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Gender and Ethnicity Differences in HIV-related Stigma Experienced by People Living with HIV in Ontario, Canada

  • Mona R. Loutfy ,

    mona.loutfy@wchospital.ca

    Affiliations Department of Medicine, Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada

  • Carmen H. Logie,

    Affiliation Department of Medicine, Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada

  • Yimeng Zhang,

    Affiliation Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada

  • Sandra L. Blitz,

    Affiliation Department of Medicine, University Health Network, Toronto, Ontario, Canada

  • Shari L. Margolese,

    Affiliation Department of Medicine, Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada

  • Wangari E. Tharao,

    Affiliation Women's Health in Women's Hands Community Health Centre, Toronto, Ontario, Canada

  • Sean B. Rourke,

    Affiliation Department of Psychiatry, St. Michael's Hospital, Toronto, Ontario, Canada

  • Sergio Rueda,

    Affiliation Department of Psychiatry, St. Michael's Hospital, Toronto, Ontario, Canada

  • Janet M. Raboud

    Affiliation Department of Medicine, University Health Network, Toronto, Ontario, Canada

Gender and Ethnicity Differences in HIV-related Stigma Experienced by People Living with HIV in Ontario, Canada

  • Mona R. Loutfy, 
  • Carmen H. Logie, 
  • Yimeng Zhang, 
  • Sandra L. Blitz, 
  • Shari L. Margolese, 
  • Wangari E. Tharao, 
  • Sean B. Rourke, 
  • Sergio Rueda, 
  • Janet M. Raboud
PLOS
x

Abstract

This study aimed to understand gender and ethnicity differences in HIV-related stigma experienced by 1026 HIV-positive individuals living in Ontario, Canada that were enrolled in the OHTN Cohort Study. Total and subscale HIV-related stigma scores were measured using the revised HIV-related Stigma Scale. Correlates of total stigma scores were assessed in univariate and multivariate linear regression. Women had significantly higher total and subscale stigma scores than men (total, median = 56.0 vs. 48.0, p<0.0001). Among men and women, Black individuals had the highest, Aboriginal and Asian/Latin-American/Unspecified people intermediate, and White individuals the lowest total stigma scores. The gender-ethnicity interaction term was significant in multivariate analysis: Black women and Asian/Latin-American/Unspecified men reported the highest HIV-related stigma scores. Gender and ethnicity differences in HIV-related stigma were identified in our cohort. Findings suggest differing approaches may be required to address HIV-related stigma based on gender and ethnicity; and such strategies should challenge racist and sexist stereotypes.

Introduction

HIV-related stigma remains one of the greatest barriers to the health and well being of people living with HIV (PLHIV) [1], [2]. HIV-related stigma refers to the devaluing of HIV-positive people, and may result in discrimination based on actual or perceived HIV-positive serostatus [2]. HIV-related stigma may exacerbate pre-existing social inequities based on race, class, gender, and sexual orientation [3], [4]. It is particularly important to understand the interactions of HIV-related stigma with race and gender as HIV infections are rising among women globally and there is an overrepresentation of new HIV infections among Black and Aboriginal people in Canada [5], [6].

Prior research with PLHIV has indicated that HIV-related stigma is associated with deleterious mental, psychological, and emotional health outcomes [7][13]. HIV-related stigma may also compromise treatment, care and support for PLHIV. Disclosure of one's HIV positive serostatus to friends, family, social support networks and health care providers has been associated with marginalization, isolation and social exclusion [12], [14], [15]. Fear of disclosure associated with purchasing and taking antiretroviral drugs may negatively impact treatment adherence [13], [16][18]. Thus HIV-related stigma may lead to sub-standard treatment and can also present a barrier for PLHIV accessing and retaining health care services and social supports [19][21]. Reducing HIV-related stigma is therefore key to promoting the health of PLHIV.

Understanding and reducing HIV-related stigma, however, is complicated by its intersection with cross-cultural differences, structural inequalities, and social processes [3], [22][24]. Also, there remains a gap in understanding how HIV-related stigma interacts with socio-demographic factors such as gender and ethnicity [25], [26]. In a meta-analysis of demographic correlates of HIV-related stigma among PLHIV in North America, only 2 out of 24 studies examined ethnicity and 3 examined gender [25]. This study highlighted contradictory findings regarding the associations between HIV-related stigma and race/ethnicity [25][29] and gender [26], [28], [30][34]. This area therefore warrants further exploration.

Stigma analyses are also complicated by the myriad types of stigma, including perceived, internalized, enacted, layered/compounded, and symbolic. Perceived stigma refers to awareness of negative societal attitudes, fear of discrimination and feelings of shame [7], [35][37]. Internalized stigma refers to an individual's acceptance of negative beliefs, views and feelings towards the stigmatized group they belong to and oneself [36], [38][40]. Enacted stigma encompasses overt acts of discrimination, such as violence and exclusion [35], [41]. Layered or compounded stigma refers to a person holding more than one stigmatized identity, for example a gay PLHIV who faces stigma associated with HIV as well as sexual orientation [41][43]. Symbolic HIV-related stigma refers to blaming and judging already stigmatized groups for causing, spreading and perpetuating the HIV epidemic [35], [44][46].

This study was guided by the theoretical concept of intersectionality. Intersectionality refers to the interdependent relationships between social identities (e.g. gender, race/ethnicity) and social inequities (e.g. sexism, racism) [47][49]. Intersectional perspectives conceptualize that the convergence of different identities (e.g. gender, race/ethnicity) produces distinct and different experiences of inequity and opportunity [47], [50][52]. Intersectionality has been used as a guiding theoretical framework for HIV research in the United States (U.S.) and the United Kingdom (U.K.): these studies revealed that race and gender shaped PLHIV's experiences of HIV-related stigma [53][55]. Qualitative research in Canada suggests that HIV prevention barriers among Black women include sexism, racism and HIV-related stigma [56][59], underscoring the salience of working from an intersectional approach.

The objective of this study was to understand the associations between gender, ethnicity and HIV-related stigma among PLHIV in Ontario, Canada. The secondary objective was to explore associations between HIV-related stigma and other demographic and clinical variables. A clear understanding of the associations between HIV-related stigma, gender and ethnicity can inform the development, implementation and evaluation of tailored stigma reduction interventions [41], [44], [60].

Methods

Ethical Considerations

Written informed consent was obtained from all participants in the OCS. This study was approved by the OHTN Governance Committee and the University of Toronto Research Ethics Board. Research methods for this study were conducted following the principles of the Helsinki Declaration.

Study Design and Population

The study was a cross-sectional analysis using the baseline visit of the prospective observational study, the Ontario HIV Treatment Network (OHTN) Cohort Study (OCS) [61]. The OCS is a multi-site, clinical and population health prospective observational research study that recruited participants through primary and tertiary care sites. Clinical data was collected from multiple sources including electronic medical records, chart abstraction and linkages to other laboratory databases. In October 2007, the OCS introduced an annual interviewer-administered questionnaire which was either a 20-minute core questionnaire or a 90-minute extended questionnaire providing extensive socio-behavioural and demographic information [61]. For this analysis, only those completing the extended questionnaire which includes the HIV-related Stigma Scale were included. The current analysis included participants recruited from October 2007 to September 2009. Four clinic sites recruited for the OCS extended questionnaire during that time period and all were tertiary hospital clinics in Toronto. Sampling was non-random and targeted to those enrolled in a prior cohort and harder-to-reach populations including women, heterosexual men, those born in countries with a high prevalence of HIV, Aboriginal individuals, those with recent infection and injection drug users [61]. Additional detail on sampling and recruitment is available in a prior publication [61]. Refusal rates were approximately from 5% to 20% and varied by clinic [62].

Inclusion criteria for this analysis were that participants must: 1) be HIV positive based on a positive HIV antibody test or other laboratory evidence of HIV infection; 2) have provided OCS data on gender; 3) must have completed the OCS HIV-related Stigma Scale.

Measuring HIV-related Stigma

Stigma outcomes were measured using a revised shorter version of the HIV Stigma Scale developed by Berger and colleagues [63], [64]. The 16-item stigma questionnaire has four subscales: “Personalized Stigma” (enacted stigma), “Disclosure Concerns” (enacted stigma), “Negative Self-Image” (internalized stigma), and “Concern with Public Attitudes” (perceived stigma) [63]. Each subscale contained four items on a 5-point Likert scale. The total stigma score was calculated by summing the scores for the four subscales; missing values were imputed. The total HIV Stigma score ranges from 16 to 80, with higher scores indicating a higher degree of HIV-related stigma.

Definition of Correlates

The primary study outcomes were comparisons of severity and prevalence of HIV-related stigma by gender and ethnicity. For the comparative analyses of gender, only participants identifying as men or women were included. Due to the small number of participants (n = 9) self-identifying as transsexual, transgender or inter-sexed, these responses were excluded from the analysis.

Participants were assigned to an ethnicity category based on self-reported answer to the question “How would you describe your ethnicity?” Response options included White, Black, Latin American, South Asian, South East Asian, Arab/West Indian, Aboriginal, other, don't know, and refuse to answer. Participants were then sub-categorized into Black, White, Aboriginal, and Asian/Latin-American/Unspecified for the analyses.

Other HIV-related stigma correlates were assessed by examining associations with demographic and clinical variables including: age, HIV risk factors, sexual orientation, country of origin, immigration status, rural/urban residence, education, employment status, housing status, personal income, alcohol and drug use, duration of HIV diagnosis, CD4 count, viral load, and antiretroviral adherence.

Statistical Analysis

Baseline demographic information, clinical characteristics, and HIV-related stigma scores were tabulated by gender (male vs. female). Categorical variables were summarized with frequencies and proportions and compared between groups using chi-square tests or Fisher's exact test. Continuous variables were summarized with medians and inter-quartile ranges (IQR) and compared between groups using Wilcoxon Rank Sum tests. Types of HIV-related stigma types were examined by tabulating the subscale scores by gender and by ethnicity within gender.

Linear regression models were used to determine the estimates of total stigma scores associated with gender and ethnicity after adjusting for other covariates. Covariates which were significant in univariate models with a significance level <0.10 or which were a priori believed to be associated with HIV-related stigma were considered as candidates for inclusion in the multivariate logistic regression model. Covariates that were considered included variables such as: age, duration of HIV infection, injection drug use (IDU), HIV risk factors, country of origin, immigration status, education, employment status, housing status, and personal income. These statistical analyses were performed using SAS Statistical Software Version 9.2 by SAS Institute Inc., Cary, NC, USA.

Results

Cohort Characteristics

Of the 1073 participants who completed the extended questionnaire as of November, 2009, 1035 met the inclusion criteria (38 participants were excluded as there was not enough data to calculate a total stigma score). Of these respondents, nine self-identified as transgender or inter-sexed. Seven of the nine transgender individuals were transwomen (n = 7); their median age was 46 (IQR 44–50). Cohort characteristics of the remaining 1026 participants, grouped by gender, are summarized in Table 1. There were significant differences between men and women in age, HIV risk factors, sexual orientation, ethnicity, country of origin, immigration status, years since immigration, and years since HIV diagnosis. Men were more likely to be: an older age ([median IQR] 48 years old [42][54] vs. 41 years old [34][49], p<0.0001), White (68% vs. 34%, p<0.0001), and gay/bisexual (81% vs. 5%, p<0.0001). Men also had a longer duration of HIV infection (12 years vs. 8 years, p<0.0001).

Total Stigma and Subscale Scores by Gender

The total and subscale stigma scores analyzed by gender are summarized in Table 2. Women had significantly higher median total stigma scores and scores across all four subscales than men.

Comparison of Stigma Scores Across Ethnicities by Gender

Among women, White women had lower median total stigma scores than Black, Aboriginal, and Asian/Latin-American/Unspecified women (Table 3). These differences were influenced by differences between ethnicities in the “Concern with Public Attitudes” subscale: Black women had significantly higher scores on this subscale than Aboriginal, Asian/Latin-American/Unspecified and White women (Table 3). There were no significant differences in the subscale scores for “Personalized Stigma”, “Disclosure Concerns”, and “Negative Self-Image” across all four ethnicities for female participants (Table 3).

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Table 3. Total Stigma Scores and Subscale Scores by Female Gender and Ethnicity.

https://doi.org/10.1371/journal.pone.0048168.t003

Black men had significantly higher total stigma scores than Aboriginal, Asian/Latin-American/Unspecified, and White men. There were also similar significant differences across all four subscales (Table 4). Black men had the highest total stigma and the highest stigma for each subscale except Personalized Stigma, for which Aboriginal men had the highest levels.

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Table 4. Total Stigma Scores and Subscale Scores by Male Gender and Ethnicity.

https://doi.org/10.1371/journal.pone.0048168.t004

Linear Regression Analysis of Total Stigma Scores

For modelling purposes, ethnicities were divided into 3 groups: White, Black and Aboriginal/Asian, Latin-American/Unspecified. Significant correlates associated with higher total stigma scores in the univariate regression analysis were female gender, non-White race, heterosexual contact or contaminated blood contact and unspecified HIV risk factor, origin from a country with high HIV prevalence, non-Canadian-born immigration status, low income, and living outside of an urban area (Toronto) (Table 5). Older age, longer duration of HIV diagnosis, lesbian gay bisexual (LGB) sexual orientation, higher education, men who have sex with men (MSM) HIV risk factor, and more frequent alcohol use, marijuana use in the last 12 months, and any non-medicinal drug use in the last 6 months were associated with lower total stigma scores in the univariate model.

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Table 5. Univariate and Multivariable Linear Regression Models with Outcomes of Total Stigma Scores.

https://doi.org/10.1371/journal.pone.0048168.t005

In the multivariate model, we examined the effect of gender and ethnicity simultaneously using an interaction term with the reference group (White male); in the final model, HIV-related scores for Aboriginal/Asian/Latin-American/Unspecified men and Black women were significantly higher than White men; and nearly significant for Black men. Residence outside of the urban area and contaminated blood contact or unspecified HIV risk factor were also associated with higher stigma scores. Correlates of lower stigma included older age, longer duration since HIV diagnosis, LGB sexual orientation, higher education level, and more frequent alcohol use (Table 5).

Discussion

In this study female gender and non-White ethnicity were consistently associated with higher total and subscale HIV-related stigma scores. Gender and ethnicity interacted to increase the degree of stigma experienced: Black women, Aborginal/Asian/Latin-American/Unspecified men, and Black men reported the highest HIV-related stigma. Lower HIV-related stigma was associated with older age, time since diagnosis, LGB sexual orientation, higher education and alcohol frequency. Overall, findings suggest that HIV-related stigma may exacerbate certain pre-existing social inequities based on race and gender. Yet there may not be a clear-cut relationship between marginalization and HIV-related stigma: sexual minorities experienced lower HIV-related stigma than heterosexuals, and drug users reported lower rates of stigma than non-drug users.

Experiences of high levels of HIV-related stigma among women in this study, in particular Black women, suggests that sexist and racist stereotypes continue to permeate HIV discourse [65][69]. HIV-positive women have been positioned as “dirty, diseased and undeserving” [70] and may be blamed and shamed for HIV infection due to lasting assumptions of “deviant” sexual behaviour (e.g. sex work, promiscuity) [27], [31], [33], [60], [69], [71]. Gender norms that construct women as caregivers, mothers and nurturers can exacerbate stigma directed toward HIV-positive women who may be viewed as ill/diseased and therefore a failure in personal and social roles [32], [70], [72], [73]. The intersection of gender, race/ethnicity and class oppression are integral to understanding contexts of women's HIV risk and experiences of stigma [59], [74].

Racist stereotypes have been entrenched within constructions of HIV since the epidemic's beginning, with HIV constructed as first a “Haitian” and later an “African” disease [65], [66], [68]. HIV discourse has promoted racial stereotypes of ethnic minorities, in particular Black populations, as promiscuous, dangerous, and a threat to society [65], [68]. Higher HIV-related stigma among ethnic minorities and Aboriginal PLHIV in comparison with White PLHIV, found in this study, has also been reported in previous studies [28], [75] and reveals the embeddedness of racist stereotypes in HIV-related stigma [27]. Activism surrounding HIV and (homo)sexuality may have reduced HIV-related stigma among some LGBQ communities, yet there does not appear to be the same history of activism or success in challenging racist and sexist stereotypes ingrained in HIV discourse [65], [68]. In light of the growing HIV infection rates among Black and Aboriginal communities in Canada, in particular among Black and Aboriginal women, [5] such findings underscore the salience of challenging sexist and racist stereotypes.

Since the beginning of the epidemic, HIV and AIDS have been associated with “deviant sexuality” (e.g. homosexuality, sex work) – reinforcing the notion of the disease as punishment [65][68], [76]. Challenging homophobia and HIV-related stigma have been central components of lesbian, gay, bisexual, and queer (LGBQ) community mobilization and activism in North America, Western Europe and Australia since the early 1980's [68, -69]. The present study's finding that sexual minorities experience lower HIV-related stigma than heterosexuals suggests that such activism may have been successful in reducing the associations between “deviance”, homosexuality and HIV, and in creating safe places within urban LGBQ communities for PLHIV in Canada. Higher levels of HIV-related stigma among heterosexuals than sexual minorities have been reported in other studies, perhaps also due to concerns of heterosexual PLHIV being perceived as a sexual minority and/or fears of homophobia [25], [26], [45].

Drug use was associated with lower HIV-related stigma in this analyis. There are conflicting findings regarding drug use and stigma: some authors suggest drug use is a factor that exacerbates HIV-related stigma [23], [42], while others have found drug use is correlated with lower HIV-related stigma among PLHIV [32]. Drug users may have developed coping mechanisms related to drug use to decrease stigma [32], and may also perceive lower HIV-related stigma due to to greater concerns regarding drug use stigma [77].

Other factors associated with lower HIV-related stigma in the current study–urban residence, older age and higher levels of education–corroborate previous research [10], [25], [78], [79]. Factors underpinning higher stigma outside of urban areas may include a lack of visibility of HIV prevention initiatives, and thus less dialogue and education regarding HIV, reduced support services, and a lack of privacy and confidentiality [10], [78], [79]. Increased age and education may be associated with internal resources such as self-esteem, coping, life satisfaction, and emotional health, as well as higher income: these factors may mitigate experiences of HIV-related stigma [25]. Longer duration of HIV diagnosis–correlated with lower HIV-related stigma–is also associated with older age. People living with HIV may develop coping strategies and social support networks over time to help reduce stigma.

Understanding how racism and sexism may exacerbate HIV-related stigma can inform interventions to challenge stigma. Systematic reviews have underscored a paucity of evidence-based HIV-related stigma reduction interventions [23], [43], [80]. These reviews recommend multi-level interventions that use a variety of approaches. For example, individual and community interventions to reduce HIV-related stigma can incorporate: counseling and support groups for PLHIV; information and education for non-PLHIV; mass media campaigns; and skills-building for family/friends to improve care for PLHIV [23], [43], [80], [81]. Structural level interventions can include institutional protection from discrimination based on HIV serostatus, race/ethnicity, gender, and sexual orientation, as well as anti-discrimination training for health/social service providers [23], [82], [83]. HIV-related stigma reduction interventions must challenge racist and sexist stereotypes not only in HIV discourse but also in Canadian society in order to benefit women and ethnic minorities–among the most stigmatized PLHIV.

This study had several limitations. The OCS is a voluntary study involving a non-random sampling of PLHIV who are in care and there was a potential for selection bias as the participants in the OCS may differ from the general population of PLHIV in Ontario [61], [62]. It is possible that PLHIV who participate in the OCS experience lower levels of stigma and fewer concerns regarding disclosure of information. Although the sample size for the cohort was significant, the small number of female participants may have limited the determination of significant differences in stigma levels between ethnicity groups. The study was also not able to capture the experiences of transgender PLHIV due to the small number enrolled within the OCS. Small numbers of certain ethnicities such as Asian and Latin American resulted in combining these populations, precluding understanding the similarities/differences in HIV-related stigma within and between these groups. No data was available on pregnancy which may impact stigma experienced by women due to issues of disclosure or if HIV diagnosis occurred during pregnancy.

Our findings suggest the need to move beyond a layered or compounded stigma model. Layered/compounded stigma posits that more marginalized identities result in more cumulative oppression, whereas intersectionality suggests that social identities are multi-dimensional and cannot be summed up [42], [47], [48], [51], [52]. Current findings reveal that certain marginalized identitites, such as gender, may interact with HIV-related stigma to increase stigmatization while others, such as sexual orientation, may reduce experiences of HIV-related stigma. These findings build on conceptualizations of HIV-related stigma that describe racism, sexism, and pre-existing stigma towards drug users and men who have sex with men (MSM) as predisposing facilitators of HIV-related stigma [23], [43] to suggest that stigma may additionally be complicated by identity, context, history, and socio-cultural and political factors. Intersectionality therefore affords a more nuanced understanding of stigma that challenges the notion of who may be pre-disposed to stigma.

This situational nature of HIV-related stigma cannot be understated. For example, human rights violations among sexual minorities in multiple countries highlight the importance of understanding context in ascertaining the meaning and significance of sexual orientation in experiences of HIV-related stigma [84], [85]. HIV has long been constructed as a “gay disease” and an abundance of literature highlights the convergence of HIV-related stigma with sexual stigma and homophobia [32], [45], [84][87]. This literature serves as a reminder that the current study's findings of lower HIV-related stigma among sexual minorities may not be generalizable outstide of urban Canadian settings.

Conclusions

In our study, we found that female gender and non-White ethnicity were associated with higher total and subscale HIV-related stigma scores. In our multivariable model, gender and ethnicity interacted to increase the degree of stigma experienced by Black women, Aborginal/Asian/Latin-American/Unspecified men, and Black men. Future research could explore why some marginalized groups may experience lower HIV-related stigma while others experience higher HIV-related stigma. Understanding contextual factors, such as culture, country, and rural/urban differences, is also central to understanding and addressing HIV-related stigma. Additional research should examine the intersection of HIV-related stigma with ethnicity, gender, and sexual orientation at multiple levels (micro, meso and macro) locally, regionally, and globally [25], [59]. There is a clear need for evidence-based interventions to challenge HIV-related stigma among diverse populations of PLHIV [43], [88], [89] at multiple levels. The complexity of HIV-related stigma necessitates engaging with all aspects of PLHIV identity to promote equity and human rights.

Acknowledgments

We gratefully acknowledge all of the people living with HIV who volunteered to participate in the OHTN Cohort Study and the work and support of the past and present members of the OCS Governance Committee: Darien Taylor, Dr. Evan Collins, Dr. Greg Robinson, Shari Margolese, Patrick Cupido, Tony Di Pede, Rick Kennedy, Michael Hamilton, Ken King, Brian Finch, Lori Stoltz, Dr. Ahmed Bayoumi, Dr. Clemon George, Dr. Curtis Cooper, Dr. Troy Grennan, Adrian Betts, Tracey Conway, and Colleen Price. We thank all the interviewers, data collectors, research associates and coordinators, nurses and physicians who provide support for data collection and extraction. The authors wish to thank the OHTN staff and their teams for data management and IT support (Mark Fisher, Director, IT), and OCS project coordination (Samantha Robinson, Project Coordinator). The OHTN Cohort Study is supported by the Ontario Ministry of Health and Long-Term Care.

Sources of Support

The OHTN Cohort Study is supported by the AIDS Bureau – Ontario Ministry of Health and Long-Term Care. Three investigators are also the recipients of salary support from the Canadian Institutes of Health Research (MRL, CHL) and the Ontario HIV Treatment Network (JMR).

The OHTN Cohort Study Team

Additional members of The OHTN Cohort Study Team consists of Dr. Ann Burchell (Co-Principal Investigator, OHTN), Dr. Sandra Gardner (OHTN), Dr. Ahmed Bayoumi, St. Michael's Hospital; Dr. Jeffrey Cohen, Windsor Regional Hospital; Dr. Curtis Cooper, Ottawa General Hospital; Dr. Don Kilby, University of Ottawa Health Services; Dr. Fred Crouzat, Maple Leaf Medical Clinic; Dr. Anita Rachlis and Dr. Nicole Mittmann, Sunnybrook Health Sciences Centre; Dr. Irving Salit, Toronto General Hospital; Dr. Edward Ralph, St. Joseph's Health Care; Dr. Roger Sandre, Sudbury Regional Hospital; Dr. Marek Smieja, Hamilton Health Sciences, McMaster University Medical Centre; and Dr. Wendy Wobeser, Hotel Dieu Hospital.

Author Contributions

Conceived and designed the experiments: MRL WET. Performed the experiments: CHL YZ SLM. Analyzed the data: SBR JMR. Contributed reagents/materials/analysis tools: SBR SR. Wrote the paper: MRL CHL YZ SLB. Provided editorial and feedback regarding ethnicity analysis: WET.

References

  1. 1. Herek GM (1999) AIDS and Stigma. Am Behav Sci 42: 1106–1116.
  2. 2. UNAIDS (2007) AIDS epidemic update 2007. Geneva: UNAIDS. Available: http://data.unaids.org/pub/epislides/2007/2007_epiupdate_en.pdf. Accessed 2012 Jan 25.
  3. 3. Parker R, Aggleton P (2003) HIV and AIDS-related stigma and discrimination: A conceptual framework and implications for action. Soc Sci Med 57: 13–24.
  4. 4. Sumartojo E (2000) Structural factors in HIV prevention: Concepts, examples, and implications for research. AIDS 14 Suppl: 3–10
  5. 5. Public Health Agency of Canada (PHAC) (2009) HIV and AIDS in Canada. Surveillance Report to December 31, 2008. Ottawa: Public Health Agency of Canada. Available: http://www.phac-aspc.gc.ca/aids-sida/publication/survreport/2008/dec/pdf/survrepdec08.pdf. Accessed 25 January 2012.
  6. 6. UNAIDS 2010. UNAIDS Report on the Global AIDS Epidemic. Geneva: UNAIDS. Available: http://www.unaids.org/globalreport/documents/20101123_GlobalReport_full_en.pdf. Accessed 2012 Jan 25.
  7. 7. Berger BE, Ferrans CE, Lashley FR (2001) Measuring Stigma in People with HIV: Psychometric Assessment of the HIV Stigma Scale. Res Nurs Health 24: 518–529.
  8. 8. Buseh AG, Stevens PE (2007) Constrained but not determined by stigma: Resistance by African American women living with HIV. Women Health 44: 1–18.
  9. 9. Courtney-Quirk C, Wolitski RJ, Parsons JT, Gomez CA (2006) Seropositive Urban Men's Study Team (2006) Is HIV/AIDS stigma dividing the gay community? Perceptions of HIV-positive men who have sex with men. AIDS Educ Prev 18: 56–67.
  10. 10. Heckman TG, Anderson ES, Sikkema KJ, Kochman A, Kalichman SC (2004) Emotional distress in non-metropolitan persons living with HIV disease enrolled in a telephone-delivered, coping improvement group intervention. Health Psychol 23: 94–100.
  11. 11. Rueda S, Gibson K, Rourke S, Bekele T, Gardner S, et al. (2011) Mastery moderates the negative effect of stigma on depressive symptoms in people living with HIV. AIDS Behav 16: 660–669.
  12. 12. Vanable PA, Carey MP, Blair DC, Littlewood RA (2006) Impact of HIV-Related Stigma on Health Behaviors and Psychological Adjustment among HIV-Positive Men and Women. AIDS Behav 10: 473–482.
  13. 13. Ware NC, Wyatt MA, Tugenberg T (2006) Social relationships, stigma and adherence to antiretroviral therapy for HIV/AIDS. AIDS Care 18: 904–910.
  14. 14. Abell N, Rutledge SE, Mccann TJ, Padmore J (2007) Examining HIV/AIDS provider stigma: Assessing regional concerns in the islands of the Eastern Caribbean. AIDS Care 19: 242–247.
  15. 15. Kymla J (2005) Dynamics of hope in adults living with HIV/AIDS: A substantive theory. J Adv Nurs 52: 620–630.
  16. 16. Konkle-Parker DJ, Erlen JA, Dubbert PM (2008) Barriers and facilitators to medication adherence in a southern minority population with HIV disease. JANAC 19: 98–104.
  17. 17. Rao D, Kekwaletswe TC, Hosek S, Martinez J, Rodriguez F (2007) Stigma and social barriers to medication adherence with urban youth living with HIV. AIDS Care 19: 28–33.
  18. 18. Rintamaki LS, Davis TC, Skripkauskas S, Bennett CL, Wolf MS (2006) Social Stigma Concerns and HIV Medication Adherence. AIDS Patient Care ST 20: 359–368.
  19. 19. Bradford JB, Coleman S, Cunningham W (2007) HIV system navigation: An emerging model to improve HIV care access. AIDS Patient Care ST 21 Suppl1: 49–58.
  20. 20. Naar-King S, Bradford J, Coleman S, Green-Jones M, Cabral H, et al. (2007) Retention in care of persons newly diagnosed with HIV: Outcomes of the outreach initiative. AIDS Patient Care ST 21 Suppl 140–48.
  21. 21. White RC, Carr R (2005) Homosexuality and HIV/AIDS stigma in Jamaica. Cult Health Sex 7: 347–359.
  22. 22. Campbell C, Deacon H (2006) Unravelling the contexts of stigma: From internalization to resistance to change. J Community Appl Soc Psychol 16: 411–417.
  23. 23. Mahajan AP, Sayles JN, Patel VA, Remien RH, Sawires SR, et al. (2008) Stigma in the HIV/AIDS epidemic: a review of the literature and recommendations for the way forward. AIDS 22 Suppl 267–79.
  24. 24. Van Brakel WH (2006) Measuring health-related stigma: A literature review. Psychol Health Med 11: 307–334.
  25. 25. Logie C, Gadallla TM (2009) Meta-analysis of health and demographic correlates of stigma towards people living with HIV. AIDS Care 21: 742–753.
  26. 26. Lee RS, Kochman A, Sikkema KJ (2002) Internalized Stigma Among People Living with HIV-AIDS. AIDS Behav 6: 309–319.
  27. 27. Lekas HM, Siegel K, Schrimshaw EW (2006) Continuities and discontinuities in the experiences of felt and enacted stigma among women with HIV/AIDS. Qual Health Res 16: 1165–1190.
  28. 28. Emlet CA (2006) A comparison of HIV stigma and disclosure patterns between older and younger adults living with HIV/AIDS. AIDS Patient Care ST 20: 350–358.
  29. 29. Schuster MA, Collins R, Cunningham WE, Morton SC, Zierler S, et al. (2005) Perceived discrimination in clinical care in a nationally representative sample of HIV-infected adults receiving health care. J Gen Intern Med 20: 807–813.
  30. 30. Steward WT, Herek M GM, Ramakrishna J, Bharat S, Chandy S (2008) HIV-related stigma: Adapting a theoretical framework for use in India. Soc Sci Med 67: 1225–1235.
  31. 31. Sandelowski M, Lambe C, Barroso J (2004) Stigma in HIV-positive Women. J Nurs Scholarship 36: 122–128.
  32. 32. Swendeman D, Rotheram-Borus MJ, Comulada S, Weiss R, Ramos ME (2006) Predictors of HIV-related Stigma among Young People Living with HIV. Health Psychol 25: 501 – 509.
  33. 33. Sowell RL, Lowenstein A, Moneyham L, Demi A, Mizuno Y, et al. (1997) Resources, stigma, and patterns of disclosure in rural women with HIV infection. Public Health Nurs 14: 302–312.
  34. 34. Emlet CA (2005) Measuring stigma in older and younger adults with HIV/AIDS: An analysis of an HIV stigma scale and initial exploration of subscales. Res Social Work Prac 15: 291–300.
  35. 35. Herek GM, Capitanio JP, Widaman KF (2002) HIV-related Stigma and Knowledge in the United States: Prevalence and Trends, 1991 – 1999. Am J Public Health 92: 371–377.
  36. 36. Herek GM, Garnets LD (2007) Sexual orientation and mental health. Annu Rev Clin Psycho 3: 353–375.
  37. 37. Meyer IH (2003) Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychol Bull 129: 674–697.
  38. 38. Mak WS, Poon CY, Pun LY, Cheung SF (2007) Meta-analysis of stigma and mental health. Soc Sci Med 65: 245–261.
  39. 39. Steward WT, Herek GM, Ramakrishna J, Bharat S, Chandy S, et al. (2008) HIV-related stigma: Adapting a theoretical framework for use in India. Soc Sci Med 67: 1225–1235.
  40. 40. Kalichman SC, Simbayi LC, Cloete A, Mthembu PP, Mkhonta RN, et al. (2009) Measuring AIDS stigmas in people living with HIV/AIDS: the Internalized AIDS-related Stigma Scale. AIDS Care 21: 87–93.
  41. 41. Nyblade LC (2006) Measuring HIV stigma: Existing knowledge and gaps. Psychology, Health & Medicine. Special Issue: Perspect Health-related Stigma 11: 335–345.
  42. 42. Reidpath DD, Chan KY (2005) A Method for the Quantitative Analysis of the Layering of HIV-Related Stigma. AIDS Care 17: 425–432.
  43. 43. Sengupta S, Banks B, Jonas D, Miles MS, Smith GC (2011) HIV interventions to reduce HIV/AIDS stigma: A systematic review. AIDS Behav 15: 1075–87.
  44. 44. Deacon H (2006) Towards a sustainable theory of health-related stigma: Lessons from the HIV/AIDS literature. J Community Appl Soc Psychol 16: 418–425.
  45. 45. Herek GM, Capitanio JP (1999) AIDS stigma and sexual prejudice. Am Behav Sci 42: 1130–1147.
  46. 46. Herek GM, Capitanio JP, Widaman KF (2003) Stigma, social risk and health policy: Public attitudes towards HIV surveillance policies and the social construction of illness. Health Psychol 22: 533–540.
  47. 47. Vanable PA, Carey MP, Blair DC, Littlewood RA (2006) Impact of HIV-Related Stigma on Health Behaviors and Psychological Adjustment among HIV-Positive Men and Women. AIDS Behav 10: 473–482.
  48. 48. Collins PC (2000) Black Feminist Thought, 2nd Edition. New York: Routledge. 75p.
  49. 49. Crenshaw K (1989) Demarginalizing the intersection of race and sex: A black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics. Univ Chicago Legal Forum 139: 139–167.
  50. 50. Collins PH (1991) Black Feminist Thought: Knowledge, Consciousness, and the Politics of Empowerment. New York: Routledge. 109p.
  51. 51. Shields SA (2008) Gender: An Intersectionality Perspective. Sex Roles 59: 301–311.
  52. 52. Purdie-Vaughns V, Eibach RP (2008) Intersectional Invisibility: The Distinctive Advantages and Disadvantages of Multiple Subordinate-Group Identities. Sex Roles 59: 377–391.
  53. 53. Collins PY, von Unger H, Armbrister A (2008) Church ladies, good girls, and locas: Stigma and the intersection of gender, ethnicity, mental illness, and sexuality in relation to HIV risk. Soc Sci Med 67: 389–397.
  54. 54. Doyal L (2009) Challenges in researching life with HIV/AIDS: An intersectional analysis of black African migrants in London. Cult Health Sex 11: 173–188.
  55. 55. Margulies P (1994) Asylum, Intersectionality, and AIDS: Women with HIV as a Persecuted Social Group. Georgetown Law J 8: 521–555.
  56. 56. Newman PA, Williams CC, Massaquoi N, Brown M, Logie C (2008) HIV prevention for Black women: Structural barriers and opportunities. J Health Care Poor Underserved 19: 829–841.
  57. 57. Williams CC, Newman PA, Sakamoto I, Massaquoi NA (2009) HIV prevention risks or Black women in Canada. Soc Sci Med 68: 12–20.
  58. 58. Tharao E, Massaquoi N, Teclom S (2006) Silent Voices of the HIV/AIDS Epidemic: African and Caribbean Women Research Study (2002–2004). Toronto: Women's Health in Women's Hands.
  59. 59. Logie CH, James L, Tharao W, Loutfy MR (2011) HIV, gender, race, sexual orientation, and sex work: A qualitative study of intersectional stigma experienced by HIV-positive women in Ontario, Canada. PLoS Med 8: e1001124.
  60. 60. Link BG, Phelan JC (2001) Conceptualizing stigma. Annu Rev Social 27: 363–385.
  61. 61. Rourke SB, Gardner S, Burchell AN, Raboud J, Rueda S, et al.. (2012) Cohort Profile: The Ontario HIV Treatment Network Cohort Study (OCS). Int J Epidemiol Feb 16. [Epub ahead of print].
  62. 62. Raboud J, Su D, Walmsley S, Cooper C, Cohen J, et al.. (2010) Representativeness of the Ontario Cohort Study of the clinics from which they are recruiting. In Proceeding of the OHTN Research Conference, Toronto, Ontario, Canada, November 2010.
  63. 63. Berger BE, Ferrans CE, Lashley FR (2001) Measuring stigma in people with HIV: Psychometric assessment of the HIV stigma scale. Res Nurs Health. 24(6): 518–29.
  64. 64. Gibson K, Bekele T, Rueda S (2009) Sociobehavioural Variables in the OHTN Cohort Study Extended Questionnaire: Summary of the Literature and Options for Scoring. Toronto: Ontario HIV Treatment Network.
  65. 65. Farmer P (2001) Infections and inequalities: The modern plagues. Berkeley: University of California Press. 111p.
  66. 66. Gilman S (1988) Disease and Representation: Images of Illness from Madness to AIDS. Ithaca, NY: Cornell University Press. 97p.
  67. 67. Herek GEG (1988) An epidemic of stigma: Public reactions to AIDS. Am Psychol 43: 886–891.
  68. 68. Patton C (2002) Globalizing AIDS. Minneapolis: University of Minnesota Press. 115p.
  69. 69. Wolffers I (2000) Biomedical and development paradigms in AIDS prevention. Bulletin of the World Health Organization 78: 267–273.
  70. 70. Lawless S, Kippax S, Crawford J (1996) Dirty, diseased and undeserving: the positioning of HIV positive women. Soc Sci Med 43: 1371–1377.
  71. 71. Katz S, Nevid JS (2005) Risk factors associated with posttraumatic stress disorder symptomatology in HIV-infected women. AIDS Patient Care ST 19: 110–120.
  72. 72. Green G (1996) Stigma and social relationships of people with HIV: Does gender make a difference? In: AIDS as a gender issue: Psychosocial perspectives. Sherr L, Hankins C, Bennett L (Eds), Washington, DC: Taylor & Francis. 46–63p.
  73. 73. Ingram D, Hutchinson SA (2000) Double binds and the reproductive and mothering experiences of HIV-positive women. Qual Health Res 10: 117 –132.
  74. 74. Amaro H, Raj A (2000) On the margin: Power and women's HIV risk reduction strategies. Sex Roles 42: 723–749.
  75. 75. Newman PA, Woodford MR, Logie CH (2012) HIV vaccine acceptability and culturally appropriate dissemination among sexually diverse Aboriginal peoples in Canada. Global Public Health 7: 87–100.
  76. 76. Cloete A, Simbayi LC, Kalichman SC, Strebel A, Henda N (2008) Stigma and discrimination experiences of HIV-positive men who have sex with men in Capetown, South Africa. AIDS Care 20: 1105–10.
  77. 77. Goffman E (1963) Stigma: Notes on the management of spoiled identity. Englewood Cliffs, NJ: Prentice Hall. 30p.
  78. 78. Reif S, Golin CE, Smith SR (2005) Barriers to accessing HIV/AIDS care in North Carolina: Rural and urban differences. AIDS Care 17: 558–565.
  79. 79. Stephenson J (2000) Rural HIV/AIDS in the United States. JAMA 284: 167–168.
  80. 80. Brown L, Macintyre K, Trujillo L (2003) Interventions to reduce HIV/AIDS stigma: What have we learned? AIDS Educ Prev 15: 49–69.
  81. 81. UNAIDS 2005 (2005) HIV-related stigma, discrimination and human rights violations: case studies of successful programmes. Geneva: UNAIDS. Available: http://data.unaids.org/publications/irc-pub06/jc999-humrightsviol_en.pdf. Accessed 2012 Jan 25.
  82. 82. Brondolo E, Gallo LC, Myers HF (2009) Race, racism and health: Disparities, mechanisms, and interventions. J Behav Med 32: 1–8.
  83. 83. Schwartz J, Lindley L (2009) Impacting Sexism through Social Justice Prevention: Implications at the Person and Environmental Levels. J Pri Prev 30: 27–41.
  84. 84. Baral S, Sifakis F, Cleghorn F, Beyrer C (2007) Elevated risk for HIV infection among men who have sex with men in low- and middle-income countries 2000–2006: A systematic review. PLoS Med 4: e339.
  85. 85. Baral S, Adams D, Lebona J, Kaibe B, Letsie P, et al. (2011) A cross-sectional assessment of population demographics, HIV risks and human rights contexts among men who have sex with men in Lesotho. J Int AIDS Soc 14: 36.
  86. 86. Wright K, Naar-King S, Lam P, Templin T, Frey M (2007) Stigma scale revised: Reliability and validity of a brief measure of stigma for HIV+ youth. J Adolescent Health 40: 96–98.
  87. 87. Crandall CS, Glor J, Britt TW (1997) AIDS-related stigmatization: Instrumental and symbolic attitudes. J Appl Soc Psychol 27: 95–123.
  88. 88. Scott-Sheldon LA, Kalichman SC, Carey MP, Fielder RL (2008) Stress management interventions for HIV+ adults: a Meta-analysis of randomized controlled trials, 1989 to 2006. Health Psychol 27: 129–39.
  89. 89. Simbayi LC, Kalichman S, Strebel A, Cloete A, Henda N, et al. (2007) Internalized stigma, discrimination, and depression among men and women living with HIV/AIDS in Capetown, South Africa. Soc Sci Med 64: 1823–31.