Correlates of perceived HIV-related stigma among HIV-positive pregnant women in rural Mpumalanga province,South Africa

The study investigated correlates of perceived HIV-related stigma among 673 HIV-positive women from rural Mpumalanga province, South Africa (mean age 28 years old, SD = 5.73 years). The women completed measures of HIV-related stigma experience and related personal factors. Following multivariable logistic regression, results showed that lack of male involvement during the ante-natal visits was significantly associated with all four perceived HIV-related stigma factors. Lower income, intimate partner violence (IPV), lower education, and experienced HIV-related stigma were associated with a combination of the four components of perceived HIV-related stigma. From these findings, we conclude that higher levels of education, income, and partner involvement are protective factors against perceived HIV-related stigma, at multiple layers. Improving on adult education and income generating activities can help in reducing HIV-related stigma. Male partner involvement in their partner’s pregnancy, the initiation of support groups for both women and men, as well as community-based IPV prevention interventions may help to reduce perceived HIV-related stigma among women living with HIV.     

The Impact of Stigma and Social Support on Development of Post-traumatic Growth Among Persons Living with HIV

Given high rates of trauma in people living with HIV (PLH) and the health benefits of posttraumatic growth (PTG), understanding how to foster PTG in PLH exposed to trauma could be of interest to clinical psychologists working with this population. The current study examined factors theoretically related to development of PTG in PLH, namely HIV-related stigma, disclosure of HIV status, and emotional support. A sample of 334 HIV-positive adults answered a battery of self-report questionnaires. HIV-related stigma, disclosure to sexual partners, and emotional support were significant predictors of PTG: stigma was associated with lower PTG, whereas disclosure and emotional support were associated with higher PTG. Disclosure and emotional support remained significantly associated with PTG in the model including demographic factors and stigma. These findings highlight the need for development of interventions that can aid PLH in disclosing their HIV status to sexual partners and increasing available social support.     

HIV-related stigma among market workers in China.

HIV-related stigma was examined among 209 employees and owners of stalls in 5 markets in an eastern coastal city in China. Of the participants 53% were women and 47% were men; 100% were Han. Ages ranged from 18 to 49 years (M=35, SD=8.1). Half of the participants believed that punishment was an appropriate response toward those living with HIV (50%). Over half (56%) were unwilling to be friends with infected individuals. The majority thought that those living with HIV should be isolated (73%). They agreed that persons living with HIV should not take care of other people's children (85%). Punishing beliefs toward persons living with HIV were related to being male, older, married, less educated, and unwilling to be tested for HIV.     

Stigma and Psychological Distress in People With HIV/AIDS

Using a community sample of 197 people living with HIV/AIDS, we examined how awareness of societal stigma (felt stigma) and negative feelings toward oneself as a member of a stigmatized group (self-stigma) are related to psychological well-being. Both felt stigma and self-stigma were significantly correlated with symptoms of depression and anxiety, but controlling for felt stigma reduced self-stigma's association with depressive symptoms to nonsignificance. Global self-esteem and social avoidance fully mediated the associations between self-stigma and distress but only partially mediated the associations between felt stigma and distress. Felt stigma mediated the relationship between distress and HIV-related changes in physical appearance.     

HIV-related stigma in African and Afro-Caribbean communities in the Netherlands: manifestations, consequences and coping

HIV-related stigma in African and Afro-Caribbean diaspora communities in the Netherlands was investigated. Interviews with HIV-positive and HIV-negative community members demonstrated that HIV-related stigma manifests as social distance, physical distance, words and silence. The psychological consequences of HIV-related stigma among those diagnosed with HIV reported were emotional pain, sadness, loneliness, anger, frustration and internalised stigma. The social consequences included decreased social network size, limited social support and social isolation, and resulted from not only enacted stigma but also self-imposed social withdrawal. Also, poor treatment adherence was a health-related consequence. People living with HIV employed both problem-focused and emotion-focused coping strategies to mitigate the negative consequences of stigma. Problem-focused coping strategies included selective disclosure, disengagement, affiliating with similar others, seeking social support and, to a lesser extent, activism. Emotion-focused strategies included distraction, positive reappraisal, religious coping, external attributions, disidentification and acceptance. HIV-related stigma clearly permeates African and Afro-Caribbean communities in the Netherlands, and should be targeted for intervention.     

Experiences of HIV-related discrimination and consequences for internalised stigma,depression and alcohol use

Objective: HIV stigma undermines health and well-being of people living with HIV (PLWH). Conceptual work on stigma mechanisms suggests that experiences of stigma or discrimination increase internalised stigma. However, not all PLWH may internalise the HIV discrimination they experience. We aimed to investigate the role of stress associated with events of HIV-related discrimination on internalised HIV stigma, as well as the downstream effects on depressive symptoms and alcohol use severity.

Design: 199 participants were recruited from an HIV clinic in the southeastern United States.

Main study measures: HIV-related discrimination was assessed using items adapted from measures of enacted HIV stigma and discrimination. Participants rated perceived stress associated with each discrimination item. Internalised HIV stigma was assessed using the internalised stigma subscale of the HIV Stigma Mechanisms Scale. Depressive symptoms were assessed with the Centre for Epidemiological Studies-Depression Index. Alcohol use severity was assessed with the Alcohol Use Disorders Identification Test.

Results: In serial mediation models, HIV-related discrimination was indirectly associated with both depressive symptoms and alcohol use severity through its associations with stress and internalised HIV stigma.

Conclusions: Understanding the mechanisms through which PLWH internalise HIV stigma and lead to poor health outcomes can yield clinical foci for intervention.     

Unable to be a Human Being in Front of Other People: A Qualitative Study of Self-Isolation Among People Living with HIV/AIDS in China

In China, acute stigma accompanying an HIV diagnosis can lead to self-isolation. In a cultural setting where family relationships are highly valued and contribute critically to well-being, such self-isolation can thwart HIV self-management and engagement in medical care, and so heighten risk for health disparities. To understand this phenomenon, we conducted individual in-depth interviews with 34 persons living with HIV/AIDS (PLwHA) in Shanghai and Beijing. Inductive content analysis revealed a range of forms of self-isolation motivation, beliefs, and behaviors influenced by: 1) internalized stigma and desire to avoid discrimination; 2) HIV-related factors such as HIV knowledge and disease progression; and 3) familial factors such as a sense of responsibility and family members’ reactions. Based on a proposed framework centering on dialectical family influences (whereby PLwHA are pushed away from, yet pulled toward the family fold), implications for provision of multidisciplinary care in medical settings are considered, including culturally appropriate strategies to decrease health disparities.     

Measuring HIV stigma: existing knowledge and gaps

The growing recognition of the reduction of HIV stigma as central to effective programs across the HIV/AIDS prevention to care and treatment continuum is leading to an increasing number of programs focused on stigma reduction. Correctly evaluating the impact of these programs depends on having a good set of measures that effectively capture and distinguish the complexities of HIV stigma. This paper reviews the existing literature on HIV stigma measurement and identifies key gaps that remain. There is a need for measures at the general population level that are unambiguous about the cause of the stigmatizing behavior, that capture enacted stigma (discrimination), and that can distinguish compound (layered) stigma. In addition, studies are needed in a wider variety of contexts and on a larger scale that include a comprehensive set of measures to capture the complexity of HIV-related stigma and ensure appropriate evaluation of stigma-reduction programs.     

Social capital and PTSD among PLWHA in China: the mediating role of resilience and internalized stigma

Post-traumatic Stress Disorder (PTSD) is frequent among people living with HIV/AIDS (PLWHA). Few studies have investigated social-psychological predictors of PTSD in China. This study aimed to examine relationships between social capital, stigma, resilience and PTSD among PLWHA in China, and to provide effective suggestions for PTSD intervention. A cross-sectional study of 520 PLWHA was conducted from November 2015 to January 2016. Survey data were collected using anonymous self-reported questionnaire. Multivariable analyses were used to examine related factors of PTSD, and causal mediation analyses were conducted to assess whether stigma and resilience were mediators. Results indicated that higher risk of PTSD was independent associated with stronger stigma, decreasing social capital and lower resilience. There was an indirect relationship of social capital on PTSD mediated through resilience and HIV-related stigma. Therefore, PTSD intervention programs should not only pay attention to the role of social capital on PTSD, but also attach importance to stigma and resilience on PTSD symptoms.     

Coping,social support,stigma, and gender difference among people living with HIV in Guangxi,China

The current study examined whether gender, HIV-related stigma, social support, and the interaction between gender and social support are associated with coping responses among people living with HIV and AIDS (PLWHA) in Guangxi, China. A total of 2987 PLWHA in Guangxi participated from October 2012 to August 2013. Multivariate analysis of covariance was conducted with gender and social support as main factors in the model, and stigma and other variables as covariates. After controlling for demographic variables and stigma, there were significant main effects of emotional social support (F = 1.61, p < .001), functional social support (F = 1.67, p < .001), and informational social support (F = 3.67, p < .001) on various coping strategies. The interaction between gender and informational social support (F = 1.33, p < .05), internalized stigma (F = 37.03, p < .001) and perceived stigma (F = 9.16, p < .001) were associated with various coping strategies. Findings signify the importance of HIV-related stigma and social support differences in the coping strategies among PLWHA in Guangxi, China.     

The Problematization of Sexuality among Women Living with HIV and a New Feminist Approach for Understanding and Enhancing Women’s Sexual Lives

In the context of HIV, women’s sexual rights and sexual autonomy are important but frequently overlooked and violated. Guided by community voices, feminist theories, and qualitative empirical research, we reviewed two decades of global quantitative research on sexuality among women living with HIV. In the 32 studies we found, conducted in 25 countries and composed mostly of cis-gender heterosexual women, sexuality was narrowly constructed as sexual behaviours involving risk (namely, penetration) and physiological dysfunctions relating to HIV illness, with far less attention given to the fullness of sexual lives in context, including more positive and rewarding experiences such as satisfaction and pleasure. Findings suggest that women experience declines in sexual activity, function, satisfaction, and pleasure following HIV diagnosis, at least for some period. The extent of such declines, however, is varied, with numerous contextual forces shaping women’s sexual well-being. Clinical markers of HIV (e.g., viral load, CD4 cell count) poorly predicted sexual outcomes, interrupting widely held assumptions about sexuality for women with HIV. Instead, the effects of HIV-related stigma intersecting with inequities related to trauma, violence, intimate relations, substance use, poverty, aging, and other social and cultural conditions primarily influenced the ways in which women experienced and enacted their sexuality. However, studies framed through a medical lens tended to pathologize outcomes as individual “problems,” whereas others driven by a public health agenda remained primarily preoccupied with protecting the public from HIV. In light of these findings, we present a new feminist approach for research, policy, and practice toward understanding and enhancing women’s sexual lives—one that affirms sexual diversity; engages deeply with society, politics, and history; and is grounded in women’s sexual rights.     

Reducing AIDS-related stigma in developing countries: the importance of theory- and evidence-based interventions

In many developing countries persons living with HIV and AIDS experience strong stigma and discrimination, and AIDS-related stigma has an enormous negative impact on their social relationships, access to resources, and psychological well being. Moreover, AIDS-related stigma hampers HIV-related health promotion, including voluntary HIV counselling and testing. In this article, we will argue that programs to reduce AIDS-related stigma are most likely to be effective if these programs are based upon thorough needs assessments, theory- and evidence-based intervention strategies and collaborative planning. A protocol for health promotion programs design is outlined. Furthermore, psychosocial correlates of AIDS-related stigma in developing countries, social-psychological theories that might be useful in designing intervention strategies to reduce stigmatisation and successful elements of previous interventions aimed at stigma reduction are discussed. It is concluded that psychological theory does provide guidelines for the development of stigma-reducing intervention programs, but that such programs can only be effective when based upon context-specific needs assessment and collaborative planning.     

Individual attitudes and perceived social norms: Reports on HIV/AIDS‐related stigma among service providers in China

This study examined HIV/AIDS‐related stigma among Chinese service providers by comparing their personal attitudes toward people living with HIV/AIDS with their perception of social norms related to people living with HIV/AIDS. We randomly selected three provincial hospitals, four city/prefecture hospitals, 10 county hospitals, 18 township health clinics, and 54 village clinics from Yunnan, China. Doctors and nurses were randomly sampled proportionally to the doctor–nurse ratio of each hospital or clinic. Lab technicians were over‐sampled in order to include an adequate representation in the analysis. A total of 1,101 service providers participated in a voluntary, anonymous survey where demographic characteristics, individual attitude and perceived social norms toward people living with HIV/AIDS, discrimination intent at work, general prejudicial attitude and knowledge on HIV/AIDS were measured. A majority of the sample demonstrated a similarity between their personal views and what they thought most people in society believe. Multiple logistic regressions revealed that participants who were younger or reported personal contact with people living with HIV/AIDS were significantly more likely to report personal attitudes toward the population that were more liberal than their perceived social norms. Holding a more liberal personal attitude toward people living with HIV/AIDS than perceived social norms was significantly and negatively related to the level of discrimination intent at work, perceived discrimination at interpersonal level and the level of general prejudicial attitude toward people living with HIV/AIDS. Results underscored the importance of understanding social norms and personal attitudes in studying HIV‐related stigma and called for the incorporation of existing human capital into future HIV stigma reduction programs.     

The Multilevel Relationships of HIV‐Related Stigma to Child and Caregiver Mental Health among HIV‐Affected Households in South Africa

HIV/AIDS‐related (HAR) stigma is still a prevalent problem in Sub‐Saharan Africa, and has been found to be related to mental health of HIV‐positive individuals. However, no studies in the Sub‐Saharan African context have yet examined the relationship between HAR stigma and mental health among HIV‐negative, HIV‐affected adults and families; nor have any studies in this context yet examined stigma as an ecological construct predicting mental health outcomes through supra‐individual (setting level) and individual levels of influence. Multilevel modeling was used to examine multilevel, ecological relationships between HAR stigma and mental health among child and caregiver pairs from a systematic, community‐representative sample of 508 HIV‐affected households nested within 24 communities in KwaZulu‐Natal, South Africa. Two distinct dimensions of HAR stigma were measured: individual stigmatizing attitudes, and perceptions of community normative stigma. Findings suggest that individual‐level HAR stigma significantly predicts individual mental health (depression and anxiety) among HIV‐affected adults; and that community‐level HAR stigma significantly predicts both individual‐level mental health outcomes (anxiety) among HIV‐affected adults, and mental health outcomes (PTSD and externalizing behavior scores) among HIV‐affected children. Differentiated patterns of relationships were found using the two different stigma measures. These findings of unique relationships identified when utilizing two conceptually distinct stigma measures, at two levels of analysis (individual and community) suggest that HAR stigma in this context should be conceptualized as a multilevel, multidimensional construct. These findings have important implications both for mental health interventions and for interventions to reduce HAR stigma in this context.     

Disengagement and Engagement Coping with HIV/AIDS Stigma and Psychological Well-Being of People with HIV/AIDS

The stigma associated with HIV/AIDS poses a psychological challenge to people living with HIV/AIDS. We hypothesized that that the consequences of stigma-related stressors on psychological well-being would depend on how people cope with the stress of HIV/AIDS stigma. Two hundred participants with HIV/AIDS completed a self-report measure of enacted stigma and felt stigma, a measure of how they coped with HIV/AIDS stigma, and measures of depression and anxiety, and self-esteem. In general, increases in felt stigma (concerns with public attitudes, negative self-image, and disclosure concerns) coupled with how participants reported coping with stigma (by disengaging from or engaging with the stigma stressor) predicted self-reported depression, anxiety, and self-esteem. Increases in felt stigma were associated with increases in anxiety and depression among participants who reported relatively high levels of disengagement coping compared to participants who reported relatively low levels of disengagement coping. Increases in felt stigma were associated with decreased self-esteem, but this association was attenuated among participants who reported relatively high levels of engagement control coping. The data also suggested a trend that increases in enacted stigma predicted increases in anxiety, but not depression, among participants who reported using more disengagement coping. Mental health professionals working with people who are HIV positive should consider how their clients cope with HIV/AIDS stigma and consider tailoring current therapies to address the relationship between stigma, coping, and psychological well-being.     

Striving Towards Empowerment and Medication Adherence (STEP-AD): A Tailored Cognitive Behavioral Treatment Approach for Black Women Living With HIV

In the U.S. Black women with HIV face numerous psychosocial challenges, particularly trauma, racism, HIV-related discrimination, and gender role expectations, that are associated with negative HIV health outcomes and low medical treatment adherence. Yet many of these factors are unaddressed in traditional cognitive behavioral approaches. This study presents a case series of a tailored cognitive behavioral treatment approach for Black women living with HIV. Striving Towards EmPowerment and Medication Adherence (STEP-AD) is a 10-session treatment aimed at improving medication adherence for Black women with HIV by combining established cognitive behavioral strategies for trauma symptom reduction, strategies for coping with race- and HIV-related discrimination, gender empowerment, problem-solving techniques for medication adherence, and resilient coping. A case series study of five Black women with HIV was conducted to evaluate the preliminary acceptability and feasibility of the treatment and illustrate the approach. Findings support the potential promise of this treatment in helping to improve HIV medication adherence and decrease trauma symptoms. Areas for refinement in the treatment as well as structural barriers (e.g., housing) in the lives of the women that impacted their ability to fully benefit from the treatment are also noted.     

Stigma, social risk, and health policy: public attitudes toward HIV surveillance policies and the social construction of illness.

Data from a 1999 national telephone survey with a probability sample of English-speaking US adults (N=1,335) were used to assess how support for HIV surveillance policies is related to AIDS stigma and negative attitudes toward groups disproportionately affected by the epidemic. Anonymous reporting of HIV results to the government was supported by a margin of approximately 2-to-l, but name-based reporting was opposed 3-to-l. Compared with other respondents, supporters of name-based surveillance expressed significantly more negative feelings toward people with AIDS, gay men, lesbians, and injecting drug users. More than one third of all respondents reported that concerns about AIDS stigma would affect their own decision to be tested for HIV in the future. Implications for understanding the social construction of illness and for implementing effective HIV surveillance programs are discussed.     

Personal Meaning,Social Support,and Perceived Stigma in Individuals Receiving HIV Mental Health Services

Human immunodeficiency virus (HIV) stigma represents a significant source of stress among individuals living with HIV disease, prompting interest in research to identify factors that may help to ameliorate the stress burden associated with HIV stigma. Consistent with this research line, the current study was conducted as a cross-sectional investigation examining associations between positive global personal meaning, social support, and perceived HIV stigma. Global personal meaning refers to beliefs and aspirations through which one ascribes value and purpose in living. The study sample was comprised of individuals living with HIV disease who presented for an initial visit in a specialty HIV mental health services program. In bivariate analyses, social support was negatively correlated with multidimensional aspects of HIV stigma that included distancing, blaming, and discrimination stigma, whereas personal meaning was negatively associated only with blaming stigma. In further analyses using structural equation modeling, social support significantly mediated the association between personal meaning and both distancing and blaming stigma. Interactions between positive personal meaning and social support may be useful to consider in future research on psychological resource factors and HIV stigma. Understanding these interactions may also inform clinical efforts to address HIV stigma concerns.     

Predictors of HIV-related stigma among young people living with HIV.

Enacted and perceived HIV stigma was examined among substance-using young people living with HIV (YPLH) in Los Angeles, San Francisco, and New York City (N = 147). Almost all YPLH (89%) reported perceived stigma, and 31% reported enacted experiences in the past 3 months; 64% reported experiences during their lifetime. The HIV stigma questions were characterized by factors of avoidance, social rejection, abuse, and shame. In multivariate models, enacted stigma was associated with gay or bisexual identity, symptomatic HIV or AIDS, and bartering sex. Perceived stigma was associated with female gender, symptomatic HIV or AIDS, bartering sex, lower injection drug use, and fewer friends and family knowing serostatus. Gay or bisexual YPLH who were also HIV symptomatic or AIDS diagnosed experienced more HIV stigma than their heterosexual peers.     

Emotional distress in nonmetropolitan persons living with HIV disease enrolled in a telephone-delivered, coping improvement group intervention.

The study delineated depressive symptoms and modeled emotional distress in persons living with HIV disease in nonmetropolitan areas of 13 U.S. states. Participants (N=329) were enrolled in a randomized clinical trial of a telephone-delivered, coping improvement group intervention, and 60% reported moderate or severe levels of depressive symptomatology on the Beck Depression Inventory. Structural equation modeling indicated that participants who experienced more severe HIV symptomatology, received less social support, and engaged in more avoidant coping also experienced more emotional distress (a latent construct comprising depressive symptoms and emotional well-being). Greater HIV-related stigma and rejection by family led to more emotional distress, with social support and avoidant coping mediating almost entirely the effects of the former 2 variables. The model accounted for 72% of the variance in emotional distress in nonmetropolitan persons living with HIV disease.