Skip to main content
Browse Subject Areas

Click through the PLOS taxonomy to find articles in your field.

For more information about PLOS Subject Areas, click here.

  • Loading metrics

Religion, faith, and spirituality influences on HIV prevention activities: A scoping review

  • Vivian Vigliotti ,

    Contributed equally to this work with: Vivian Vigliotti, Tamara Taggart, Mahaya Walker, Sasmita Kusmastuti

    Roles Data curation, Project administration, Resources, Writing – review & editing

    Affiliation Robbins Institute for Health Policy & Leadership, Baylor University, Waco, Texas, United States of America

  • Tamara Taggart ,

    Contributed equally to this work with: Vivian Vigliotti, Tamara Taggart, Mahaya Walker, Sasmita Kusmastuti

    Roles Formal analysis, Investigation, Validation, Writing – review & editing

    Affiliations Department Social and Behavioral Sciences, Yale School of Public Health, New Haven, Connecticut, United States of America, Prevention and Community Health, George Washington University School of Public Health, Washington, DC, United States of America

  • Mahaya Walker ,

    Contributed equally to this work with: Vivian Vigliotti, Tamara Taggart, Mahaya Walker, Sasmita Kusmastuti

    Roles Data curation, Project administration, Writing – review & editing

    Affiliation Department Social and Behavioral Sciences, Yale School of Public Health, New Haven, Connecticut, United States of America

  • Sasmita Kusmastuti ,

    Contributed equally to this work with: Vivian Vigliotti, Tamara Taggart, Mahaya Walker, Sasmita Kusmastuti

    Roles Data curation, Formal analysis, Investigation, Software, Visualization, Writing – review & editing

    Affiliation Department of Public Health, University of Copenhagen, Copenhagen, Kobenhavns, Denmark

  • Yusuf Ransome

    Roles Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – review & editing

    Affiliation Department Social and Behavioral Sciences, Yale School of Public Health, New Haven, Connecticut, United States of America


28 Oct 2020: Vigliotti V, Taggart T, Walker M, Kusumastuti S, Ransome Y (2020) Correction: Religion, faith, and spirituality influences on HIV prevention activities: A scoping review. PLOS ONE 15(10): e0241737. View correction



Strategies to increase uptake of next-generation biomedical prevention technologies (e.g., long-acting injectable pre-exposure prophylaxis (PrEP)) can benefit from understanding associations between religion, faith, and spirituality (RFS) and current primary HIV prevention activities (e.g., condoms and oral PrEP) along with the mechanisms which underlie these associations.


We searched PubMed, Embase, Academic Search Premier, Web of Science, and Sociological Abstracts for empirical articles that investigated and quantified relationships between RFS and primary HIV prevention activities outlined by the United States (U.S.) Department of Health and Human Services: condom use, HIV and STI testing, number of sexual partners, injection drug use treatment, medical male circumcision, and PrEP. We included articles in English language published between 2000 and 2020. We coded and analyzed studies based on a conceptual model. We then developed summary tables to describe the relation between RFS variables and the HIV prevention activities and any underlying mechanisms. We used CiteNetExplorer to analyze citation patterns.


We identified 2881 unique manuscripts and reviewed 29. The earliest eligible study was published in 2001, 41% were from Africa and 48% were from the U.S. RFS measures included attendance at religious services or interventions in religious settings; religious and/or spirituality scales, and measures that represent the influence of religion on behaviors. Twelve studies included multiple RFS measures. Twenty-one studies examined RFS in association with condom use, ten with HIV testing, nine with number of sexual partners, and one with PrEP. Fourteen (48%) documented a positive or protective association between all RFS factors examined and one or more HIV prevention activities. Among studies reporting a positive association, beliefs and values related to sexuality was the most frequently observed mechanism. Among studies reporting negative associations, behavioral norms, social influence, and beliefs and values related to sexuality were observed equally. Studies infrequently cited each other.


More than half of the studies in this review reported a positive/protective association between RFS and HIV prevention activities, with condom use being the most frequently studied, and all having some protective association with HIV testing behaviors. Beliefs and values related to sexuality are possible mechanisms that could underpin RFS-related HIV prevention interventions. More studies are needed on PrEP and spirituality/subjective religiosity.


An estimated 40 million people are living with HIV (PLWH) and the number of people newly HIV infected declined by a modest 10% between 2013 and 2017 [1]. Approximately 40% of PLWH are not accessing antiretroviral therapy (ART); therefore, they miss opportunities to improve their quality of life and lower transmission risk in the population [2, 3]. To halt transmission and reduce HIV incidence, combination approaches—those that integrate biomedical, behavioral, and structural factors, are necessary [4]. Currently, biomedical technologies in the form of antiretroviral drugs have been dominating the discourse both for secondary treatment as prevention (TasP) promoted through campaigns such as “Undetectable = Untransmittable” (U = U) [5] and primary prevention activities such as Pre-Exposure Prophylaxis (PrEP) [6, 7]. However, for those biomedical modalities to be effective and achieve maximum population impact; individuals need to maintain high levels of adherence [8], which requires attention to cultural context [9] and who is being targeted [10] because ART can be used for either prevention or treatment [11].

Beyond cost and other structural barriers such as availability, one’s ability to achieve high levels of adherence are largely affected by one’s social circumstances [12]. We know that norms within cultural contexts either constrain or empower one’s agency to engage in HIV prevention behaviors [1315]. Therefore, to reduce HIV incidence through combination prevention approaches, we need to understand the influence of upstream social and cultural factors including norms, values, networks, structures, and institutions [16, 17]. However, to date, we know little about effectiveness and impact of social and cultural interventions on reducing HIV burden and forward transmission [18].

We conducted this study, therefore, to investigate the role of religion, faith, and spirituality (RFS) on primary HIV prevention. Religion is one key social and cultural factor [1921] with pervasive influence over the norms, values, structures, and institutions, which profoundly impact individuals’ behaviors and decisions [22, 23]. Religion can be defined broadly as a system of symbols, rites, experiences, and rituals that have powerful, pervasive, and long-lasting actions and motivations that are generated through concepts of existence, which captures awe and dependence of a power greater than one’s self [24, 25]. Religion is timely to study and imperative to include in any combination of HIV prevention activity [26]. Approximately 84% of the world’s population self-report being religiously affiliated [27]. Moreover, the countries with the fastest growing population, including those with highest HIV burden, report high religious involvement [28]. For instance, in South Africa, the region with highest HIV prevalence in the world; 56% of the population report being active members of church or religious organizations [29]. Faith is another construct, that when applied to religion describes a psychological cognitive process of developing a system of knowing, giving coherence to life, and valuing [30]. Spirituality is another construct that overlaps but is distinct from religiosity. It has been defined as one’s personal experience, belief or relationship with a divine/higher power or search for the sacred, where the sacred may or may not be connected to religion [3133].

We study primary HIV prevention because of the increasing trend towards and rapid availability of biomedical prevention options such as long-acting injectable PrEP, MK-8591-eluting implant, and dolutegravir (DTG)-based HIV treatment during pregnancy. Therefore, we need to better understand and activate social and cultural factors that could expedite uptake and adherence of these technologies. We also focus on primary prevention because prior review studies of religion and HIV already covered health and HIV-clinical outcomes among PLWH such as viral suppression, CD4+ count, and ART adherence [34, 35]. Next, there is only one published systematic review on religion and primary HIV prevention, however that study narrowed in on sexual HIV risk behaviors such as sexual initiation and sexual experience [36]. The consensus from those studies was that religious factors are mostly protective. However, several gaps in knowledge remain, which our study aims to fill.

First, we provide evidence of the association between RFS and other key primary HIV prevention activities outlined by the United States Department of Health and Human Services (U.S. DHHS): condom use, HIV and sexually transmitted infection (STI) testing, reducing number of sexual partners, injection drug use treatment, medical male circumcision, and PrEP [37]. Second, we identify potential mechanisms which underlie both positive and negative associations. Clarifying these mechanisms may inform HIV prevention interventions and implementation science activities worldwide. Third, we provide a fuller description of “religion’s” impact on HIV by expanding or refining operational definitions to include constructs such as faith and spirituality, given these are sometimes conflated yet may have different implications for interventions.


Search strategy

We searched five databases—PubMed, Embase, Academic Search Premier, Web of Science, Sociological Abstracts—using predefined keywords (S1 Table) developed in consultation with our university librarian. We conducted the search in accordance to the PRISMA Statement, for articles published between January 1, 2000 and February 20, 2020. We submitted our protocol to PROSPERO (S1 Document) at the beginning of our study, however, it was not registered since scoping reviews are not considered.

Study selection

Our inclusion criteria were articles: (1) written in English; (2) published between January 1, 2000 and February 20, 2020; (3) peer-reviewed; (4) considered an HIV prevention activity and RFS; and (5) quantified the association between RFS and the HIV prevention activities (S2 Table). First, two authors (VV, MW) independently reviewed the title and abstract and then the full-text of each article, with a third author (YR) involved to resolve conflicts. Next, two authors (VV, MW) extracted data from the included articles. We (VV, YR, TT) further excluded articles during the extraction phase, after closer scrutiny against the inclusion criteria. Senior author (YR) conducted a final round of exclusions during the analysis phase. The selection process resulted in 29 final articles for inclusion.

Quality assessment

One reviewer (TT) conducted a quality assessment of the 29 included studies using a checklist for assessing quality in observational studies [38]. Six domains were used to assess risk of bias: 1) methods for selecting study participants, 2) methods for measuring independent and dependent variables, 3) design-specific source bias, 4) method for controlling confounding, 5) statistical methods, and 6) other biases including conflict of interest and disclosure of funding sources. We scored each study as low, high, or unclear for risk of bias for each domain [39].

Data extraction

Religion, faith, spirituality.

We identified pre-specified categories for the RFS measures used in Shaw and El-Bassel [36] and expanded the operational definitions of those categories based on theoretical frameworks of religion, spirituality and health [33, 40]. This process resulted in four RFS categories. The first category is service attendance, which we operationalized as studies that measured individuals’ frequency of attending religious or spiritual services or studies where there was an intervention that involved attending sessions within an RFS setting. The intervention could be RFS-based or secular. However, for measures that included attendance as part of a longer composite index, we did not include it in the attendance category because we could not isolate its unique impact. The second category is religious scales, which includes studies that used validated scales from prior literature (e.g., The Duke University Religion Index (DUREL) [41] or a new scale the authors created using psychometric methodologies (e.g., prevalence of religious beliefs discouraging homosexuality in society) [42].

The third category is a combination of spirituality and subjective religiosity measures. Spirituality characterizes one’s personal experience or relationship with God or a higher power [43]. Spirituality measures may also include indicators of subjective religiosity, which defines experiences unique to the individual that are not directly observable (e.g., self-rated importance of God in one’s daily life) [44, 45]. The fourth category is the influence of religion on behaviors. This category was developed to account for studies that do not include service attendance or spirituality measures, but rather include a global belief system perspective.

Religious denomination.

In addition to those four categories, we organized data according to the broad typologies of religious traditions/denominations used in Shaw and El-Bassel (2014) and others identified through the abstract review stage. The categories included: Catholic; Muslim; Protestant (because not all studies permitted distinguishing the three major branches); Christian (for those that did not specify tradition but examined Judeo-Christian aspects); and other, which included studies that did not necessarily mention denomination or others that fell outside of the prior categories (e.g., Buddhism). We extracted and coded denomination only from quantitative studies where we could compare the association with an HIV prevention activity across one or more denomination. In qualitative studies, we coded denomination when we could examine differences in text according to the denomination. Studies were not included if they were conducted among one or more of these groups but did not provide information that facilitated comparisons.


We classified studies by the mechanisms that potentially connect the associations between RFS measures and the HIV prevention activities. We began with categories used in Shaw and El-Bassel (2014) then added other established behavioral and psychosocial pathways [40, 46] or new pathways identified during review (e.g., beliefs and values). This process resulted in seven mechanisms. We identified mechanisms in quantitative studies through methods such as mediation analysis, multiple adjustment or partial correlations, or from the text if the authors described factors not presented in tables. In qualitative or mixed-methods studies, we identified mechanisms through blocks of text if they discussed examples that explained their findings.

The first mechanism is behavioral norms, which describes the use of religious doctrine to regulate behaviors (e.g., Old Testament laws that prohibit pre-marital sex). The second mechanism is social organization and social support, which describes the features of religious institutions (e.g., having a health ministry) and other types of non-tangible support that influences behavior. The third mechanism is social influence, which describes the degree of regulating one’s behavior by virtue of belonging to a religious congregation or faith tradition, but not necessarily tied to a religious doctrine (e.g., self-regulation from identifying as Christian). Fourth is education, which includes information delivered directly through faith institutions and ministries, directly from faith leaders, clergy, or knowledge shared among parishioners. Fifth is beliefs and values related to sex and sexuality, which deals specifically with issues of sex, love, and marriage between people of the same gender. The sixth mechanism is circumcision. The seventh mechanism is alcohol use, which we identified as a unique category given its relationship to both religion and HIV [47, 48].

Direction of association.

We coded direction of association in quantitative studies based on coefficients and in qualitative studies based on interpreting passages of texts. We identified four categories: (1) positive/protective, (2) negative, (3) mixed findings (i.e., either positive and negative associations) in the same study, and (4) neutral, not significant or insufficient information to qualitatively determine a direction. Mixed findings in the same study could indicate either one RFS measure was significantly associated with one HIV prevention activity but not another or that some RFS measure have significant or different directions of association with the same HIV prevention activity. In qualitative studies, this indicated that some factors were viewed positively for one HIV prevention activity but negatively for others.

Data synthesis and analysis

Reviewers (YR and TT) reviewed for consensus, the categories of the RFS categories and the mechanisms then compiled the studies into Stata 15.0 software for data management and descriptive analysis. Reviewer (YR) conducted descriptive analysis based on the study’s conceptual model, and (YR and TT) developed the tables.

Secondary exploratory analyses

One of the secondary aims of this review was to characterize how studies of RFS and HIV prevention are informed by prior studies. There is significant variation in study designs and measurement of RFS constructs which may inhibit the potential to obtain consensus about the impact of religion in HIV prevention. We downloaded the full record contents of the 29 included articles from our primary search on Web of Science Core Collection database, as well as all secondary articles that cited or were cited by the primary articles. We then performed analyses and visualizations on citation patterns in the scientific literature using the CiteNetExplorer software.

Ethical consideration

The study did not require IRB review since it does not involve human subjects.


Descriptive study characteristics

We screened 2557 titles and abstracts after duplicates were removed and reviewed 441 for full text, then included 29 studies for data extraction. We excluded studies when they did not assess RFS or did not include one of the HIV prevention activities (Fig 1).

Fig 1. PRISMA flow-chart of included articles (n = 29).

Among 2881 articles, approximately one percent (n = 29) were met criteria and included for this review. Among the full-texts that were assessed for eligibility (n = 441), the majority (56%, n = 248) were excluded because they did not allow us to assess the association between religion, faith, and spirituality with an HIV prevention variable.

Quality assessment

Among the 29 selected studies, 14 were at low risk for all 6 methodological quality items. The remaining studies (n = 15) had at least one of the bias items and none of the selected studies were at high risk for all the bias items (S3 Table).

Descriptive information for the 29 studies is in Table 1 and (S4 Table) for more details. While not all studies reported relevant information such as age, gender, etc., percentages are based on all the studies. The first study was published in year 2001 and four (14%) were published in year 2013. Twelve studies (41%) were based on samples from Africa and fourteen (48%) on samples from the U.S. Seventeen studies (59%) were quantitative, one qualitative, and eleven (37%) were mixed methods. The sample size of individuals studied ranged from 43 to 5534 with a mean of 1136 (SD = 1187). The ages of the individuals across the studies ranged between 12 and 80 years of which six (21%) were among individuals 12–24 years. Twenty-one studies (72%) included both men and women. Twelve studies (41%) included only one RFS measure and 12 that use multiple RFS measures. For the HIV prevention activities, the studies are not mutually exclusive, and percentages do not always sum to 100. Twenty-one studies examined condom use, ten studies examined HIV testing, and nine with number of sexual partners. Only one study examined the association with PrEP during our review period.

Table 1. Selected characteristics of the studies included in the review (n = 29), sorted by ascending publication date.

Twelve studies included measures of religious service attendance. Five included spirituality/subjective religiosity scales in whole or modified, and thirteen included the influence of religion on behavior. Among the studies where we could compare the association across denominations/religious traditions, Catholic (n = 8) and Christian denominations (n = 7) were the most frequently included. Fourteen studies (48%) reported a positive/protective direction of association between the RFS variables they examined and an HIV prevention activity; three (12%) reported negative associations, and eight (27%) mixed (both positive & negative associations in the same sample). Four studies (14%) contained findings that were neutral, not significant or insufficient information to qualitatively determine a direction of association.

Summary from statistical analysis

Direction of associations.

The following results are from statistical analysis guided by our conceptual model (S1 Fig). We observed a broad trend for HIV testing where 100% of the studies that examined religious service attendance and influence of religion on behavior were positive/protective. Next, five of eight (62%) of the studies that examined service attendance and condom use were positive/protective. The one study that examined PrEP also found a significant positive association (Table 2).

Table 2. Summary of the direction of associations for the religion, faith, and spirituality in association with HIV prevention activities.


This section describes patterns of common mechanisms stratified by studies reporting positive/protective and then negative associations between RFS and HIV prevention activities (Table 3). First, among the studies that documented a positive association; social influence and beliefs and values related to sexuality were the primary mechanisms identified, and these were most represented for condom use and number of sexual partners. For HIV testing, social influence and education were the most often identified mechanisms. Second, among these studies, mechanisms were mostly identified when service attendance or influence on behavior was the focal RFS measure. One that examined condom use documented a negative association with RFS. Mechanisms identified from that one study included behavioral norms, beliefs and values related to sex and sexuality, and social influence. There were no studies among the other HIV prevention activities that documented a significant negative association. Lastly, we found no evidence of alcohol use as a mechanism linking religion and HIV prevention activities.

Table 3. Top two mechanisms among studies that document a positive/protective or negative association between religious and spiritual measures and HIV prevention variables.

Expanded details from statistical analysis

The following results section provides greater detail on the RFS measures and the HIV prevention activities and mechanisms involved according to our conceptual model.

Condom use.

Attendance. Eight studies examined condom use in association with service attendance [4956]. Five of those eight studies (62%) documented a positive/protective association and were statistically significant [49, 51, 52, 54, 56]. The most frequent mechanism reported among studies that documented a protective association was beliefs and values related to sex or sexuality and social influence. One study [53] reported a negative association with condom use. They found that, among a sample of persons attending Mainline Protestant Churches in Maputo and Chibuto, Mozambique, those who attended church three times or more per week had 47% lower odds of using condoms with a partner compared to other prevention measures. Behavioral norms, and beliefs around sex and sexuality were the primary mechanisms identified.

Religion and/or spirituality scale. Four quantitative studies examined condom use in association with religious or spiritual scales [42, 5759]. Most of these studies reported some psychometric properties such as Cronbach’s alpha. In other studies, the authors created new scales using scale creation methods such as factor analysis. The authors gave the scales their own names such as “religiosity,” “religiosity/spirituality,” and “prevalence of discouraging homosexuality beliefs” [42, 57, 59].

Two studies documented a positive/protective statistically significant association [58, 59]. One example is Coleman and Ball (2009), who analyzed the Spiritual Well-Being Scale among a sample of middle aged African American HIV-infected men. They found that higher religious well-being was associated with higher self-efficacy to use condoms. Social influence and beliefs related to sex and sexuality were identified as the primary mechanisms in that study. No studies documented significant negative associations and some studies were null or could not be determined.

Spirituality/subjective religiosity. There were no studies in this category.

Influence of religion on behavior. Eleven studies examined condom use in association with the influence of religion on behavior [42, 49, 50, 5456, 6064]. These studies were mostly mixed methods (n = 7). One example was Berkeley-Patton, Bowe-Thompson et al. 2010, a mixed-methods study where approximately 50% of participants reported incorrect responses about the proper way to use condoms. After asking participants how they could explain the low proportion of correct responses, they said that several pastors believed that the church was not the most appropriate setting to discuss condoms. Four of the eleven studies reported a positive/protective statistically significant association, or for the qualitative studies, mentioned religion directly as a factor [49, 54, 56, 64]. For example, in Trinitapoli 2009, pastors privately advising condom use was significantly associated with higher condom use. Social influence, social support and organization, education, and beliefs and values related to sex and sexuality were identified with similar frequency within the studies. One study found a negative association, and social influence was the primary mechanism. One other study had mixed directions where influence on behavior was not associated with condom use but was significantly associated with another HIV prevention activity.

HIV/STI testing.

Attendance. Five studies examined HIV/STI in association with service attendance [49, 6568]. Two studies were mixed methods and three were quantitative. Positive/protective associations were observed for all studies. For instance, in Ezeanolue, Obiefune et al. 2015, participants in an intervention group who received health education at baby showers held in churches (compared to control group churches) had higher adjusted odds of HIV testing post-intervention. Berkley-Patton, Thompson, and Moore et al. 2019 found significant increases in HIV testing at 12 months among participants who attended (59% vs 42%, p = 0.008) their Taking it to the Pews (TIPS) vs standard-information intervention. The most frequent mechanisms identified among studies reporting a positive/protective association were social organization/support, beliefs and values related to sexuality, and education.

Religion and/or spiritual scale. There was only one study in this category [67]. The authors assessed religiosity using a seven-item version of the Religious Background and Behavior Survey on participant’s engagement in church activities and one item on a description of their degree of religiosity. Religiosity was statistically unrelated to HIV testing in the multivariable model.

Spirituality/ subjective religiosity. There were no studies in this category.

Influence of religion on behavior and HIV/STI testing. Three studies met the criteria [49, 68, 69]. One mixed methods study examined HIV/STI testing in association with the influence of religion on behavior [49]. That study found a positive/protective association where encouragement from church members to get tested for HIV was significantly greater than encouragement from family and friends. Also, people exposed to religious teachings on HIV and stigma were more likely to get tested for HIV. Several mechanisms were present in those studies including behavioral norms, social support and organization, social influence, and education. One example of social support and organization and social influence was that 87% of participants in that study [49] believed it was important for their church to talk about testing for HIV and 77% reported that the church should offer HIV testing.

Number of sexual partners.

Attendance. Four studies examined the number of sexual partners in association with our definition of religious service attendance [50, 54, 55, 67]. No mechanisms were identified. Those studies did not find a statistically significant relationship between the variables.

Religion and/or spiritual scale. Two studies examined the number of sexual partners in association with religion and/or spiritual scale [42, 67] but the associations were not significant in those studies.

Spirituality/ subjective religiosity. There were no studies in this category.

Influence of religion on behavior. Six studies examined the number of sexual partners in association with the influence of religion on behavior [42, 50, 54, 55, 60, 61]. Five were quantitative and one was mixed methods. Only one found a significant positive relationship with this outcome. In the study that found the positive relationship, one measure of influence on behavior was “trying hard to implement religious teachings.” Those with high influence (i.e., participation in religious activities multiple times a day) compared to lower influence had higher odds of having one sexual partner [54].

Injection drug use.

Attendance. Only one study examined injection drug use in association with religious service attendance [51]. This quantitative study, conducted among a sample of methadone clients, reported a positive association.

Religion and/or spiritual scale. There were no studies in this category.

Spirituality/ subjective religiosity. One study examined injection drug use in association with spirituality/subjective religiosity [70] and found that higher mean spiritual support ratings was associated with a higher number of weeks not using illicit drugs. No mechanisms were identified.

Influence of religion on behavior. There were no studies in this category.

Pre-exposure prophylaxis (PrEP).

There was only one published study in this category [68]. The study found that persons who attended religious services a few times a year (compared to those who never attended) had 50% higher odds of being willing to use PrEP. They also found that participants who reported hearing faith leader’s messages about same-sex relationships were also willing to use PrEP.

Medical male circumcision.

One qualitative study examined male circumcision in association with influence of religion on behavior [62]. They found a negative association, where 60% of participants worried that promoting circumcision in church would increase promiscuity. We identified social influence and behavioral norms as mechanisms.

Comparisons across religious denominations.

Eight studies included denomination, but only six studies were structured to facilitate direct comparisons across religious denominations, so two were excluded [71, 72]. There was significant variation in the categorization of denominations, the number included, and the HIV prevention variable that was compared although most examined condom use [53, 56, 7375] and one also examined HIV testing [76]. Significant differences were observed in all but one study. For example, in Agadjanian 2005, the impact of attending services three or more times a week on condom use was protective (OR = 0.47) for participants in mainline churches compared to those in “healing churches,” (OR = 0.97) (e.g., Apostolic & Pentecostals). In another study, healing churches tended to have lower mean messaging around condom use and HIV prevention compared to other denominations [73].

Citation analysis findings.

Fig 2 shows a visualization of citation links among the 29 included studies, displayed according to a timeline of publication year, with more recent studies being located below older studies. Each circle represents a study labeled by the last name of the first author and curved lines represent direct citation links. If studies cited each other and published in the same year, then the citing study is always located somewhere below the corresponding cited study. The position of the study on the horizontal axis is determined by the closeness of publications in the citation networks; the closer the circles are to each other, the closer the studies are related to each other. Clear clusters were observed. Jemmott et al. 2020, the latest study, cited studies that were published from 2013 to present. Among the 29 included studies, five were in the top 100 most cited (S2 Fig). Berkley-Patton, Bowe-Thompson et al. 2010 was the highest cited among the 29 studies, followed by Agadjanian 2005, Trinitapoli 2009, McCree, Wingood et al. 2003, and Agha, Hutchinson et al. 2006. Only five of the included 29 studies also directly cited one or more authors, and this could be likely a result of similar topics or concepts being examined (S2 Fig).

Fig 2. Citation analysis patterns among 29 included studies.

Visualization of citation links among the 29 included studies, displayed according to timeline of publication year with more recent studies being located below older studies. Each circle represents a study labeled by the last name of the first author and curved lines represent direct citation links. Out of the 29 studies, ten studies directly cited one or more studies in the group and this could likely be a result of similar topics or concepts being examined.


This review provides a comprehensive assessment of the associations and mechanisms connecting religion, faith, and spirituality (RFS) constructs to primary HIV prevention activities (i.e., condom use, HIV and STI testing, PrEP) and discusses current research gaps and implications for future research and practice.

The first primary finding was that condom use was the most studied strategy in association with RFS and frequency of religious service attendance was the most assessed RFS factor. Our study confirmed what is already documented that RFS is often positively associated with several of the prevention outcomes and that degree of protective association varies. For instance, higher frequency of service attendance was positively associated with condom use in 62% of the studies in this review and positively associated with HIV testing in 100% of the studies included. Second, despite a few recent studies showing an association between RFS and willingness to use- and acceptability of- PrEP [77] and RFS, PrEP remains understudied [68]. Third, only one study examined the associations between spirituality and subjective religiosity and HIV prevention. This is a notable gap that should be addressed in future work on this topic in-light of evidence from the U.S. [78] that more people are identifying as spiritual but not religious [79]. One plausible explanation for this finding is that challenges related to conceptualizing and measuring these factors include tautological errors (e.g., correlating spirituality as positive psychological state and using it as a predictor of other psychological states). Another challenge is little consideration for other cultural and psychosocial factors, and subjectivity [80, 81].

The fourth major finding is related to mechanisms likely to link RFS and HIV prevention. Social influence was the most commonly identified mechanism among studies reporting a positive/protective association and was often present in studies that examined service attendance or used a religious and spiritual scale. The behavioral norms category was the most commonly reported pathway for studies reporting a negative association. These findings indicate that RFS-based HIV prevention interventions may benefit from including strategies that draw upon social norms, expectations, and networks. Other recent work suggests that non-fundamentalist theology (i.e., those not based on strict interpretations of the Bible and religious text) may be important for congregations to be engaged in HIV prevention activities [82]. The fifth finding is that, among the few studies that facilitated comparisons across religious denominations/traditions, there are significant differences in the size of associations. This finding, along with projected shifts in religious denominations in countries with a high HIV incidence [83], suggests that denomination should be assessed when determining the scalability and generalizability of results from RFS-based interventions. Sixth, we found that a limited number of studies were highly cited by other studies not included in this review. Further, among the 29 studies identified, even fewer authors cited each other. This limitation could be explained by differences in disciplines of research (e.g., sociology or public health) or cultural context. However, the lack of cross-citation of prior work potentially weakens the evidence base for interventions and diminishes consensus on common measures or operationalizations for RFS categories.

Our main study strengths, that builds upon a recent prior study [36], are that we identify the associations between RFS and a broader set of HIV prevention activities, and we assess mechanisms among studies that find both positive and negative associations. We also conducted citation analyses which, to date, has not been previously reported in the literature on RFS and HIV prevention. Our findings indicate that future studies may wish to draw from studies in different contexts and further in time. Some limitations are that we did not include an exhaustive set of prevention activities (e.g., Post-exposure Prophylaxis (PEP) or vaccines). Nevertheless, we captured the most prevalent HIV prevention activities [9]. Next, our RFS categories could potentially miss other religious traditions and practices, such as traditional healing or Hinduism. However, we used and tested a comprehensive search strategy and the RFS categories we used reflect the distribution of religious groups globally [83]. Moreover, the included studies are from regions (e.g., Asia and Africa) where these other traditions may be used. We did not consider grey-literature sources such as reports, since the quality and validity of these studies can be questionable, and methods might not contain sufficient details to be reproducible. Last, the mechanisms are not exhaustive, but we aimed to build upon prior work and identify others as they arose from our search.


We found protective associations between RFS and some primary HIV prevention activities such as condom use and HIV testing. We recommend that future work should include other measures of HIV prevention strategies that align with Ending the HIV Epidemic goals, such as PrEP use and adherence. Studies should also include reliable and multidimensional measures of spirituality and subjective religiosity and assess denomination. More studies should include randomized controlled and quasi-experimental designs that better facilitate causal inference, mediation analyses that can statistically quantify potential mechanisms, and ethnographic methods to observe how RFS works in practice. Next, quantitative studies that investigate HIV stigma as a mechanism (e.g., mediator between RFS and some HIV prevention outcome) are needed since there is already several interventions tackling stigma [65, 8486]. One recent study that evaluated an intervention “Love with no Exceptions” among clergy and church members in Alabama found very little change in HIV stigma attitudes before and after the intervention [87]. For current practice, interventionists can utilize RFS [88, 89] to address other known social and cultural factors such as stigma and discrimination [90], which are barriers to PrEP uptake [91, 92] and likely to also influence uptake of next generation biomedical technologies.


Y. Ransome’s research was supported by the National Institute of Mental Health of the National institutes of Health under award number (s) K01MH111374, R25MH083620, and P30MH062294.

Disclaimer: The content of this manuscript is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or Center for Interdisciplinary Research on AIDS (CIRA) at Yale University or The Brown Initiative in HIV and AIDS Clinical Research for Minority Communities at Brown University.

The funders of the study played no role in the design and conduct of the study; collection, management, analysis, interpretation of the data; or the preparation, review or approval of the manuscript. The funders of this study had no further role in its design, collection, analysis and interpretation of data, writing of the report, or in the decision to submit the paper for publication.


  1. 1. UNAIDS. Global HIV & AIDS statistics-2018 fact sheet 2019 [cited 2019 January 15].
  2. 2. Günthard HF, Saag MS, Benson CA, Del Rio C, Eron JJ, Gallant JE, et al. Antiretroviral drugs for treatment and prevention of HIV infection in adults: 2016 recommendations of the International Antiviral Society–USA panel. JAMA. 2016;316(2):191–210.
  3. 3. Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365(6):493–505. pmid:21767103
  4. 4. UNAIDS. Combination HIV prevention: tailoring and coordinating biomedical, behavioural and structural strategies to reduce new HIV infections Geneva, Switzerland: Joint United Nations Programme on HIV/AIDS; 2010 [cited 2019 July 7].
  5. 5. Eisinger RW, Dieffenbach CW, Fauci AS. HIV viral load and transmissibility of HIV infection: undetectable equals untransmittable. JAMA. 2019;Online First.
  6. 6. Anderson PL, Glidden DV, Liu A, Buchbinder S, Lama JR, Guanira JV, et al. Emtricitabine-tenofovir concentrations and pre-exposure prophylaxis efficacy in men who have sex with men. Sci Transl Med. 2012;4(151):151ra25–ra25. pmid:22972843.
  7. 7. McCormack S, Dunn DT, Desai M, Dolling DI, Gafos M, Gilson R, et al. Pre-exposure prophylaxis to prevent the acquisition of HIV-1 infection (PROUD): effectiveness results from the pilot phase of a pragmatic open-label randomised trial. The Lancet. 2016;387(10013):53–60.
  8. 8. Bekker L-G, Beyrer C, Quinn TC. Behavioral and biomedical combination strategies for HIV prevention. Cold Spring Harbor Perspectives in Medicine. 2012;2(8). pmid:22908192
  9. 9. Vermund SH, Tique JA, Cassell HM, Pask ME, Ciampa PJ, Audet CM. Translation of biomedical prevention strategies for HIV: prospects and pitfalls. J Acquir Immune Defic Synd. 2013;63 Suppl 1(0 1):S12–S25. pmid:23673881.
  10. 10. Baral S, Rao A, Sullivan P, Phaswana-Mafuya N, Diouf D, Millett G, et al. The disconnect between individual-level and population-level HIV prevention benefits of antiretroviral treatment. The Lancet HIV. 2019;Online First(July 19):S2352–3018.
  11. 11. Eakle R, Weatherburn P, Bourne A. Understanding user perspectives of and preferences for oral PrEP for HIV prevention in the context of intervention scale-up: a synthesis of evidence from sub-Saharan Africa. J Int AIDS Soc. 2019;22(S4):e25306. pmid:31328429
  12. 12. Archer MS. Structure, Agency and the Internal Conversation. Cambridge, UK: Cambridge University Press; 2003.
  13. 13. Kippax S, Stephenson N, Parker RG, Aggleton P. Between individual agency and structure in HIV prevention: understanding the middle ground of social practice. Am J Public Health. 2013;103(8):1367–75. Epub 2013/08/. pmid:23763397.
  14. 14. Gupta GR, Parkhurst JO, Ogden JA, Aggleton P, Mahal A. Structural approaches to HIV prevention. Lancet. 2008;372(9640):764–75. pmid:18687460
  15. 15. Farmer P. AIDS and accusation: Haiti and the geography of blame, updated with a new preface. Berkeley and Los Angeles: Universit of California Press; 2006.
  16. 16. Auerbach JD, Parkhurst JO, Cáceres CF. Addressing social drivers of HIV/AIDS for the long-term response: conceptual and methodological considerations. Glob Public Health. 2011;6(sup3):S293–S309.
  17. 17. Latkin CA, Knowlton A. Micro-social structural approaches to HIV prevention: A social ecological perspective. AIDS Care. 2005;17(S1):102–13.
  18. 18. Mannell J, Cornish F, Russell J. Evaluating social outcomes of HIV/AIDS interventions: a critical assessment of contemporary indicator frameworks. J Int AIDS Soc. 2014;17(1):19073. pmid:25160645
  19. 19. Idler EL, editor. Religion as a social determinant of public health. New York, NY: Oxford University Press; 2014.
  20. 20. Koenig HG, McCullough ME, Larson DB. Handbook of religion and health. New York, NY: Oxford University Press; 2001. 728 p.
  21. 21. Oman D, editor. Religion, spirituality, and health. Cham, Switzerland: Springer International Publishing AG; 2018.
  22. 22. Weber M. The Protestant ethic and the spirit of capitalism. New York, NY: Penguin; 2002.
  23. 23. Taylor MC. After God. Taylor MC, Carlson TA, editors. Chicago, IL: The University of Chicago Press; 2007.
  24. 24. Geertz C. Religionas a cultural system. In: Lambek M, editor. A reader in the anthropology of religion. 2nd ed. ed. Malden, MA 1966 Blackwell Pub Ldt; 2008. p. 57–76.
  25. 25. Pickering W, Redding J, editors. Durkheim on religion: a selection of readings with bibliographies. Boston, MA Routledge 1975.
  26. 26. Dalmida SG, Thurman S. HIV/AIDS. In: Idler EL, editor. Religion as a social determinant of public health. New York, NY: Oxford University Press; 2014. p. 364–80.
  27. 27. Pew Research Center. The global religious landscape Washington, DC: Pew Research Center; 2012 [cited 2017 April 3].
  28. 28. Pew Research Center. The age gap in religion around the world Washington, DC: Pew Research Center; 2018 [cited 2019 January 1].
  29. 29. World Values Survey. A098. Active/Inactive membership of church or religious organization. World Values Survey, online data analysis Vienna, Austria: Institute for Comparative Survey Research; 2019 [cited 2019 July 15].
  30. 30. Nelson JM. Psychology, religion, and spirituality. New York, NY: Springer; 2009. p. 233–4.
  31. 31. Kesson K. Contemplative spirituality, currere, and social transformation: finding our "way". Counterpoints. 2002;38:46–70.
  32. 32. Hill PC, Pargament KI, Hood RW, McCullough ME Jr, Swyers JP, Larson DB, et al. Conceptualizing religion and spirituality: points of commonality, points of departure. J Theory Soc Behav. 2000;30(1):51–77.
  33. 33. Zinnbauer BJ, Pargament KI, Cole B, Rye MS, Butter EM, Belavich TG, et al. Religion and spirituality: unfuzzying the fuzzy. J Sci Study Relig. 1997;36(4):549–64.
  34. 34. Doolittle BR, Justice AC, Fiellin DA. Religion, spirituality, and HIV clinical outcomes: a systematic review of the literature. AIDS Behav. 2016;22(6):1792–801. pmid:28004218
  35. 35. Medved Kendrick H. Are religion and spirituality barriers or facilitators to treatment for HIV: a systematic review of the literature. AIDS Care. 2017;29(1):1–13. pmid:27410058
  36. 36. Shaw SA, El-Bassel N. The influence of religion on sexual HIV risk. AIDS Behav. 2014;18(8):1569–94. pmid:24510402
  37. 37. United States (US) Department of Health and Human Services. HIV prevention activities Washington, DC: / Office of HIV/AIDS and Infectious Disease Policy (OHAIDP); 2017 [updated May 20, 2017; cited 2019 January 14].
  38. 38. Sanderson S, Tatt ID, Higgins J. Tools for assessing quality and susceptibility to bias in observational studies in epidemiology: a systematic review and annotated bibliography. Int J Epidemiol. 2007;36(3):666–76. pmid:17470488
  39. 39. Higgins J, Green S, editors. Cochrane handbook for systematic reviews of interventions Chichester, UK: Wiley-Blackwell; 2008.
  40. 40. Ellison CG, Levin JS. The religion-health connection: evidence, theory, and future directions. Health Educ Behav. 1998;25(6):700–20. pmid:9813743
  41. 41. Koenig HG, Büssing A. The Duke University Religion Index (DUREL): a five-item measure for use in epidemological studies. Religions. 2010;1(1):78–85.
  42. 42. Nelson LE, Wilton L, Zhang N, Regan R, Thach CT, Dyer TV, et al. Childhood exposure to religions with gigh prevalence of members who discourage homosexuality is associated with adult HIV risk behaviors and HIV infection in black men who have sex with men. Am J Mens Health. 2017;11(5):1309–21.
  43. 43. Powell LH, Shahabi L, Thoresen CE. Religion and spirituality: linkages to physical health. Am Psychol. 2003;58(1):36–52.
  44. 44. Taylor RJ, Mattis J, Chatters LM. Subjective religiosity among African Americans: A synthesis of findings from five national samples. J Black Psychol. 1999;25(4):524–43.
  45. 45. Chatters LM, Levin JS, Taylor RJ. Antecedents and dimensions of religious involvement among older black adults. J Gerontol. 1992;47(6):S269–S78. pmid:1430864
  46. 46. Idler EL, Musick MA, Ellison CG, George LK, Krause N, Ory MG, et al. Measuring multiple dimensions of religion and spirituality for health research: conceptual background and findings from the 1998 General Social Survey. Res Aging. 2003;25(4):327–65.
  47. 47. Adong J, Lindan C, Fatch R, Emenyonu NI, Muyindike WR, Ngabirano C, et al. The relationship between spirituality/religiousness and unhealthy alcohol use among HIV-infected adults in Southwestern Uganda. AIDS Behav. 2018;22(6):1802–13. pmid:28555316
  48. 48. Ransome Y, Mayer KH, Tsuyuki K, Mimiaga M, Diaz-Rodriguez CE, Srithanaviboonchai K, et al. The role of religious service attendance, psychosocial and behavioral determinants of antiretroviral therapy (ART) adherence: results from HPTN 063 cohort study. AIDS Behav. 2018;23(2):459–74.
  49. 49. Berkley-Patton J, Bowe-Thompson C, Bradley-Ewing A, Hawes S, Moore E, Williams E, et al. Taking it to the pews: A CBPR-guided HIV awareness and screening project with black churches. AIDS Educ Prev. 2010;22(3):218–37. pmid:20528130
  50. 50. Jemmott LS, Jemmott JB III, Icard LD, Hsu J. Effects of church-based parent–child abstinence-only interventions on adolescents’ sexual behaviors. J Adolesc Health. 2020;66(1):107–14.
  51. 51. Margolin A, Beitel M, Schuman-Olivier Z, Avants SK. A controlled study of a spirituality-focused intervention for increasing motivation for HIV prevention among drug users. AIDS Educ Prev. 2006;18(4):311–22. pmid:16961448.
  52. 52. Wingood GM, Robinson LR, Braxton ND, Er DL, Conner AC, Renfro TL, et al. Comparative effectiveness of a faith-based HIV intervention for African American women: importance of enhancing religious social capital. Am J Public Health. 2013;103(12):2226–33. pmid:24134367.
  53. 53. Agadjanian V. Gender, religious involvement, and HIV/AIDS prevention in Mozambique. Soc Sci Med. 2005;61(7):1529–39. pmid:15869833.
  54. 54. Kagimu M, Guwatudde D, Rwabukwali C, Kaye S, Walakira Y, Ainomugisha D. Religiosity for promotion of behaviors likely to reduce new HIV infections in Uganda: a study among Muslim youth in Wakiso district. J Relig Health. 2013;52(4):1211–27. pmid:22203379
  55. 55. Mash R, Mash RJ. A quasi-experimental evaluation of an HIV prevention programme by peer education in the Anglican Church of the Western Cape, South Africa. BMJ Open. 2012;2(2):e000638. pmid:22505307
  56. 56. Trinitapoli J. Religious teachings and influences on the ABCs of HIV prevention in Malawi. Soc Sci Med. 2009;69(2):199–209. pmid:19447536.
  57. 57. Cerqueira-Santos E, Koller S, Wilcox B. Condom use, contraceptive methods, and religiosity among youths of low socioeconomic level. Span J Psychol. 2008;11(1):94–102. pmid:18630652.
  58. 58. Coleman CL, Ball K. Predictors of self-efficacy to use condoms among seropositive middle-aged African American men. West J Nurs Res. 2009;31(7):889–904. pmid:19858525.
  59. 59. McCree DH, Wingood GM, DiClemente R, Davies S, Harrington KF. Religiosity and risky sexual behavior in African-American adolescent females. J Adolesc Health. 2003;33(1):2–8. pmid:12834991.
  60. 60. Agardh A, Emmelin M, Muriisa R, Ostergren PO. Social capital and sexual behavior among Ugandan university students. Glob Health Action. 2010;3. pmid:21042434.
  61. 61. Agardh A, Odberg-Pettersson K, Ostergren PO. Experience of sexual coercion and risky sexual behavior among Ugandan university students. BMC Public Health. 2011;11:527. pmid:21726433
  62. 62. Downs JA, Fuunay LD, Fuunay M, Mbago M, Mwakisole A, Peck RN, et al. The body we leave behind: a qualitative study of obstacles and opportunities for increasing uptake of male circumcision among Tanzanian Christians. BMJ Open. 2013;3(5):49.
  63. 63. Stewart JM, Rogers CK, Bellinger D, Thompson K. A contextualized approach to faith-based HIV risk reduction for African American women. West J Nurs Res. 2016;38(7):819–36. pmid:26879828.
  64. 64. Wu F, Zhang KL, Shan GL. An HIV/AIDS intervention programme with Buddhist aid in Yunnan Province. Chin Med J (Engl). 2010;123(8):1011–6. pmid:20497706.
  65. 65. Derose KP, Griffin BA, Kanouse DE, Bogart LM, Williams MV, Haas AC, et al. Effects of a pilot church-based intervention to reduce HIV stigma and promote HIV testing among African Americans and Latinos. AIDS Behav. 2016;20(8):1692–705. pmid:27000144.
  66. 66. Ezeanolue EE, Obiefune MC, Ezeanolue CO, Ehiri JE, Osuji A, Ogidi AG, et al. Effect of a congregation-based intervention on uptake of HIV testing and linkage to care in pregnant women in Nigeria (Baby Shower): a cluster randomised trial. Lancet Glob Health. 2015;3(11):e692–700. pmid:26475016.
  67. 67. Berkley-Patton JY, Thompson CB, Moore E, Hawes S, Berman M, Allsworth J, et al. Feasibility and outcomes of an HIV testing intervention in African American churches. AIDS Behav. 2019;23(1):76–90. pmid:30121728
  68. 68. Ransome Y, Bogart LM, Nunn AS, Mayer KH, Sadler KR, Ojikutu BO. Faith leaders’ messaging is essential to enhance HIV prevention among black Americans: results from the 2016 National Survey on HIV in the black community (NSHBC). BMC Pub Health. 2018;18(1):1392.
  69. 69. Williams MV, Derose KP, Haas A, Ann Griffin B, Fulton BR. In what ways do religious congregations address HIV? examining predictors of different types of congregational HIV activities. J HIV/AIDS Soc Serv. 2018;17(4):290–312.
  70. 70. Avants SK, Warburton LA, Margolin A. Spiritual and religious support in recovery from addiction among HIV-positive injection drug users. J Psychoactive Drugs. 2001;33(1):39–45. pmid:11333000
  71. 71. Perez-Jimenez D, Seal DW, Serrano-Garcia I. Barriers and facilitators of HIV prevention with heterosexual Latino couples: beliefs of four stakeholder groups. Cultur Divers Ethnic Minor Psychol. 2009;15(1):11–7. pmid:19209976.
  72. 72. Szaflarski M, Ritchey PN, Jacobson CJ, Williams RH, Grau AB, Meganathan K, et al. Faith-based HIV prevention and counseling programs: findings from the cincinnati census of religious congregations. AIDS Behav. 2013;17(5):1839–54. pmid:23568226
  73. 73. Agha S, Hutchinson P, Kusanthan T. The effects of religious affiliation on sexual initiation and condom use in Zambia. J Adolescent Health. 2006;38(5):550–5.
  74. 74. Trinitapoli J. The AIDS-related activities of religious leaders in Malawi. Glob Public Health. 2011;6(1):41–55. pmid:20552476
  75. 75. Muula AS, Thomas JC, Pettifor AE, Strauss RP, Suchindran CM, Meshnick SR. Religion, condom use acceptability and use within marriage among rural women in Malawi. World Health Popul. 2011;12(4):35–47. pmid:21677533.
  76. 76. Eriksson E, Lindmark G, Haddad B, Axemo P. Young people, sexuality, and HIV prevention within Christian faith communities in South Africa: a cross-sectional survey. J Relig Health. 2014;53(6):1662–75. pmid:23832228
  77. 77. Witzel TC, Nutland W, Bourne A. What are the motivations and barriers to pre-exposure prophylaxis (PrEP) use among black men who have sex with men aged 18–45 in London? Results from a qualitative study. Sex Trans Infect. 2019;95(4):262–6.
  78. 78. Ransome Y. Religion spirituality and health: new considerations for epidemiology. Am J Epidemiol. 2020;Published Online March 4, 2020.
  79. 79. Lipka M, Gecewicz C. More Americans now say they’re spiritual but not religious Washington, DC: Pew Research Center; 2017 [cited 2017 September 27].
  80. 80. Koenig HG. Spirituality and health research: methods, measurements, statistics, and resources. West Conshohocken, PA: Templeton Press; 2011.
  81. 81. Ackah W, Dodson JE, Smith DR, editors. Religion, culture and spirituality in African and the African diaspora. New York: NY: Routledge: a Taylor & Francis Group; 2018.
  82. 82. Mendel P, Green HD, Palar K, Kanouse DE, Bluthenthal RN, Mata MA, et al. Congregational involvement in HIV: a qualitative comparative analysis of factors influencing HIV activity among diverse urban congregations. Soc Sci Med. 2020;246:112718. pmid:31931449
  83. 83. Pew Research Center. The changing global religious landscape. Washington, DC: Pew Research Center, 2017.
  84. 84. Abara W, Coleman JD, Fairchild A, Gaddist B, White J. A faith-based community partnership to address HIV/AIDS in the southern United States: implementation, challenges, and lessons learned. J Relig Health. 2015;54(1):122–33. pmid:24173601.
  85. 85. Payne-Foster P, Bradley EL, Aduloju-Ajijola N, Yang X, Gaul Z, Parton J, et al. Testing our FAITHH: HIV stigma and knowledge after a faith-based HIV stigma reduction intervention in the rural south. AIDS Care. 2018;30(2):232–9. pmid:29119799
  86. 86. Berkley-Patton JY, Moore E, Berman M, Simon SD, Thompson CB, Schleicher T, et al. Assessment of HIV-related stigma in a US faith-based HIV education and testing intervention. J Int AIDS Soc. 2013;16(3 Suppl 2):18644. pmid:24242259.
  87. 87. Lanzi RG, Footman AP, Jackson E, Araya BY, Ott C, Sterling RD, et al. Love with No Exceptions: a statewide faith-based, university–community partnership for faith-based HIV training and assessment of needs in the deep south. AIDS Behav. 2019;23(11):2936–45.
  88. 88. Bluthenthal RN, Palar K, Mendel P, Kanouse DE, Corbin DE, Derose KP. Attitudes and beliefs related to HIV/AIDS in urban religious congregations: barriers and opportunities for HIV-related interventions. Soc Sci Med. 2012;74(10):1520–7. pmid:22445157
  89. 89. Ansari DA, Gaestel A. Senegalese religious leaders’ perceptions of HIV/AIDS and implications for challenging stigma and discrimination. Cult Health Sex. 2010;12(6):633–48.
  90. 90. Katz IT, Ryu AE, Onuegbu AG, Psaros C, Weiser SD, Bangsberg DR, et al. Impact of HIV-related stigma on treatment adherence: systematic review and meta-synthesis. J Int AIDS Soc. 2013;16(3S2):18640. pmid:24242258
  91. 91. Golub SA. PrEP stigma: implicit and explicit drivers of disparity. Current HIV/AIDS Reports. 2018;15(2):190–7. pmid:29460223
  92. 92. Cahill S, Taylor SW, Elsesser SA, Mena L, Hickson D, Mayer KH. Stigma, medical mistrust, and perceived racism may affect PrEP awareness and uptake in black compared to white gay and bisexual men in Jackson, Mississippi and Boston, Massachusetts. AIDS Care. 2017;29(11):1351–8. pmid:28286983