Social-cultural factors of HIV-related stigma among the Chinese general population in Hong Kong

HIV-related public stigma in the era of "Undetectable = Untransmittable": a population-based study in Hong Kong

BACKGROUND

While global efforts are increasingly relying upon biomedical advancements such as antiretroviral therapy and pre-exposure prophylaxis (PrEP) to end the HIV epidemic, HIV-related stigma remains a concern. This study aimed to assess the general public's awareness and perception of "Undetectable = Untransmittable" (U = U) and PrEP, and the patterns of public stigma towards people living with HIV (PLWH) and their determinants in an Asian Pacific city.

METHODS

A population-based, self-administrated online survey was conducted between 10-20 March 2023. All adults aged ≥ 18 years and currently living in Hong Kong were eligible. Participants' socio-demographic characteristics, awareness and perception of U = U and PrEP, as well as HIV-related stigma drivers, experience and practices were collected. Latent class analysis was used to delineate population subgroups based on their stigma profiles as reflected by 1.) fear of infection, 2.) concern about socioeconomic ramification of the disease, 3.) social norm enforcement, 4.) perceived stigma in the community, and 5.) stigmatising behaviours and discriminatory attitudes. Memberships of identified subgroups were then correlated with sociodemographic factors, awareness and perception of U = U and PrEP, using multinominal logistic regression.

RESULTS

Responses from a total of 3070 participants (55% male; 79% aged 18-54) were analysed. A majority, 69% and 81%, indicated that they had never heard of U = U and PrEP respectively, and only 39-40% of participants perceived these to be effective in protection from HIV. Four distinct subgroups were identified, namely "Low stigma" (37%), "Modest stigma" (24%), "Moderate stigma" (24%), and "High stigma" (15%). Compared with "Low stigma", lack of awareness of and/or negative perceptions towards U = U and/or PrEP, not knowing any PLWH were associated with increased odds of higher stigma group membership. Lower educational level and not in employment were associated with increased odds of membership in "Moderate stigma" and "High stigma". While older people were more likely to belong to "High stigma", female were more likely to belong to "Moderate stigma". "Modest stigma" included more younger people who were economically active.

CONCLUSION

Two-thirds of participants endorsed modest-to-high HIV-related stigma, suggesting the prevalence of HIV-related stigma was high among the general population in Hong Kong. Tailored interventions targeting specific stigma drivers and manifestations of individuals as reflected from the stigma profiles of distinct subgroups could form an important strategy for stigma reduction.

Influences of mpox disease perceptions, sources and contents of information exposure on mpox vaccine uptake among gay, bisexual, and other men who have sex with men in Hong Kong, China

BACKGROUND

Following the global mpox outbreak in 2022, multiple regions in Asia have been reporting ongoing mpox cases within high-risk groups, including gay, bisexual, and other men who have sex with men (GBMSM). An optimal level of vaccination rate is essential to prevent further mpox outbreaks. However, no existing studies have examined mpox vaccine uptake among GBMSM in East Asia.

METHODS

A cross-sectional survey was conducted among a sample of 531 GBMSM in Hong Kong, China, between March and October 2023. The study used multivariable logistic regression models to investigate the associations between mpox-related disease perceptions, exposures to sources and contents of mpox-related information, and mpox vaccine uptake.

RESULTS

The prevalence of mpox vaccine uptake among GBMSM in Hong Kong was 21.7%, with 7.7% completing one dose and 13.9% completing two doses. GBMSM who were younger or earning less monthly income were less likely to have been vaccinated. After adjusting for confounding variables, participants who perceived more negative impacts on their lives if they were to contract mpox, more severe symptoms, and a more coherent understanding of mpox were positively associated with mpox vaccine uptake. In addition, more frequent exposure to information through the following sources: TV, newspaper, radio and posters, government websites, news websites or apps, other people's social media, and communication over the phone or face-to-face was positively associated with mpox vaccine uptake. Finally, more frequent exposure to the following information contents: mpox statistics from other countries, the Hong Kong government's responses to mpox cases, negative information about patients with mpox, and information on prevention and treatment of mpox were positively associated with mpox vaccine uptake.

CONCLUSIONS

This study provides timely and evidence-based implications to address health communication and messaging needs in promoting mpox vaccination among GBMSM in Hong Kong, relevant to regions with similar sociocultural contexts.

Retiring the term AIDS for more descriptive language

The term acquired immunodeficiency syndrome (AIDS) was coined to describe a condition marked by weakened cell-mediated immunity in the absence of a clear cause. Due to unfortunate messaging during the early days of the HIV epidemic, this term became loaded with stigma. After the discovery of HIV, the term AIDS became redundant, but its use has persisted and has come to embody negative connotations in the current landscape of the HIV epidemic. People commonly associate AIDS with a terminal illness. This misconception promotes stigma by others, including health-care workers, but also self-stigma, which can prevent individuals from accessing health care. Also, the link between AIDS and gay men generated during the early epidemic with use of the term gay-related immune disorder is misleading regarding which populations are at risk, which can delay diagnosis. The use of the term AIDS is now discouraged by several professional associations, some of which ironically have the word as part of their name. Ending use of the term AIDS would not eradicate stigma. However, this term has outlasted its usefulness, and we should transition towards more descriptive language that aligns with contemporary challenges in HIV.

Safe on Blued? A Qualitative Exploration of Sex, Risk, and Stigma on a Gay Social Application in China

Introduction

Mobile dating apps emerged with the development of technology, for example, Blued in China, becoming a new risk field for gay men in the AIDS era. Users use social apps to chat online and date offline to achieve the satisfaction of lust or sexual practice, but the risk of AID looms over the whole process of using apps.

Methods

Nineteen interviewees were invited to participate in this study, which included gay men who were using or had used Blued. The content of the semi-structured interviews focused on the relationship between gay social apps and HIV risk.

Results

The study finds Blued interweaved with sex, risk, and stigma. Blued is sexualized due to sexual intentions and practices. There is also a sexual stratification of risk with Blued and its users based on socioeconomic factors. Users experience a dilemma between pursuing sex while being concerned about latent risk within a context of stigmatization.

Conclusions

Blued is sexualized in terms of the process of stimulating sexual gratification and facilitating sexual practices. The experience of Blued is an example of sexual stratification, and a structure of desire based on app users and app uses. Furthermore, the social stigma against men who have sex with men is transferred to Blued, which bears the stigma of "AIDS-Blued" with a dual stigma-HIV-related and homosexual stigma. However, with the authorized approval of Blued in public health, Blued could play an essential role in HIV/AIDS prevention and control.

Effects of (In)Congruency in Fertility Motivation on Fertility Desire and Intention Among Couples Living with HIV: A Dyadic Approach

Background

Fertility decision-making plays a negligible role in completing fertility goals among couples living with HIV (CLWH). Being commonly matched concerning fertility motivation seems essential for fertility desire/intention. Few studies report on intra-couple congruences or incongruences in fertility motivation on desire/intention. This study aims to assess the effects of (in)congruency in fertility motivation on fertility desire and intention among couples living with HIV.

Methods

This study uses the actor-partner interdependence model (APIM) to assess the independent direct and indirect effect of fertility motivation on intention, and dyadic response surface analysis with congruency/incongruent effect (DRSA) of fertility motivation on intention using fertility desire as mediator variable among CLWH. CLWH were selected from a clinic in Kunming, China, between October and December 2020. Cross-sectional research included 314 CLWH.

Results

APIM revealed that the wife's fertility motivation had an indirect influence on fertility intention of couples mediated by her fertility desire (R2 = 0.42). There was a significant effect on fertility intention by interaction of (in)congruency in fertility motivation among couples. DRSA shows that linear congruency in fertility motivation of both husband and wife increased fertility desire and intention of couples. However, if there was an incongruent in fertility motivation among husband and wife, husband's domination in fertility motivation was common and negatively affect the wife's fertility desire to have a child. Overall, couples who were matched on fertility motivation reported a significant greater relationship with fertility intention than couples who were mismatched.

Conclusion

Counseling could help both the husband and wife achieve a greater positive fertility intention by addressing comparable fertility goals.

Stigmatizing and discriminatory attitudes toward people living with HIV/AIDS (PLWHA) among general adult population: the results from the 6th Thai National Health Examination Survey (NHES VI)

Background

Thailand has an ongoing action plan to reduce human immunodeficiency virus (HIV) discrimination and stigma. We aimed to monitor the level of stigmatizing and discriminatory attitudes toward people living with HIV/AIDS (PLWHA) among the general adult population and to investigate its related factors.

Methods

This study was based on data from the 6^th Thai National Health Examination Survey, a large-scale country-wide survey in 2019-2020. We used a multistage sampling technique and included 11 843 adults aged 20 to 59. We collected data through face-to-face interviews which included six items related to HIV stigma domains. We weighted all analyses to account for the probability of sampling the Thai population aged 20 to 59 years.

Results

We found that anticipated stigma had the highest percentage of negative stigmatizing attitude responses (78.5%), followed by perceived stigma (66.6%), fear of HIV infection (54.4%), and social judgment (28.2%). Regarding the UNAIDS global indicator for discriminatory attitude, 48.6% of respondents had negative perceptions to questions about experienced stigma or discrimination. Multiple logistic regression showed that factors associated with discriminatory attitudes toward PLWHA were being aged 20-39 (adjusted odds ratio (aOR) = 1.32, 95% confidence interval (CI) = 1.18-1.47) or 50-59 (aOR = 1.23, 95% CI = 1.09-1.40) compared to being aged 40-49, being Muslim compared to Buddhist (aOR = 1.73, 95% CI = 1.46-2.06), being married compared to being single (aOR = 1.15, 95% CI = 1.04-1.28), holding certificate degree or higher compared to not studying or studying at a primary level (aOR = 0.81, 95% CI = 0.68-0.97), living in the Northeast (aOR = 1.27, 95% CI = 1.12-1.45) and Bangkok (aOR = 1.30, 95% CI = 1.12-1.51) compared to living in the North, having no HIV/AIDS infected relative or acquaintance compared to having an HIV/AIDS infected relative or acquaintance (aOR = 1.56, 95% CI = 1.41-1.73), and not obtaining an HIV test compared to obtaining it (aOR = 1.10, 95% CI = 1.02-1.19).

Conclusions

We found that HIV stigmatizing and discriminatory attitudes toward PLWHA decreased, but remained concerning among Thai adult people. A public education and awareness campaign, as well as an intervention to reduce HIV-related stigma and discrimination in the country's health care facilities, must still be maintained.

Awareness of HIV functional cure and willingness in participating in related clinical trials: comparison between antiretroviral naïve and experienced men who have sex with men living with HIV

Background

Human immunodeficiency virus (HIV) functional cure is a novel biomedical strategy characterized by sustained viral suppression without the need for life-long medications. The attitude of people living with HIV (PLHIV) towards functional cure and clinical trials are understudied. We aimed to examine the awareness and levels of anticipation for HIV functional cure among men who have sex with men (MSM) living with HIV, and their willingness to join trials as differentiated by their antiretroviral treatment status.

Methods

MSM living with HIV with and those without treatment history were recruited from Hong Kong’s HIV specialist clinics. Self-administered questionnaires covering behavioral profile, perceived impact of HIV cure, attitude towards HIV functional cure and related clinical trials were collected. Clinical data were separately transcribed. Determinants of perceptions and attitudes were identified by logistic regression models.

Results

Of 356 MSM living with HIV recruited, less than half (42%) were aware of HIV functional cure, but they had a high level of anticipation for it. Treatment-experienced participants were more likely to be aware of HIV functional cure. Awareness was associated with continued engagement in sexual activities after HIV diagnosis and sexually transmitted infection (STI) diagnosis. Higher anticipation was observed among older MSM living with HIV but it was negatively associated with one’s awareness. Over 90% were willing to join functional cure trials, especially those who had previously been diagnosed with STI and had engaged in chemsex in the past year. Advice from healthcare professional was an important factor considered by those willing to join clinical trials. Younger, better educated MSM, and those with lower CD4 counts were more concerned about potential risk of AIDS and potential complications upon trial participation.

Conclusions

MSM living with HIV, especially those sexually active, showed positive attitude towards functional cure and willingness to join related clinical trials despite low awareness. To enhance preparedness for HIV functional cure trials, community education, updated information and appropriate medical advice would be needed. Safety is a major concern for potential enrollees in HIV functional cure trials.

Measurement characteristics and correlates of HIV-related stigma among adults living with HIV: a cross-sectional study from coastal Kenya

OBJECTIVE

We studied the psychometric properties of the 12-item short version of the Berger HIV stigma scale and assessed the correlates of HIV-related stigma among adults living with HIV on the Kenyan coast.

DESIGN

Cross-sectional study.

SETTING

Comprehensive Care and Research Centre in the Kilifi County Hospital.

PARTICIPANTS

Adults living with HIV on combination antiretroviral therapy were recruited and interviewed between February and April 2018 (n=450).

MAIN OUTCOME MEASURES

HIV-related stigma.

RESULTS

450 participants with a median age of 43 years (IQR=36-50) took part in the study. Of these, 356 (79.1%) were female. Scale reliability and validity were high (alpha=0.80, test-retest reliability intraclass correlation coefficient=0.92). Using confirmatory factor analysis, we observed that the 12-item short version of the HIV stigma scale had a good fit for its hypothesised model (Comparative Fit Index=0.966, Tucker Lewis Index=0.955, root mean square error of approximation=0.044). Multigroup confirmatory factor analysis indicated measurement invariance across gender and age groups as ΔCFI was ≤0.01. Multivariate linear regression established that being female (β=2.001, 95% CI: 0.21 to 3.80, p=0.029), HIV status non-disclosure (β=4.237, 95% CI: 1.27 to 7.20, p=0.005) and co-occurrence of depressive and anxiety symptoms (β=6.670, 95% CI: 3.40 to 9.94, p<0.001) were significant predictors of perceived HIV-related stigma and that these variables accounted for 10.2% of the explained variability in HIV-related stigma among adults living with HIV from Kilifi.

CONCLUSIONS

Our results indicate that the 12-item short version of the HIV stigma scale is a valid and reliable measure of HIV stigma in Kenya. Furthermore, our study indicates that interventions aimed at reducing stigma need to take into account gender to address the specific needs of women, people who have not disclosed their HIV status, and those exhibiting symptoms of depression and anxiety, thereby improving their quality of life.

Protective and Compensatory Effects of Group Identification on the Mental Health of People Living with HIV

Despite persistent stigmatization of people living with HIV (PLHIV) across the globe, group identification among these individuals may serve to counteract the detrimental effect of prejudice and discrimination associated with the stigmatized identity. Drawing on resilience theory and social identity theory, this study examined how multiple dimensions of group identification (i.e., in-group ties, in-group affect, and centrality) function to buffer and neutralize the negative impact of HIV stigma. A total of 281 PLHIV were recruited from the only community-based public HIV clinic in Hong Kong to participate in this study. The results revealed a protective effect of in-group affect, which moderated the relationship between HIV stigma and mental health, such that HIV stigma was not associated with mental health among people with higher positive in-group affect. In addition, a positive compensatory effect of in-group ties was found in people with higher HIV identity centrality. Given the protective effect of in-group affect, it is important to re-story the lives among PLHIV by challenging their maladaptive beliefs about being PLHIV and building a positive sense of identity in their personal narratives. Community-based interventions should be provided to individuals with higher HIV identity centrality by offering peer support groups and engaging them in community work.

Effects of HIV-Related Discrimination on Psychosocial Syndemics and Sexual Risk Behavior among People Living with HIV

In the context of HIV-related stigma and discrimination, people living with HIV (PLHIV) might be vulnerable to a ‘syndemic’ of co-occurring psychosocial challenges that can affect sexual behavior. The present study examined how HIV-related discrimination contributes to co-occurring psychosocial syndemic problems and results in inconsistent condom use among PLHIV in Hong Kong. Two-hundred and ninety-one PLHIV were recruited to complete a self-report questionnaire. More than one-quarter of the sample experienced two or more psychosocial syndemic problems, and 74.1% of the participants who had sex with steady partners reported inconsistent condom use over the past three months. The results indicated that HIV-related discrimination was positively predictive of the number of psychosocial syndemic problems. HIV-related discrimination and psychosocial syndemics were associated with increased odds of inconsistent condom use with steady partners (AOR = 5.40 and AOR = 3.09 respectively). Findings from structural equation modeling showed that psychosocial syndemics mediated the effect of HIV-related discrimination on condom use consistency with steady partners. PLHIV in Hong Kong suffered from the syndemic effects of stigma, social isolation, and poor mental health, which rendered them vulnerable to condomless sex. In order to curb the rapidly increasing incidence of HIV, multi-level strategies should be adopted to concurrently address the structural inequities and psychosocial syndemics faced by PLHIV.

LGBT Older Adults at a Crossroads in Mainland China: The Intersections of Stigma, Cultural Values, and Structural Changes Within a Shifting Context

In this article, we explore the lives of lesbian, gay, bisexual, and transgender (LGBT) older adults in mainland China, with an emphasis on the shifting nature of the cultural context. Based on a culturally informed perspective, the intersection of LGBT stigma with cultural values (familial responsibility, filial piety, and loss of face) and larger structural changes (the aftermath of the one-child policy, economic reforms and globalization, LGBT human rights, and HIV policies) are creating dramatic shifts in Chinese society and impacting the lives of LGBT older adults. The increasing prevalence of HIV among gay and bisexual older men, although rarely acknowledged, is also contributing to challenges facing LGBT older adults and their families. These changes render LGBT older adults and those living with HIV and their caregivers at risk of economic insecurity. Resilience and resistance of LGBT older adults in China must be considered in both practice and policy to strengthen LGBT human rights globally.

Beyond Homonegativity: Understanding Hong Kong People's Attitudes About Social Acceptance of Gay/Lesbian People, Sexual Orientation Discrimination Protection, and Same-Sex Marriage

This study examined attitudes about social acceptance, discrimination protection, and marriage equality for gay/lesbian people with a representative sample of 1,008 Hong Kong Chinese adults via a telephone survey. Despite majority endorsement of homosexuality (52.29% positive vs. 34.12% negative) and discrimination protection (50.72% favorable vs. 14.64% opposed), attitudes toward same-sex marriage diverged (32.79% favorable vs. 39.41% opposed). There was a sharp distinction in accepting gay/lesbian people as co-workers (83.57%) and friends (76.92%) versus relatives (40.19%). Having more homosexual/bisexual friends or co-workers contributed to greater endorsement of social acceptance and discrimination protection but not same-sex marriage. Age, religion, political orientation, and homonegativity consistently predicted attitudes toward social acceptance, discrimination protection, and same-sex marriage, whereas gender-role beliefs, conformity to norms, and cultural orientations had varying impacts. This article informs theory and advocacy by disentangling homonegativity from attitudes about gay/lesbian issues and highlighting the centrality of family-kinship and relative-outsider delineation in Chinese societies.