Unpacking the Influence of Sexual Stigma on HIV Risk: Results From a Prospective Study of Men Who Have Sex With Men in Beijing, China

Associations Between Internalized and Anticipated HIV Stigma and Depression Symptoms Among People Living with HIV in China: A four-wave Longitudinal Model

Previous research has documented that HIV-related stigma (e.g., internalized and anticipated stigma) is detrimental to the mental health of people living with HIV (PLWH). However, longitudinal data on the bidirectional relationship between HIV-related stigma and depression symptoms are limited. The purpose of this study was to examine the bidirectional association among internalized and anticipated HIV stigma and depression symptoms among Chinese PLWH. A four-wave longitudinal design (6 months intervals) was employed among 1,111 Chinese PLWH (Mage = 38.58, SD = 9.16, age range: 18-60 years; 64.1% men). The bidirectional model was examined using a random-intercept cross-lagged panel model (RI-CLPM), which evaluated the within- and between-person effects of study variables. At the within-person level, results indicated that depression symptoms at T2 mediated the linkage between internalized HIV stigma at T1 and anticipated HIV stigma at T3, and that anticipated HIV stigma at both T2 and T3 mediated the relationship between depression symptoms at the previous time point and internalized HIV stigma at the subsequent time point. Furthermore, a bidirectional association was found between anticipated HIV stigma and depression symptoms across four waves. At the between-person level, internalized and anticipated HIV stigma were significantly associated with depression symptoms. This study highlights the complex interplay between different forms of HIV-related stigma and mental health problems among PLWH and underscores the importance of considering the bidirectional relationship between the development of psychopathology and stigmatization process in clinical practice.

'How can I fix my disrupted life?' Embodied experiences and biocitizenship among men who have sex with men living with HIV in China

Drawing on qualitative data collected from men who have sex with men living with HIV in Fujian and Sichuan provinces in southeast and southwest China, respectively, this study aims to understand their lived experiences in the context of social norms, institutions and roles. We argue that informants encountered biographical disruption as a result of their diagnosed infection. They then painfully experienced different forms of social death on the one hand, while on the other, some also exerted agency/autonomy by strategically fighting for their rights and interests in both private and public domains. By examining these lived experiences, this study discusses the biological citizenship of the respondents so as to deepen understanding of embodied life experiences and trajectories.

Sociodemographic characteristics and HIV risk behaviors of native-born and displaced Syrian men and transgender women who have sex with men in Lebanon

HIV rates among men and transgender women who have sex with men (MTWSM) in Lebanon are consistent with a concentrated epidemic. Geopolitical and social circumstances leave these communities vulnerable to HIV spread. To document this risk encountered by Lebanese native and displaced Syrian MTWSM, participants, recruited by respondent driven sampling beginning with Syrian seeds, completed a survey with questions covering sociodemographic, behavioral, medical, and stigma, followed by opt-out HIV testing. Analyses included descriptive statistics and linear regression to differentiate between native Lebanese and Syrians who migrated after the onset of the civil war to identify correlations among sociodemographic factors, stigma, and risk behavior as a function of country of birth. Experienced and internalized stigmas were higher in the Syrian born MTWSM and correlated with elements of HIV risk. Combatting the intersectional stigmas of Syrian MTWSM in Lebanon would be most beneficial in mitigating HIV risk for these individuals.

Patterns of sexual and HIV-related stigma among men who have sex with men and women living with HIV in Haiti

Vulnerability to contracting HIV among Men who have Sex with Men and Women (MSMW) was recognized early in the epidemic. However, while global HIV efforts have made tremendous progress for the heterosexually-identified population, the specific needs of MSMW were not directly addressed with tailored and context-adapted interventions. The purpose of this study was to inform this area of research by exploring patterns of stigma through sexual identity developmental history as well as coping mechanisms among MSMW living with HIV in Haiti. A qualitative descriptive study comprised of in-depth interviews with 32 MSMW living with HIV was carried out. Participants were recruited using snowball techniques. An inductive thematic analysis was conducted in NVivo, contextualized by the socio-ecological context of Haiti. MSMW reported struggling with their sexuality since their adolescence, often because of enacted stigma from family members, the community, and cultural conflicts. Most participants described experiencing anxiety, psychological distress, depression, social isolation, suicidal ideation and suicide attempts. Mechanisms for coping with stigma included self-acceptance, social support, hiding their sexual orientation, and tolerance of the voodoo religion. To combat stigma, and improve HIV treatment adherence and retention among MSMW, culturally-tailored multilevel initiatives should be implemented.

Methodologies of Stigma-Related Research Amongst Men Who Have Sex With Men (MSM) and Transgender People in Asia and the Pacific Low/Middle Income Countries (LMICs): A Scoping Review

Much stigma-related research focuses on marginalized populations, including men who have sex with men (MSM) and transgender people. The importance of research in this area is widely recognized, however methodologies and measures vary between studies. This scoping review will collate existing information about how stigma-related research has been conducted in low/middle income countries (LMICs) within the Asia Pacific region, and will compare research designs, sampling frameworks, and measures. Strengths and limitations of these studies will inform recommendations for future stigma-related health research. A methodological framework for scoping studies was applied. Searches of Psych INFO, Scopus, ProQuest, Global Health and PubMed were used to identify articles. Stigma-related research amongst MSM and transgender communities, published between 2010 and 2019 in LMICs within the Asia Pacific region were included. A total of 129 articles based on 123 different studies were included. Of the 129 articles 51.19% (n = 66) were quantitative; 44.96% (n = 57) were qualitative and 3.88% (n = 5) were mixed methods studies. The majority of studies (n = 57; 86.36%) implemented a cross sectional survey. In-depth interviews (n = 20, 34.48%) were also common. Only 3.88% of studies utilized mixed-methods design. Non-probabilistic and probabilistic sampling methods were employed in 99.22 and 0.78% of studies respectively. The most common measures used in quantitative studies were the Center for Epidemiological Study on Depression (CES-D) (n = 18) and the Self Stigma Scale (SSS) (n = 6). Strengths and limitations proposed by researchers included in this review are summarized as lesson learnt and best practices in stigma-related research.

Cultural context matters: Testing the minority stress model among Chinese sexual minority men

Minority stress theory (e.g., Meyer, 2003b), a model for understanding mental health disparities affecting sexual minorities, has primarily been tested in Western samples yet has not been carefully applied to the experiences of sexual minorities in a global context, including in East Asian countries. Combining minority stress theory with considerations of Chinese culture, the current study tested the associations among norm conformity, distal minority stressor (enacted stigma), proximal minority stressors (sexual identity concerns and concealment), lesbian, gay, and bisexual (LGB) family support, and psychological distress among Chinese sexual minority men (n = 748). Structural equation modeling showed that sexual identity concerns mediated the associations of norm conformity, enacted stigma, and lower family support with concealment. Psychological distress was associated with enacted stigma and lower family support, but not with proximal stressors (sexual identity concerns and concealment). Alternative model testing found sexual identity acceptance concerns predicted psychological distress and mediated the associations of norm conformity and LGB family support with distress. Findings provide partial support for the minority stress model in a Chinese context and suggest the importance of incorporating cultural considerations into minority stress conceptualizations. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Psychosocial Problems and Vulnerability to HIV in a Multi-City Prospective Cohort of Young Transgender Women in the United States: A Structural Equation Modeling Study

BACKGROUND

Gender-based stigma contributes to increased HIV prevalence, but little is known about psychosocial mechanisms linking stigma and HIV risk among young transgender women (YTW).

SETTING

This study uses data from Project LifeSkills, a randomized controlled efficacy trial of an empowerment-based HIV prevention intervention for YTW (N = 233). YTW were recruited in Boston, MA, and Chicago, IL, between 2012 and 2015 and completed study assessment visits at baseline and months 4 and 12.

METHODS

Using autoregressive structural equation modeling, we examined whether poor social support and psychological distress at 4 months mediate the prospective relationship between gender-based stigma at baseline and condomless anal and vaginal sex (CAVS) acts at 4 and 12 months; all models were adjusted for treatment arm, HIV serostatus, study site, and sociodemographics.

RESULTS

Gender-based stigma at baseline was directly associated with increased CAVS at 4 months [adjusted incidence rate ratio (aIRR) = 1.18, 95% confidence interval (CI): (1.05 to 1.33)] and 12 months [aIRR = 1.17, 95% CI: (1.02 to 1.34)]. Gender-based stigma was also associated with higher psychological distress at 4 months [b = 0.70, 95% CI: (0.13 to 1.27)], which in turn was marginally associated with increased CAVS at 12 months [aIRR = 1.03, 95% CI: (1.00 to 1.06)]. Contrary to expectations, poor social support at 4 months was associated with decreased CAVS at 12 months [aIRR = 0.40, 95% CI: (0.28 to 0.59)].

CONCLUSIONS

Future HIV prevention interventions with YTW should consider addressing experiences of gender-based stigma and the psychological distress that may ensue from gender-based stigma. More research is needed to understand the influence of poor social support on sexual behaviors in this population.

Cultural context matters: Testing the minority stress model among Chinese sexual minority men

Minority stress theory (e.g., Meyer, 2003b), a model for understanding mental health disparities affecting sexual minorities, has primarily been tested in Western samples yet has not been carefully applied to the experiences of sexual minorities in a global context, including in East Asian countries. Combining minority stress theory with considerations of Chinese culture, the current study tested the associations among norm conformity, distal minority stressor (enacted stigma), proximal minority stressors (sexual identity concerns and concealment), lesbian, gay, and bisexual (LGB) family support, and psychological distress among Chinese sexual minority men (n = 748). Structural equation modeling showed that sexual identity concerns mediated the associations of norm conformity, enacted stigma, and lower family support with concealment. Psychological distress was associated with enacted stigma and lower family support, but not with proximal stressors (sexual identity concerns and concealment). Alternative model testing found sexual identity acceptance concerns predicted psychological distress and mediated the associations of norm conformity and LGB family support with distress. Findings provide partial support for the minority stress model in a Chinese context and suggest the importance of incorporating cultural considerations into minority stress conceptualizations. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Minority stress and health: A grounded theory exploration among men who have sex with men in China and implications for health research and interventions

RATIONALE

Men who have sex with men (MSM) in China are disproportionately affected by HIV and mental health issues. Although predominately western-based research suggests a minority stress perspective to explain health disparities, how Chinese MSM experience stress related to being a sexual minority and how such experiences affect their health have not been carefully examined.

OBJECTIVE

This study was a qualitative investigation of how stress related to sexuality (e.g., stigma, discrimination, and oppression) are experienced among MSM in China and how these experiences affect their psychological and behavioral health.

METHOD

In-depth, semi-structured interviews were conducted with 24 MSM in China. Grounded theory was employed to guide data analysis.

RESULTS

Six categories emerged, which included: A Family-Oriented, Heteronormative Culture, Interpersonal Rejections and Marginalization, Internalization of Stigma, the Psychological Impact of Minority Stress, Impact on HIV-related Behavioral Health, and Coping. A conceptual model was developed, which illustrated relationships among categories and described sources, processes, and impact of minority stress among MSM in China. Cultural, social, and internalized sources of minority stress were shown to have detrimental effects on participants' psychological health and HIV-related behavioral health. Various coping strategies shared the purpose of navigating well-being in one's direct environment and in the larger culture.

CONCLUSIONS

Findings demonstrate the relevance of minority stress in behavioral health among Chinese MSM as well as the need to conceptualize minority stress within MSM's sociocultural context. HIV prevention efforts may benefit from a contextualized understanding of minority stress and addressing minority stress in a culturally congruent, community-centered fashion.

Addressing Minority Stress and Mental Health among Men Who Have Sex with Men (MSM) in China

PURPOSE OF REVIEW

Men who have sex with men (MSM) in China experience elevated risks of mental health issues in comparison to the general population in China, which contribute to vulnerability to HIV/STI risks and can comprise the effectiveness of HIV prevention efforts. A conceptual framework for understanding this mental health disparity is minority stress theory, which posits that experiences of external prejudice events (i.e., distal stressors) and internal stress processes such as internalized homophobia and concealment (i.e., proximal stressors) contribute to sexual minorities' elevated risk of psychological distress. To deepen the understanding of mental health among Chinese MSM and explore the potential utility of minority stress theory in this population, this paper synthesizes research evidence regarding prevalent mental health issues as well as how minority stress may be linked to psychological health in Chinese MSM.

RECENT FINDINGS

Results indicate that Chinese MSM experience a high prevalence of several mental health issues including depression, anxiety, suicidal behaviors, and alcohol dependence. This review further reveals minority stress to be an important determinant of psychological distress among Chinese MSM, though evidence is mixed regarding the relationship between proximal minority stress and psychological health. Nonetheless, there is a lack of mental health services and interventions focusing on MSM in China. Culturally relevant, competent, and LGBT-affirmative mental health interventions are needed for Chinese MSM. To guide future intervention research, we provide considerations for reducing minority stress and promoting psychological health among Chinese MSM.

Current risk factors for HIV infection among blood donors in seven Chinese regions

BACKGROUND

In China, there is a rising concern on the increasing trends of HIV infections in high-risk groups, who make blood donations that might potentially challenge the blood safety. Analyses on current risk factors for HIV infection among Chinese blood donors are urgently needed for developing effective strategies to defer high-risk donors and to warrant the safety of the blood supply.

STUDY DESIGN AND METHODS

We recruited 313 HIV-positive and 762 HIV-negative donors from seven study sites in China and evaluated donor demographic characteristics, current medical and behavioral risk factors associated with HIV infection in a case-control survey. Univariable analyses examined the relationship between HIV infection and donor and donation characteristics, medical and behavioral risks, living conditions, and lifestyles. Multivariable logistic regression analyses evaluated the association between selected individual risks and HIV infection. Regression tree analysis was used to select covariates correlated with both HIV infection and individual risks and thus need to be controlled for in logistic regression models.

RESULTS

Being a man who has sex with men was associated with the highest odds of HIV infection. Not using a condom, having sex with HIV-infected individuals, having sex partners with sexually transmitted diseases (STDs), having more than two concurrent sex partners, or having an STD were all associated with more than five times higher odds of having HIV. Having remunerated sex was associated with a 2.4 increased odds of having HIV infection.

CONCLUSION

High-risk sexual behaviors were among the major risks for HIV infection among Chinese blood donors.

Social Capital Moderates the Relationship Between Stigma and Sexual Risk Among Male Sex Workers in the US Northeast

Stigma contributes to elevated HIV incidence among male sex workers (MSW). Social capital (i.e., resources accessed through one's social relationships) may act as a buffer between stigma and sexual risk behaviors and HIV acquisition. Using negative binomial regression, we examined the association between both sex work-related stigma and social capital with respect to number of condomless sex acts among 98 MSW living in the US Northeast. In models adjusted for sociodemographic characteristics, sex work-related stigma was associated with number of condomless sex acts with any non-paying partner (i.e., male and female) (aIRR = 1.25, p < 0.001) and male non-paying partners (aIRR = 1.27, p = 0.09) among individuals with low social capital, not among those with high social capital. Sex work-related stigma was not associated with number of condomless anal sex acts with male paying clients at any level of social capital. Future HIV prevention interventions should consider promoting social capital among MSW.

A health communication intervention to integrate partner testing with antiretroviral therapy service among men who have sex with men in China: an observational cohort study

Background

In China, antiretroviral therapy (ART) clinics focus on treating people living with HIV and are not required to undertake testing of high-risk populations. To improve partner testing among MSM, we implemented a health communication pilot intervention integrating partner testing with ART services. We aimed to assess the feasibility of the partner referral service and identify the predictors of both successful partner referral for HIV testing and HIV-positive test results among referred partners.

Methods

This program ran from April 2014 through December 2015 at designated ART clinics in six cities. The index participants, men living with HIV enrolled at an ART clinic, were assigned a case manager who assumed responsibility for routine ART-related counseling and mobilization of HIV-positive index participants for partner referral testing. Case managers were either nurses or contract staff. The successful referral rate was the proportion of index participants who referred a sexual partner for HIV testing. The HIV-positive partner rate was the proportion of the newly referred contacts who tested HIV-positive. Factors associated with the successful referral rate and the HIV-positive partner rate were assessed.

Results

Two thousand three hundred eighty-two index participants were enrolled. The median age was 30 years (IQR 26–37). 829index participants (34.80%) successfully referred at least one sexual partner for screening, and 92 (11.10%) referred partners were HIV-positive. Having a hospital nurse as case manager was associated with both successful partner referral (AHR = 1.56, 95% CI = 1.36–1.80) and having a HIV-positive partner (AHR = 2.35, 95% CI = 1.45–3.92). Index participants who were married (AHR = 1.44, 95% CI = 1.20–1.73) or employed (AHR = 1.29, 95% CI = 1.11–1.49) were more likely to successfully refer a partner for testing. Stable male partner relations were more likely to result in a referred partner testing HIV-positive (AHR = 5.50, 95% CI = 1.85–16.39).

Conclusion

Our findings indicated that integration of MSM partner testing with ART services via health communication was feasible. Nurses as case managers effectively encouraged index participants to refer their sexual partners for HIV testing.

The Relationship Between Posttraumatic Stress Disorder Symptoms and Posttraumatic Growth Among HIV-Infected Men Who Have Sex With Men in Beijing, China: The Mediating Roles of Coping Strategies

The traumatic experience of contracting and living with HIV/AIDS may produce a myriad of mental health problems, especially posttraumatic stress disorder (PTSD) symptoms, and conversely, bring posttraumatic growth (PTG), that is, positive changes resulting from a struggle with trauma. The growing body of research into the relationship between PTSD symptoms and PTG has produced mixed results. In addition, some research has suggested that psychosocial and cognitive factors may mediate the development of PTG after trauma exposure. Specifically, individuals experience fewer psychological symptoms and better mental health when adaptive coping strategies align with stressors; however, little research is available on the relationship and the mediating effect of coping strategies on the link of PTSD symptoms and PTG among HIV-infected men who have sex with men (MSM) in China. The aims of the current study were to investigate the relationship between PTSD symptoms and PTG as well as the potential mediating effects of coping strategies through which PTSD symptoms contributes to PTG among this vulnerable population. One hundred and forty HIV-positive MSM were recruited from the Beijing Center for Disease Prevention and Control and were asked to complete a battery of self-administered questionnaires, covering sociodemographic and HIV-related characteristics, coping strategies (i.e., problem-solving, seeking social support, self-blame, and wishful thinking), PTSD symptoms, and PTG. Results showed that, after controlling for sociodemographic and HIV-related variables, a negative linear relationship was found between PTSD symptoms and PTG. In addition, problem-solving and self-blame played significant mediating roles in the association between PTSD symptoms and PTG. The mediating effects of seeking social support and engaging in wishful thinking on the PTSD symptoms and PTD link were, however, non-significant. The present study contributes to an understanding of the association between PTSD symptoms and PTG and underscores the mediators through which individuals gain growth from traumatic experience in the context of HIV infection in Beijing, China. Given these findings, the future efforts at psychological intervention should differentiate and target various types of coping strategies, especially focusing on enhancing problem-solving skills and decreasing self-blame, in response to the promotion of positive growth among HIV-infected MSM.

The Effect of Psycho-Social Problems on Risky Behaviors in People Living With HIV in Tehran, Iran

Objective: Over the past years, the prevalence and the progression rate of HIV infection in Iran especially through high-risk sexual relationships have regrettably been reported at very high levels. This cross-sectional study tries to analyze stigma, mental health, and coping skills on risky behaviors in HIV-positive adults in Tehran- Iran. Materials and methods: This cross-sectional study was conducted on a sample of 450 HIV-positive adults. Participants completed a socio-demographic questionnaire, the General HealthQuestionnaire-28, the Berger HIV Stigma Scale as well as the Lazarus Ways of Coping Questionnaire (WOCQ). To analyze the data, the independent-samples t-test and Pearson Correlation were used. Results: The findings of this study revealed that mental health, stigma, and avoidance-escape coping mechanisms were correlated with risky behaviors (p ˂ 0.05).Furthermore, the amount of stigma among female individuals compared to men was reported at higher levels and mental health status in the given group was lower than among male individuals. Conclusion: It seems that psychological treatment techniques could be effective in improving mental health and reducing risky behaviors.

The relation between mental health, homosexual stigma, childhood abuse, community engagement, and unprotected anal intercourse among MSM in China

The aim of the study was to explore the relation of various factors with unprotected anal intercourse (UAI) and provide some insight for HIV intervention on Chinese men who have sex with men (MSM). The current cross-sectional study recruited 365 MSM in Dalian, China. More than half of the respondents (117 respondents, 51.8% of the sample) had engaged in UAI. The multivariable logistic regression model suggested that poorer mental health (AOR: 7.16; 95% CI: 3.14–16.31), self-stigma (AOR: 1.53; 95% CI: 1.00–2.34), and experience(s) of physical abuse in childhood (AOR: 5.85; 95% CI: 1.77–19.30) were significantly and positively related to UAI. Community engagement was negatively associated with UAI (p < 0.05). It appears it is necessary to incorporate mental health services, eliminate the stigma against homosexuality, and facilitate MSM-related community engagement into intervention strategies to prevent UAI among Chinese MSM. Targeted UAI interventions in the subgroup with a history of childhood physical abuse should also be of great concern.