STI and HIV Stigma

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STI and HIV Stigma

• Sybil Hosek, PhD
• Clinical Psychologist
• Department of Psychiatry
• Division of Child Adolescent Psychiatry
• Stroger Hospital of Cook County

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To Get your CMEs

• After viewing this eLearning Seminar, please go
  to our website, www.stdptc.uc.edu
• Sign in, look for the title of this seminar
• Follow directions to register
• Complete the evaluation
• Print out your CEU certificate!

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Objectives

• Examine rates of STIs and HIV among historically
  stigmatized groups
• Define stigma and describe models of social
  stigma and HIV-related stigma
• Explore the impact of stigma on a variety of
  health-related outcomes
• Examine the association between stigma and
  HIV/STI testing
• Discuss stigma reduction interventions

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Definitions

• Stereotype
• A belief that ALL members of a group possess the
  same traits/characteristics exhibited by SOME
  members of the group
• Prejudice
• Preconceived judgment of certain race, gender,
  religion, sexual orientation, or social group
• Discrimination
• Unfair treatment of a particular race, ethnicity,
  gender, religion, sexual orientation, or social
  group based on bias or prejudice
• Stigma
• Negative feelings, beliefs, and behavior directed
  toward individual/group due to particular label
  or characteristic.
• National Minority AIDS Council, Stigma Training
  Program

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Epidemiology of STIs and HIV/AIDS among
Historically Stigmatized Groups

• Centers for Disease Control and Prevention (CDC)

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Chlamydia Rates by race/ethnicity and sex
United States, 2006
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Gonorrhea Rates by race/ethnicity and sex
United States, 2006
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Gonorrhea Rates among 15- to 19-year-old
females by race/ethnicity United States,
19972006
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Gonorrhea Rates among 15- to 19-year-old males
by race/ethnicity United States, 19972006
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Primary and secondary syphilis Rates by
race/ethnicity and sex United States, 2006
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Primary and secondary syphilis Rates among 15-
to 19-year-old females by race/ethnicity United
States, 19972006
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Primary and secondary syphilis Rates among 15-
to 19-year-old males by race/ethnicity United
States, 19972006
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New CDC HIV Estimates

• In August, 2008, the CDC released new estimates
  of HIV infection in the United States which
  demonstrated that the epidemic was much worse
  than originally expected.
• The CDC estimates that there are 1,106,400 adults
  and adolescents currently living with HIV/AIDS.
• The CDC also reported that the number of new
  infections in 2006 was estimated to be 56,300
  a jump from the previously reported 40,000.

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HIV and AIDS Among Adolescents
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Adolescents and HIV

• In 2006, the CDC estimates that more than 1/3 of
  all new infections occurred in Adolescents and
  Young Adults ages 13-29.
• Most impacted Female adolescents of color and
  male adolescents who have sex with other males.
• Both populations experience varying degrees of
  social control and power, and experience
  oppression in the form of sexism, racism, and
  heterosexism.

Trends in HIV Infection in 2006, by Age
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CDC HIV Diagnoses Adolescents (ages 13-24) from
1999-2003

• New HIV diagnoses among females decreased (p
  .027).
• New HIV diagnoses among males increased (p lt
  .005).
• Most significant increases among males
• 16-19 years of age (p .004)
• 20-24 years of age (p .004)
• Modes of transmission for males
• Only male-to-male sexual contact increased (plt
  .0001).
• Rangel, Gavin, Reed, Fowler, Lee, 2006

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CDC HIV Diagnoses YMSM 2001-2004

• Increases in HIV Infection Rates
• Males 13-19 years Increased 14 per year
  (plt.01).
• Males 20-24 years Increased 13 per year
  (plt.01).
• These rates were higher than for all other ages
  of men.
• Ethnic differences in HIV DiagnosisYouth Ages
  13-19 in 2004
• African American 19 times higher than White
• Latino 5 times higher than White
• Hall, Byers, Ling, Espinoza, 2007

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Definitions of Stigma

• An attribute that is deeply discrediting within
  a particular social interaction.
• The person with the attribute is reduced in our
  minds from a whole and usual person to a tainted,
  discounted one.
• Stigma falls into three categories
• Abominations of the body (e.g. physical
  deformities)
• Blemishes of character (e.g. weak, dishonest)
• Stigma of race, nation, religion (i.e. beliefs
  that are transmitted through lineages that
  contaminate all members of a family)
• Goffman, E. (1963). Stigma Notes on the
  Management of Spoiled Identity. New Jersey
  Prentice Hall.

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Stigma and Disease

• Common characteristics of stigmatized diseases
• The person with the disease is seen as
  responsible for the illness
• The disease is progressive and incurable
• The disease is not well understood among the
  public
• The symptoms cannot be concealed
• Brimlow, D.L., Cook, J.S. Seaton, R (2003).
  Stigma and HIV/AIDS A review of the literature.
  U.S. Department of Health and Human Services,
  HRSA Washington, DC.

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HIV and Stigma

• Why is HIV a stigmatized disease?
• People infected with HIV are often blamed for
  their condition.
• Although HIV is treatable, it is still a
  progressive, incurable disease.
• HIV transmission is still poorly understood by
  the general population, causing them to feel
  threatened by the mere presence of the disease.
• Although asymptomatic HIV infection can be
  concealed, symptoms associated with HIV-related
  illnesses are often visual (i.e. Karposis
  sarcoma, wasting)
• Herek, GM (1999). AIDS and stigma. American
  Behavioral Scientist, 42(7), 1106-1116.

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HIV-related Stigma

• HIV-related stigma has been defined as a
  socially shared knowledge about the devalued
  status of people living with HIV (Herek et al.,
  2002)
• Stigma can be manifested through prejudice and
  discrimination aimed at
• 1) people perceived to have HIV
• 2) individuals and groups with whom they are
  associated
• HIV-related stigma is not necessarily a stigma of
  the diseased, but rather a stigma of the
  lifestyle of infected populations or
  perceptions about racial and ethnic minorities.
• Gay men, IDUs vs. Hemophiliacs,
  perinatally-infected babies

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Current Trends Kaiser Family Foundation, 2009
Survey of Americans on HIV/AIDS
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Current Trends Kaiser Family Foundation, 2009
Survey of Americans on HIV/AIDS
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Current Trends Kaiser Family Foundation, 2009
Survey of Americans on HIV/AIDS
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Current Trends Kaiser Family Foundation, 2009
Survey of Americans on HIV/AIDS
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Models of HIV Stigma

• Steward and colleagues (2008) model has 3
  components based on Scrambler (1989)
• Enacted stigma
• Overt acts of discrimination and hostility
  directed toward HIV-positive individuals
• Felt Normative Stigma
• The HIV-positive persons subjective awareness of
  stigma and the degree to which they perceive that
  stigma to be normative
• Internalized Stigma
• The extent with which an HIV-positive individual
  accepts the stigma as valid, thus resulting in
  self-stigma.
• Steward, WT, Herek, GM, Ramakrishna, J, et al.
  (2008). HIV-related stigma Adapting a
  theoretical framework for use in India. Social
  Science Medicine, 67, 1225-1235.

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Impact of Stigma Mental Health

• Studies of HIV-positive men and women, both
  adolescents and adults, have consistently found
  that HIV stigma is associated with poorer mental
  health outcomes, including
• Depression, depressive symptoms
• Anxiety
• Hopelessness
• Loneliness, romantic loneliness
• Low self-esteem
• Avoidant coping strategies
• A history of suicidal ideation
• (Lee, Kochman Sikkema, 2002 Courtenay-Quirk,
  Wolitski, Parsons, et al, 2006 Dowshen, Binns
  Garafalo, 2009)

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Impact of Stigma Substance Use

• Cyclical stigma of substance use and HIV

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Impact of Stigma Engagement in Healthcare

• An ever increasing body of literature supports
  the idea that perceived an internalized stigma
  has a direct negative impact on HIV-positive
  individuals engagement in healthcare
• Those who report stigma are less likely to be
  retained in care (Naar-King, Bradford, Coleman et
  al., 2007)
• HIV-positive men and women report having to
  negotiate a) blame and stereotypes, b) fear of
  contagion, and c) disclosure in the context of
  the medical community (Sayles, Ryan, Silver et
  al., 2007)
• An association has been shown between stigma and
  decreased adherence to HIV medications (Wolitski,
  Pals, Kidder et al., 2008).

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Stigma and Testing Uptake

• Overall, rates of HIV testing have remained
  fairly flat over the last decade.
• HIV-related stigma affects issues related to HIV
  testing, including delays in HIV testing for high
  risk groups.
• Some signs that HIV testing is starting to be
  seen as a part of normal healthcare
• However, those who perceive stigma to be
  associated with HIV testing are LESS likely to
  get tested.
• Late testing can be associated with poorer
  health outcomes
• Afraid to find out the results

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Current Trends Kaiser Family Foundation, 2009
Survey of Americans on HIV/AIDS
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Current Trends Kaiser Family Foundation, 2009
Survey of Americans on HIV/AIDS
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Stigma in Healthcare Settings

• Healthcare professionals can be a source of
  stigma by being insensitive to patients concerns
  about stigma
• Stigma must be acknowledged
• Healthcare professionals who infrequently work
  with HIV-positive individuals may be unfamiliar
  with issues of confidentiality.
• Fear of contagion can impact a providers care
  for a patient
• Healthcare professionals can sometimes feel the
  stigma themselves as a result of their work with
  HIV-positive individuals.

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Current Trends Kaiser Family Foundation, 2009
Survey of Americans on HIV/AIDS
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Current Trends Kaiser Family Foundation, 2009
Survey of Americans on HIV/AIDS
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Bronfenbrenners Ecological Systems Theory
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Combating Stigma Individual Level

• Information based
• Brochures, information packs, classes,
  presentations
• Debunk myths, misconceptions
• Counseling
• Individual or support groups
• Provides social support for change
• Safe environment
• Coping Skills Acquisition
• Stress response, Desensitization
• Relaxation training
• Contact
• Other with HIV-infected or affected individuals
• Face-to-face, online

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Combating Stigma Community Level

• Seek to improve risk conditions and behaviors by
  focusing on community risk
• Understand and challenge community values, norms,
  and characteristics
• Engage community structures
• Churches
• Schools
• Community Centers
• Local politicians

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Combating Stigma Societal Level

• Advocacy and Policy work
• Legal protections
• Media
• Marketing
• Training

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Conclusions

• Misinformation about the disease and stigma
  against people living with HIV still hamper
  prevention, care and treatment efforts
  everywhere. If we are to get ahead of the AIDS
  epidemic, we must tackle stigma, ensure that the
  available funds are spent effectively to scale-up
  HIV prevention, care and treatment programs, and
  mobilize more resources.
• Peter Piot, Executive Director, UNAIDS

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To Get your CMEs

• After viewing this eLearning Seminar, please go
  to our website, www.stdptc.uc.edu
• Sign in, look for the title of this seminar
• Follow directions to register
• Complete the evaluation
• Print out your CEU certificate!