addresses local dynamics of intersectional stigma for Black LGBTQ people in Montreal, QC, Canada. Findings draw from fourteen semi-structured, virtual interviews with key informants providing critical services to Black LGBTQ people living in Montreal. Findings suggest intersectional stigmatization via social identity and local power dynamics converge. Specifically, language and immigration are two domains determining intersectional stigma challenges and ameliorative opportunities for Black LGBTQ people in the city. Specific immigration-related challenges included (1) insecurity (e.g. concerning Canadian residency), (2) barriers to resource access (e.g. social and legal services), and (3) stressful identity challenges. Specific language issues included (1) Francophone limitations for expressing gender and sexual diversity and (2) exclusionary linguistic divisions (i.e. Franco/Anglo, Franco/non-Franco, and Western/non-Western). Local, place-based power inequities may determine black LGBTQ experiences of intersectional stigma.

Effectiveness of a culturally tailored HIV intervention in promoting PrEP among black women who use drugs in community supervision programs in New York City: a randomized clinical trial

BACKGROUND

In the U.S. there are significant racial and gender disparities in the uptake of pre-exposure prophylaxis (PrEP). Black Americans represented 14% of PrEP users in 2022, but accounted for 42% of new HIV diagnoses in 2021 and in the South, Black people represented 48% of new HIV diagnoses in 2021 but only 21% of PrEP users in 2022. Women who use drugs may be even less likely than women who do not use drugs have initiated PrEP. Moreover, women involved in community supervision programs (CSP) are less likely to initiate or use PrEP, More PrEP interventions that focus on Black women with recent history of drug use in CSPs are needed to reduce inequities in PrEP uptake.

METHODS

We conducted a secondary analysis from a randomized clinical trial with a sub-sample (n = 336) of the total (N = 352) participants from the parent study (E-WORTH), who tested HIV negative at baseline were considered PrEP-eligible. Black women were recruited from CSPs in New York City (NYC), with recent substance use. Participants were randomized to either E-WORTH (n = 172) an HIV testing plus, receive a 5-session, culturally-tailored, group-based HIV prevention intervention, versus an HIV testing control group (n = 180). The 5 sessions included an introduction to PrEP and access. This paper reports outcomes on improved awareness of PrEP, willingness to use PrEP, and PrEP uptake over the 12-month follow-up period. HIV outcomes are reported in a previous paper.

RESULTS

Compared to control participants, participants in this study assigned to E-WORTH had significantly greater odds of being aware of PrEP as a biomedical HIV prevention strategy (OR = 3.25, 95% CI = 1.64-6.46, p = 0.001), and indicated a greater willingness to use PrEP as an HIV prevention method (b = 0.19, 95% CI = 0.06-0.32, p = 0.004) over the entire 12-month follow-up period.

CONCLUSIONS

These findings underscore the effectiveness of a culturally-tailored intervention for Black women in CSP settings in increasing awareness, and intention to initiate PrEP. Low uptake of PrEP in both arms highlight the need for providing more robust PrEP-on-demand strategies that are integrated into other services such as substance abuse treatment.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02391233 .

"Empowerment for Us by Us (E4UBU)": Developing a Model of Empowerment Using Feminist Participatory Methods with LBQT+ Persons Assigned Female at Birth in Western Kenya

Lesbian, bisexual, queer, trans and other gender diverse persons assigned female at birth (heretofore referred to as "LBQT+ persons") in Western Kenya experience intersectional oppression and stigma. This stigma can manifest in acts of sexual and gender-based violence (SGBV) and sexual and gender minority (SGM)-based violence, as well as various forms of discrimination-all of which have been linked to disproportionately higher levels of negative health outcomes for this group. Despite these challenges, many LBQT+ persons have been able to gain personal and collective power and thrive in this oppressive environment. The Empowerment for Us by Us (E4UBU) project is a mixed methods feminist participatory research study focused on exploring how LBQT+ persons conceptualize and define empowerment for themselves, and to understand their perspectives on how feelings of power and powerlessness influence their physical and mental health. This paper focuses on data from the first phase of the study, in which qualitative in-depth interviews were conducted with 40 LBQT+ persons (ages 19 to 50) from Kisumu and Homa Bay in Western Kenya. A participatory interpretive phenomenological analysis was conducted to understand the lived experiences of LBQT+ persons as they navigate intersectional oppression and its influence on their experiences of empowerment and subsequent health outcomes. Findings from this analysis were presented to two different focus groups composed of participants who had participated in the in-depth interviews to gather their insights on the interpretations of the interviews as a form of member checking. Findings revealed that "empowerment" was not experienced and viewed by LBQT+ persons as a monolithic construct, but rather a process through which LBQT+ persons are able to transform negative forces of intersectional oppression and powerlessness into experiences of power and subsequent individual and collective action and impact-all leading to improved mental health and well-being. This process is facilitated at several junctures by participatory seeking and attainment of community-appropriate resources at multiple socio-ecological levels that, when accessed with sufficient intensity, frequency, and duration, enhance one's journey through the process of empowerment. These facilitation junctures are viewed as likely points of focus for public health intervention. Analysis also revealed that the process of empowerment is dependent on the context within which the process is occurring, the specific issues being faced, and the population of focus. Recommendations for how this model can be used for future research and practice to improve the lives of LBQT+ persons in Kenya are discussed.

A Scoping Review of Approaches to Reduce Stigma and Discrimination Against People with HIV in Health-Care Settings in the United States: Few Recent Interventions Identified

This scoping review identified contemporary stigma-reduction studies across US health-care settings. Despite the significance of this problem, only 3 intervention studies were identified in the past 5 years. These studies highlight the value of intervening during formative training experiences and the importance of including interprofessional health-care providers in interventions. The findings relate to the novel approaches (eg, virtual patient simulations) that are used in interventions. The importance of using a participatory approach to intervention design is noted. Critical gaps in human immunodeficiency virus (HIV) stigma measurement and the lack of interventions are identified, laying a foundation for future programs and research.

Initial Development and Validation of the Brief Internalized Heterosexist Racism Scale for Gay and Bisexual Black Men: A Measure of Internalized Heterosexist Racism

We introduce internalized heterosexist racism (IHR), or the internalization of damaging stereotypes, harmful beliefs, and negative attitudes about being a sexual minority person of color. We also present the initial development and validation of the Brief Internalized Heterosexist Racism Scale for gay and bisexual Black men (IHR-GBBM), a unidimensional, 10-item measure of IHR. Exploratory factor analyses on an internet-obtained sample of gay and bisexual Black men (N = 312; Mean age = 30.36 years) show that the IHR-GBBM had evidence of good internal consistency, and good convergent, discriminant, concurrent, and incremental validity. The IHR-GBBM was positively correlated with internalized racism, internalized heterosexism, and discrimination (racist, heterosexist). IHR was also negatively correlated with race stigma consciousness, weakly positively correlated with sexual identity stigma consciousness, but not correlated with either race identity, sexual identity, or social desirability. Hierarchical regressions showed that the IHR-GBBM explained an additional variance of 2.8% and 3.1% in anxiety symptoms and substance use coping, respectively, after accounting for (1) sociodemographics, (2) internalized racism and internalized heterosexism, and (3) an interaction of internalized racism and internalized heterosexism. Older participants and those who were "out" about their sexual identity reported lower IHR. Those who did not know/want to report their HIV status reported greater IHR. Results revealed no sexual identity, sexual position, relationship status, income, education, or employment status differences in IHR. We hope the development of the IHR-GBBM spurs future research on predictors and consequences of IHR. We discuss limitations and implications for the future study of internalized heterosexist racism.

"Straight-acting white for same": In-person and online/app-based discrimination exposure among sexual minority men

This study quantitatively and qualitatively examined prevalence, frequency, and content of discrimination exposure among gay, bisexual and other sexually minoritized men (SMM) within sexual minority contexts. Participants were an online, U.S. national sample of 14,133 SMM who reported discrimination exposure within sexual minority contexts targeting: body type, race, sexual behavior, HIV status, gender expression, age, and income/employment. Quantitative analyses included prevalence percentages and frequencies and ANOVAs, t-tests, and correlations to examine frequency of discrimination exposure type across participant race/ethnicity, sexual identity, gender identity, HIV status, age, and income. Qualitative analyses included conventional content analysis of responses to an open-ended discrimination exposure item. Results showed that discrimination exposure was nearly universal (99%). Discrimination exposure frequency was lowest among White men and, other than for income/employment discrimination exposure, highest among Asian/Pacific Islander men. For several discrimination types, exposure frequency was highest among groups targeted by group-specific negative stereotypes (e.g., Black men were exposed to the most income/employment discrimination). Qualitative analyses highlighted specific exposures to discrimination targeting body type, race/ethnicity, gender identity, attractiveness, education, and intersections between forms of discrimination. Over 69% of write-in responses were relevant to online/app-based discrimination. Findings underscore the importance of examining individual and intersectional discrimination exposure targeting marginalized social positions within sexual minority communities, particularly in online/app contexts.

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.

The stigma of smoking among women: A systematic review

BACKGROUND

Smoking stigma has been well documented, but little is known regarding its specific features and effects on women. Notably, women face unique social, cultural, and economic challenges that may interact with smoking stigma and impact health outcomes. This review investigates the extent to which smoking women encounter and internalise stigma, while examining the various coping mechanisms they employ to manage these negative experiences.

METHODS

In November 2022, major databases were systematically searched with no time restrictions. After applying inclusion and exclusion criteria, 23 studies (three quantitative and 20 qualitative) met our criteria. We conducted a quality assessment and summarised the findings pertaining to public stigma, self-stigma, and coping strategies.

RESULTS

The stigma about smoking emerges from a variety of sources, such as family, healthcare providers, or internet forums. Women smokers are universally aware of the negative image they have in society. Yet, their experiences and management of the stigma of smoking are shaped by other variables such as cultural background, social class, or motherhood status. Smoking stigma produces ambivalent effects, such as concealment, reduced usage of support services, and to a lesser extent, smoking cessation motivation.

CONCLUSIONS

These results indicate that smoking stigma is an important social justice and public health issue and that further research is needed to better prevent its effects on women's well-being and health behaviours.

The mediation effect of social support between stigma and social alienation in patients with stroke

Background

Social alienation is prevalent and causes adverse outcomes in stroke. Previous studies have linked stigma with social alienation. However, little is known about the mechanisms behind this relationship. This study explored the mediation effects of social support between stigma and social alienation.

Methods

A cross-sectional design was used to study 248 patients with stroke admitted to a tertiary rehabilitation hospital in Beijing, China, from December 2022 to July 2023. Patients were assessed using a general information questionnaire, the Stroke Stigma Scale, the Social Support Rating Scale, and the Generalized Social Alienation Scale. The PROCESS macro in SPSS was used to examine the mediation model.

Results

The results showed that stigma has a negative effect on social support (β = -0.503, p<0.001); stigma has a positive effect on social alienation (β = 0.768, p<0.001). Social support mediated the relationship between stigma and social alienation, with a mediation effect of 0.131 (95%CI: 0.060, 0.214), and indirect effects accounted for 17.06% of the total effect.

Conclusion

Social support mediated the relationship between stigma and social alienation. These findings suggest that intervention targeting the enhancement of social support may prevent or reduce social alienation among patients with stroke.

Pathways From HIV-Related Stigma, Racial Discrimination, and Gender Discrimination to HIV Treatment Outcomes Among Women Living With HIV in Canada: Longitudinal Cohort Findings

BACKGROUND

HIV-related stigma, gender discrimination, and racial discrimination harm mental health and hamper HIV treatment access for women living with HIV. Maladaptive coping strategies, such as substance use, can further worsen HIV treatment outcomes, whereas resilience can improve HIV outcomes. We examined resilience and depression as mediators of the relationship between multiple stigmas and HIV treatment outcomes among women living with HIV.

SETTING

Ontario, British Columbia, and Quebec, Canada.

METHODS

We conducted a longitudinal study with 3 waves at 18-month intervals. We used structural equation modeling to test the associations of multiple stigmas (HIV-related stigma, racial discrimination, and gender discrimination) or an intersectional construct of all 3 stigmas at wave 1 on self-reported HIV treatment cascade outcomes (≥95% antiretroviral treatment [ART] adherence, undetectable viral load) at wave 3. We tested depression and resilience at wave 2 as potential mediators and adjusted for sociodemographic factors.

RESULTS

There were 1422 participants at wave 1, half of whom were Black (29%) or Indigenous (20%). Most participants reported high ART adherence (74%) and viral suppression (93%). Racial discrimination was directly associated with having a detectable viral load, while intersectional stigma was directly associated with lower ART adherence. Resilience mediated associations between individual and intersectional stigmas and HIV treatment cascade outcomes, but depression did not. Racial discrimination was associated with increased resilience, while intersectional and other individual stigmas were associated with reduced resilience.

CONCLUSION

Race, gender and HIV-related stigma reduction interventions are required to address intersectional stigma among women living with HIV. Including resilience-building activities in these interventions may improve HIV treatment outcomes.

A Systematic Review of Intervention Studies That Address HIV-Related Stigmas Among US Healthcare Workers and Health Systems: Applying a Theory-Based Ontology to Link Intervention Types, Techniques, and Mechanisms of Action to Potential Effectiveness

BACKGROUND

To end the HIV epidemic, we need to better understand how to address HIV-related stigmas in healthcare settings, specifically the common theoretical bases across interventions so that we can generalize about their potential effectiveness.

PURPOSE

We describe theory-based components of stigma interventions by identifying their functions/types, techniques, and purported mechanisms of change.

METHODS

This systematic review examined studies published by April 2021. We applied a transtheoretical ontology developed by the Human Behaviour Change Project, consisting of 9 intervention types (ITs), 93 behavior change techniques (BCTs), and 26 mechanisms of action (MOAs). We coded the frequency and calculated the potential effectiveness of each IT, BCT, and MOA. We evaluated study quality with a 10-item adapted tool.

RESULTS

Among the nine highest quality studies, indicated by the use of an experimental design, the highest potentially effective IT was "Persuasion" (i.e. using communication to induce emotions and/or stimulate action; 66.7%, 4/6 studies). The highest potentially effective BCTs were "Behavioral practice/rehearsal" (i.e. to increase habit and skill) and "Salience of consequences" (i.e. to make consequences of behavior more memorable; each 100%, 3/3 studies). The highest potentially effective MOAs were "Knowledge" (i.e. awareness) and "Beliefs about capabilities" (i.e. self-efficacy; each 67%, 2/3 studies).

CONCLUSIONS

By applying a behavior change ontology across studies, we synthesized theory-based findings on stigma interventions. Interventions typically combined more than one IT, BCT, and MOA. Practitioners and researchers can use our findings to better understand and select theory-based components of interventions, including areas for further evaluation, to expedite ending the HIV epidemic.

Intersectional Stigma as a Fundamental Cause of Health Disparities: A case study of how drug use stigma intersecting with racism and xenophobia creates health inequities for Black and Hispanic persons who use drugs over time

Recent evidence points to racial and ethnic disparities in drug-related deaths and health conditions. Informed by stigma, intersectionality, intersectional stigma, and fundamental cause theories, we aimed to explore whether intersectional stigma was a fundamental cause of health. We document key events and policies over time and find that when progress is made new mechanisms emerge that negatively affect health outcomes for Black and Hispanic persons. We then focus on intersectional stigma targeting Black and Hispanic persons who use drugs. We document that when a person, or group of people, occupy multiple stigmatized identities the processes of stigmatization and scapegoating are particularly persistent and pernicious since people and groups can be stigmatized and scapegoated on varying intersections. We propose that an intersectional stigma framework allows for a better understanding of observed patterns over time, thereby providing a better guide for policies and interventions designed to reduce disparities. As a framework, intersectional stigma aims to recognize that when different sources of stigma collide, a new set of circumstances is created for those who reside in the intersection. We conclude that intersectional stigma is a fundamental cause of health inequities and provide policy recommendations aimed at dismantling intersectional stigma processes and mitigating the effects of intersectional stigmas to ultimately promote better health outcomes for Black and Hispanic persons who use drugs.

The impact of social violence on HIV risk for women in Colombia: A concurrent mixed methods study

Gender, violence, and migration structurally impact health. The Venezuelan humanitarian crisis comprises the largest transnational migration in the history of the Americas. Colombia, a post-conflict country, is the primary recipient of Venezuelans. The Colombian context imposes high levels of violence on women across migration phases. There is little information on the relationship between violence and HIV risk in the region and how it impacts these groups. Evidence on how to approach the HIV response related to Venezuela's humanitarian crisis is lacking. Our study seeks to 1) understand how violence is associated with newly reported HIV/AIDS case rates for women in Colombian municipalities; and 2) describe how social violence impacts HIV risk, treatment, and prevention for Venezuelan migrant and refugee women undergoing transnational migration and resettlement in Colombia. We conducted a concurrent mixed-methods design. We used negative binomial models to explore associations between social violence proxied by Homicide Rates (HR) at the municipality level (n = 84). The also conducted 54 semi-structured interviews with Venezuelan migrant and refugee women and key informants in two Colombian cities to expand and describe contextual vulnerabilities to HIV risk, prevention and care related to violence. We found that newly reported HIV cases in women were 25% higher for every increase of 18 homicides per 100,000, after adjusting for covariates. Upon resettlement, participants cited armed actors' control, lack of government accountability, gender-based violence and stigmatization of HIV as sources of increased HIV risk for VMRW. These factors impose barriers to testing, treatment and care. Social violence in Colombian municipalities is associated with an increase in newly reported HIV/AIDS case rates in women. Violence hinders Venezuelan migrant and refugee women's access and engagement in available HIV prevention and treatment interventions.