HIV This Week

Hivstigma.com, an innovative web-supported stigma reduction intervention for gay and bisexual men

Adam BD, Murray J, Ross S, Oliver J, Lincoln SG, Rynard V. Health Educ Res. 2011 Jan 17

An intervention to address stigma directed toward HIV-positive men and to enhance the sexual health of gay and bisexual men was developed through a community-based process involving HIV prevention workers, public health, government, and researchers. The intervention aimed to diminish stigma, create greater support for HIV-positive men, make disclosure safer and easier, discourage reliance on disclosure to prevent transmission, and encourage testing. The question, 'If you were rejected every time you disclosed, would you?' was widely disseminated in the gay community and supported by the Web site, hivstigma.com, to encourage participation in blog-based discussions. Eight bloggers moderated lively discussions over 5 months. There were 20,844 unique visitors to the site averaging more than 5 min each; 4384 visitors returned more than 10 times. About 1942 men answered a pre-test survey on a popular gay dating site and 1791, a post-test evaluation. Results show a statistically significant shift among those aware of the intervention toward reduced stigma-related attitudes and behaviours and toward recognition that HIV-positive gay men face stigma in the gay community and that stigma reduces the likelihood of HIV disclosure.

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Editors’ note: This innovative web-supported stigma reduction campaign for gay and bisexual men took place in a context in which the Canadian judiciary is asserting disclosure as an obligation of HIV-positive people before engaging in sex and the common sentiment in the gay community is that disclosure is not necessary if safer sex is practiced. HIV prevalence among gay men in Ontario is 17% and 30% of gay men with HIV infection do not know they are HIV-positive. The strategy was conceptualised as community mobilisation to stimulate dialogue about stigmatising attitudes and practices that make disclosure difficult. Anticipation of rejection and fear that others may reveal information about their serostatus constitute the primary form of stigma identified by many HIV-positive men. The conversations elicited by the campaign focused on topics such as how stigma discourages disclosure, disclosure cannot be relied upon as an HIV prevention technique, and stigmatising potential sex partners with HIV (‘pozphobia’) does not help avoid HIV transmission. Evaluation of this campaign addressing stigma as an underlying social determinant of HIV transmission suggested that all three components—the Web site, traditional advertising, and community outreach with campaign materials—were necessary to achieve its positive stigma-awareness effects. This campaign showed that it is possible to engage local communities in reflecting on and advancing an ethic of social interaction that aims to reduce HIV transmission and enhance the well-being of HIV-positive men.

Meta-analysis of health and demographic correlates of stigma towards people living with HIV.

Logie C, Gadalla TM. AIDS Care. 2009 2:742-53.

HIV-related stigma may negatively impact the health, quality of life, social support and well-being of people living with HIV (PLHIV). Previous studies have used diverse samples and a multitude of measurement instruments to examine demographic and health correlates of HIV-related stigma, highlighting the importance of synthesizing findings across different studies to gain a better understanding of these associations. This study examined the relationships between HIV-related stigma and a range of demographic, social, physical and health characteristics. A meta-analysis was conducted to assess the overall strength and direction of these relationships. Twenty-four studies of PLHIV, conducted in North America and published in peer-reviewed journals between January of 2000 and November of 2007, were examined and their findings integrated. The heterogeneity of reported results was also assessed and examined. Logie etal’s review revealed substantial variability in the ways researchers measure participants' HIV-related stigma as well as their physical, emotional and mental health. In spite of this variability, high stigma level was consistently and significantly associated with low social support (r = -0.369, p<0.0005), poor physical health (r = -0.324, p<0.0005), poor mental health (r = -0.402, p<0.0005), age (-0.066, p<0.05) and income (-0.172, p<0.005). These correlations were of a medium size, which would be recognized by the individual in daily life. Health and mental health professionals working with individuals and families affected by HIV could benefit from an enhanced understanding of correlates of HIV-related stigma, which will inform assessments, interventions, and treatment plans. The association between HIV-related stigma and physical health has potential implications for treatment, care and support for people at different stages of HIV infection. AIDS Service Organizations are also encouraged to integrate findings into HIV stigma interventions and social support programs. Additionally, HIV-related stigma scales should be developed and validated, so that future studies using them are able to report findings that are operationally and conceptually consistent.

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Editors’ note: Drawing on data from 5600 individuals in 24 studies, this literature synthesis is the first to quantify the associations between HIV-related stigma and characteristics of people living with HIV. Five key variables were found to be significantly associated with high stigma levels: lack of social support, poor physical health, poor mental health, low income, and younger age. Effective interventions to address stigma operate on multiple levels and engage populations as diverse as policy makers, practitioners, communities, and people living with HIV. On a parallel track, it is high time to measure and better understand individual and collective strengths such as the resilience, resistance, solidarity, and empowerment that both help cope with stigma and reduce its prevalence.  

Li L, Liang LJ, Lin C, Wu Z, Rotheram-Borus MJ; the NIMH Collaborative HIV/STD Prevention Trial Group. AIDS. 2010 24:115-122.

The National Institute of Mental Health Collaborative HIV/Sexually Transmitted Disease Prevention Trial provided a unique opportunity to test whether, with the community-based diffusion of HIV/sexually transmitted disease prevention information and an elevated understanding of HIV, the level of stigmatizing attitudes toward people living with HIV in the community would be reduced. A total of 4510 market workers in Fuzhou, China, participated in the study, and longitudinal analyses included study samples of 3785 participants in the 12-month follow-up and 3716 participants in the 24-month follow-up. The authors graphically examined the change in HIV-related stigma indicators over time between control and intervention groups using boxplot and kernel density estimation. A logistic regression analysis with proportional odds model was further used to examine the intervention effect on HIV-related stigmatizing attitudes. Compared with no change over time for the control group, the intervention successfully reduced the level of HIV-related stigmatizing attitudes among the target population at the 12-month follow-up, and the effect increased by two-fold (with respect to odds ratios) at the 24-month follow-up. The intervention demonstrated positive attitude changes associated with HIV-related stigma. These results show the importance of social norms, rather than simply individual behaviours, in developing and implementing stigma reduction campaigns.

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Editors’ note: This trial was designed to identify, recruit, train, and engage community popular opinion leaders to convey HIV-risk reduction messages to food vendors in the markets that were randomised to the intervention arm. The ‘unintended’ finding of stigma reduction in a trial designed to reduce HIV/STD incidence and risk behaviour is puzzling. It may be due to community mobilisation and the use of social networks to convey information. It does suggest that HIV prevention and stigma reduction initiatives should be integrated for maximum benefit.

Babalola S, Fatusi A, Anyanti J. Media saturation, communication exposure and HIV stigma in Nigeria. Soc Sci Med. 2009;68:1513-1520.

HIV-related stigma constitutes an impediment to public health as it hampers AIDS control efforts in many ways. To address the complex problems of increasing HIV infection rates, widespread misinformation about the infection, and the rising level of HIV-related stigma, the various tiers of government in Nigeria are working with local and international non-governmental organizations to develop and implement strategic communication programmes. This paper assesses the link between these communication efforts and HIV-related stigma using data from a nationally representative household survey. The results show that accepting attitudes towards people living with HIV are more prevalent among men than among women. Exposure to HIV-related communication on the media is associated with increased knowledge about HIV, which is in turn a strong predictor of accepting attitudes. Communication exposure also has a significant and positive association with accepting attitudes towards people living with HIV.  In contrast, community media saturation is not strongly linked with accepting attitudes for either sex. The findings strongly suggest that media-based HIV programs constitute an effective strategy to combat HIV-related stigma and should therefore be intensified in Nigeria.

Editors’ note: Community media saturation in this study was defined as the average level of exposure to radio and television of people residing in local areas of residence, and not as actual exposure to HIV-related materials. It is perhaps not surprising therefore that community media saturation made little difference overall on accepting attitudes towards people living with HIV. Radio listening habit was the most significant predictor of HIV campaign exposure, with intensity of exposure in turn varying by sex, education, religion, urban/rural residence, household socio-economic status, and geographic zone of residence. When the messaging is HIV-specific, personal exposure to it is associated with more accepting attitudes for both men and women. However, unmeasured factors operating at community level in Nigeria will have to be addressed to change the community norms that foster stigma towards people living with HIV – simply expanding media-based HIV programming alone is unlikely to have the desired effect.

Roura M, Urassa M, Busza J, Mbata D, Wringe A, Zaba B. Scaling up stigma? The effects of antiretroviral roll-out on stigma and HIV testing. Early evidence from rural Tanzania. Sex Transm Infect. 2008. [Epub ahead of print]

This study aimed to investigate the interplay between antiretroviral therapy scale-up, different types of stigma, and voluntary counselling and testing uptake two years after the introduction of free antiretroviral therapy in a rural ward of Tanzania. Qualitative study using in-depth interviews and group activities with a purposive sample of 91 community leaders, 77 antiretroviral therapy clients and 16 health providers. Data were analysed for recurrent themes using NVIVO-7 software. The complex interplay between antiretroviral therapy, stigma, and voluntary counselling and testing in this setting is characterised by two powerful but opposing dynamics. The availability of effective treatment has transformed HIV into a manageable condition which is contributing to a reduction of self-stigma and is stimulating uptake of voluntary counselling and testing. However, this is counter-balanced by the persistence of blaming attitudes and emergence of new sources of stigma associated with antiretroviral therapy provision. The general perception among community leaders was that as antiretroviral therapy users regained health they increasingly engaged in sexual relations and «spread the disease». Fears were exacerbated because they were perceived to be very mobile and difficult to identify physically. Some leaders suggested giving antiretroviral therapy recipients drugs «for impotence», marking them «with a sign», and putting them «in isolation camps». In this context, traditional beliefs about disease aetiology provided a less stigmatised explanation for HIV symptoms contributing to a situation of collective denial. Where anticipated stigma prevails, provision of antiretroviral drugs alone is unlikely to have sufficient impact on voluntary counselling and testing uptake. Achieving widespread public health benefits of antiretroviral therapy roll-out requires community-level interventions to ensure local acceptability of antiretroviral drugs.

Editors’ note: Stigma may be internalized (self-stigma), anticipated (stigma people expect from others), secondary (affecting those related to the infected person) or enacted stigma (discrimination). Stigma related to inability of ill people living with HIV to conduct productive activities and care for themselves (‘drain of resources’) may be reduced by the health enhancing effects of antiretroviral treatment as people regain weight and energy. However, without social analysis, community engagement, and careful planning, scaling up antiretroviral treatment can lead to new sources of treatment-associated stigma that ostracizes people on treatment and dissuades others from learning their HIV serostatus.