The human immunodeficiency virus (HIV) continues to have a disproportionate impact on certain populations, particularly among ethnic minorities and men who have sex with men (MSM). This literature review analyzes how stigma and discrimination can affect health and mental outcomes within ethnic minorities and MSM. The goal of this review is to increase awareness and knowledge regarding effects of HIV and AIDS-related stigma and discrimination. In doing so, it highlights the public health actions and approaches needed for social change and help stigmatized individuals living with HIV.
The human immunodeficiency virus (HIV) is currently one of the most critical public health issues globally with over 35 million lives lost.(1) Common behavioral risk factors associated with HIV include unprotected vaginal or anal intercourse, unsafe blood transfusions, sharing contaminated needles when injecting drugs, or needle accidents. (1) United States (U.S.) surveillance data between 2007-2010 found that new cases of HIV among Blacks was 45% despite only accounting for 12% of the total population, whereas Whites account for 65% of the population and represented only 29% of new infections. (2) Furthermore, Latinos accounted for 16% of the population in the surveillance system but represented 22% of new HIV diagnoses. (2) Therefore, there are clear disparities in HIV risk among ethnic minorities, which should be further explored in order to alleviate these ethnic/racial and health inequalities.
Some researchers argue that societal stigma is related to HIV disparities among ethnic minorities as well as differences in HIV treatment and survival. (2,3) For example, Blacks are less likely to adhere to antiretroviral treatment (ART) compared to Whites. (2) There is conflicting research regarding Latinos as some studies indicate that Latinos are more compliant than Whites, whereas other studies have demonstrated that Latinos are less likely to adhere compared to whites.2 Some researchers hypothesize that these ethnic/racial disparities are related to healthcare providers holding subliminal prejudices towards Blacks, and are providing inferior care as they assume Blacks will be less adherent to ART due to homelessness, drug use or alcohol abuse. (2) However, there is limited research exploring these social determinants of health and strategies to reduce the influence of stigma among ethnic minorities. (2,3) Earnshaw et al. summarizes societal stigma as social disapproval and dismissiveness of someone due to a certain characteristic, such as ethnicity, race or sexual orientation. (2) In addition to healthcare provider prejudices, ethnic minority patients who perceive stigma from healthcare professionals are less likely to consider physician feedback, or adhere to ART treatment based on provider mistrust. (2)
Researchers have aimed to explain these structural and individual levels of stigma using the Stigma and Health Disparities Model, which explores how individual and structural factors are related to ethnic/racial HIV disparities. (2,3) For example, Blacks with HIV have increased death rates compared to whites, which may be associated with chronic stressors related to living in impoverished segregated areas at the structural level, with a higher prevalence of sexually transmitted diseases and crime. (2) Increasing chronic stress is associated with more rapid HIV disease progression, therefore decreasing the likelihood of survival as an individual level stigma. (2) In addition, perceived racial stigma is related to increased chronic stress which can negatively influence mental and physical well-being. (2,3) Also, Black men who have sex with men (MSM) not only can endure discrimination because of their sexual orientation, but can also experience racial discrimination. (4) Therefore, Black MSM are more likely to face mental illness, stress, and social isolation. (4) Based on these issues surrounding societal stigma, public health practitioners should aim to understand the social factors associated with increased risk of HIV infection for ethnic minorities, which is critical in developing public health interventions to alleviate these ethnic/racial disparities among those with HIV.
We conducted a narrative research review of the literature to assess the impact of discrimination and stigma towards ethnic minorities who are living with HIV/AIDS in an urban setting. The impacts of said discrimination include, but are not limited to mental health deterioration, physical health deterioration, and underutilized healthcare services. Searching for relevant data was conducted within four different electronic libraries and databases. The databases included Medline, PubMed, Google Scholar, and CINAHL. A range of fundamental cause keywords (e.g. stigma, discrimination) were used in combination with a range of environmental, disease, and population related keywords (e.g. ethnic minority, HIV/AIDS, urban setting). Table 1 demonstrates the search terms we used across four different electronic libraries and databases.
HIV AND AIDS-RELATED STIGMA AND DISCRIMINATION.
HIV/AIDS research in prior decades has been prolific, and there have been many medical advances to the treatment of HIV. Due to these medical advances more individuals are living with HIV. (1,5) However, in recent years many researchers have focused on HIV and AIDS-related stigma and discrimination. This focus was sparked by the pervasive negative social response and treatment to individuals with HIV, especially within ethnic minority communities.5 Goffman defines stigma as “an attribute that is significantly discreting”, and its purpose is to diminish the individual who is undesirably different. (6) There is still a limited understanding on how stigma and discrimination contributes to HIV health outcomes, mental health status, and individual behaviors. (5) This is especially true for ethnic minorities as they also experience multiple stigmas and discrimination, such as low socioeconomic status, unequal access to quality healthcare, unequal treatment within the healthcare system, limited/inadequate sex and HIV education. (2,3,5) Earnshaw et al, 2013 introduced the Stigma and HIV Disparities Model to describe how societal stigma and discrimination related to race and ethnicity and its association with ethnic HIV disparities.(2) The Stigma and HIV Disparities Model demonstrates that at the structural level, stigma exists when there are historical traumatic events and medical mistrust. At the individual level, stigma exists when there is a lack or loss of social support, and lack of coping skills.(2)
Rao et al used the HIV Stigma Scale to compare African Americans and Caucasians in order to determine whether cross-cultural differences exist on perceived and experienced stigmatization.(7) The HIV Stigma Scale assesses stigmatization perceived and experienced by people living with HIV/AIDS. Results indicate that Black respondents had a higher probability of indicating greater stigmatization in which others discriminated against them, and White respondents had a higher probability of indicating greater stigmatization to keep their status a secret and fears of interpersonal rejection.(7) Experiencing negative stigma-related discriminatory attitudes, makes it difficult to cope with a positive diagnosis let alone take initiative. Multiple studies emphasize looking at HIV and AIDS-related stigma and discrimination as a social process (2,5,7) and for ethnic minorities it is important to adopt an intersectional and interdependence framework among co-occurring stigmas.(2)
LIVING WITH HIV & MENTAL HEALTH
Mental health is a critical component when assessing the impact of discrimination and stigma for those who are HIV positive. This impacts their ability to take care of themselves, live a happy and healthy life, and contribute back to society. The most vulnerable population with regards to this topic are individuals who are a part of the LGBTQ community.8 This population experiences discrimination and stigma based on their race/ethnicity, sexual orientation, and the stigma surrounding being HIV positive.8 Such stigmas are internalized and thus individuals may isolate themselves, refrain from accessing medical and social services, or are ostracized from their social networks. By not taking into account the role of mental health within this population it allows for increased depression, substance abuse and suicidality.8 Methods to measure anxiety, depression and suicide proneness are common throughout the literature through the Depression Anxiety Stress Scale, Coping with Discrimination Scale, and Internalized AIDS-Related Scale. (8) The magnitude of HIV-related stigma suggests that such variables should be given high priority in clinical decision-making settings concerning depression and increased substance-related coping.(8)
THE INFLUENCES OF STIGMA AND DISCRIMINATION ON BLACK MSM
Men who have sex with men account for the majority of new HIV infections in the United States, especially among Blacks, which exemplifies the importance of developing culturally sensitive interventions to alleviate stigma among those living with the disease.4 Within the MSM community, there is a higher prevalence of HIV infection among Black, non-Hispanics (28%) when compared to Hispanic (18%) and White, non-Hispanics (16%).4 Moreover, young Black MSM have a higher risk of new HIV infections (48%) in comparison to white MSM aged 13-29 years old. (4)Researchers indicate that stigma may be more severe among Black MSM as they not only can encounter discrimination based on their sexual orientation, but can also endure discrimination regarding their race and diagnosis.4 Furthermore, Black MSM are two times as likely as whites to believe that homosexuality is wrong due to increased internalized homophobia.(4) While some studies have confirmed a direct association between stigma and HIV risk, there are conflicting results in the literature, which warrants further investigation. (4) Some researchers have indicated that HIV positive MSM who experience higher levels of stigma are more likely to have unprotected sex due to social isolation whereas another study did not note an association between stigma and HIV risk behavior.4 These inconsistent results may be due to the varying definitions of stigma in the literature, which should be better defined and standardized in order to create effective interventions to alleviate stigma among Black MSM. (3,4)
Research regarding medical care among Black MSM is limited and should be further explored as some studies indicate that medical mistrust among this population is high.4 More specifically, studies have reported that some medical providers discriminate against Black MSM who exhibit bisexual behavior. (4) Thus, experiencing these acts of discrimination can lead to distrust with their provider, which may reduce ART adherence and decrease the frequency of health care utilization among Black MSM.(4) Understanding these cultural barriers within the healthcare system and stigma-related behaviors are critical in assessing effective methods to reducing these health disparities among Black MSM.
The Stigma and HIV Disparities Model encourages further research in reviewing the effectiveness of interventions at the individual and structural levels. (2 ) Individual level buy in through an individual’s trust, and thus adherence will follow. The following should be met at the individual level: physician and patient trust, common in-group identity, social support and adaptive coping. (2) Furthermore, structural level buy in through community involvement such as community education, interventions that empower neglected communities, community outreach programs, and faith-based organizations to name a few.
This review suggests that there is still a limited understanding on how stigma leads to racial HIV disparities further questioning, what can be done to reduce impact of stigma to alleviate these disparities? It has been determined that further research is needed to address such gaps. There is a need for racial ethnic minority representation in clinical traits.9 Racial ethnic minorities are underrepresented in clinical trials due to lack of medical centers and geographic regions where this population resides. (9)Therefore, aforementioned suggestions would help increase representation of racial ethnic minorities in clinical trials with the primary goal to alleviate the current stigma experienced by racial ethnic minorities living with HIV.
To alleviate such disparities it is evident that education is needed among this underserved population. Therefore, we further suggest directing focus in providing educational seminars on HIV and other sexually transmitted diseases where ethnic minorities reside. Development of community outreach programs that will access neglected communities to provide them with existing resources that these communities are not aware of such as wellness centers, counseling services, and free screenings. Additionally, fundamental causes continue to affect ethnic minorities living with HIV, therefore, reforming access to healthcare is critical. The cost of healthcare is at an all-time high and yet government officials have not developed a successful healthcare reform plan that will help lower the current healthcare deficit. Revising immigration policies, tackling HIV/AIDS stigma and homophobia would essentially aid the current state our healthcare system is in.
1. Organization WH. HIV/AIDS. 2017; http://www.who.int/mediacentre/factsheets/fs360/en/. Accessed October 12, 2017.
2. Earnshaw VA, Bogart LM, Dovidio JF, Williams DR. Stigma and racial/ethnic HIV disparities: moving toward resilience. Am Psychol. 2013;68(4):225.
3. Earnshaw VA, Chaudoir SR. From conceptualizing to measuring HIV stigma: a review of HIV stigma mechanism measures. AIDS Behav. 2009;13(6):1160.
4. Maulsby C, Millett G, Lindsey K, et al. HIV among black men who have sex with men (MSM) in the United States: a review of the literature. AIDS Behav. 2014;18(1):10-25.
5. Parker R, Aggleton P. HIV and AIDS-related stigma and discrimination: a conceptual framework and implications for action. Soc Sci Med. 2003;57(1):13-24.
6. Goffman E. Stigma: Notes on a spoiled identity. Jenkins, JH & Carpenter. 1963.
7. Rao D, Pryor JB, Gaddist BW, Mayer R. Stigma, secrecy, and discrimination: ethnic/racial differences in the concerns of people living with HIV/AIDS. AIDS Behav. 2008;12(2):265-271.
8. Vanable PA, Carey MP, Blair DC, Littlewood RA. Impact of HIV-related stigma on health behaviors and psychological adjustment among HIV-positive men and women. AIDS Behav. 2006;10(5):473-482.
9. Corbie-Smith G, Odeneye E, Banks B, Shandor Miles M, Roman Isler M. Development of a multilevel intervention to increase HIV clinical trial participation among rural minorities. Health Educ Behav. 2013;40(3):274-285.
Database - Search Terms
“HIV/AIDS AND Stigma AND Discrimination AND Ethnic Minorities”.
“New Yorkers AND Transgender Persons”, “HIV AND Stigma AND Social Stigma AND Discrimination”
“HIV AND AIDS AND Accessibility”.
“HIV AND discrimination OR stigma AND ethnic minorities AND urban setting”
“Stigma, discrimination, HIV/AIDS, and ethnic minorities”
“Stigma AND Discrimination AND HIV/AIDS AND United States”,
“HIV Stigma AND Minorities AND Urban Areas”
Table 1: Search terms used across