'We are the change' - An innovative community-based response to address self-stigma: A pilot study focusing on people living with HIV in Zimbabwe

Community-based interventions against HIV-related stigma: a systematic review of evidence in Sub-Saharan Africa

BACKGROUND

HIV-related stigma remains a key barrier to the attainment of the UNAIDS global goal of ending AIDS by 2030. Due to the social and contextual nature of HIV-related stigma, community-based interventions may be more effective in addressing it. In this review, we synthesized evidence on the effectiveness and features of community-based interventions against HIV-related stigma in Sub-Saharan Africa.

METHODS

MEDLINE, EMBASE, CINAHL, Psych INFO, and Web of Science were searched in July 2023. We also searched Google Scholar and reference lists of all selected studies. Included studies were randomized controlled trials, mixed methods studies, as well as pre-test and post-test studies that evaluated the effectiveness of a community-based intervention to reduce HIV-related stigma in the general population or among specific groups. Data extraction was done using a pre-designed and pre-tested form. We performed a synthesis without meta-analysis, utilizing Fisher's method to combine p-values, to demonstrate evidence of an effect in at least one study. Additionally, we applied framework thematic analysis to qualitatively synthesize the intervention characteristics of the included studies.

RESULTS

A total of nine journal articles were included, largely with a high risk of bias. Results from the combined p-values provide strong evidence supporting the effectiveness of community-based interventions in reducing HIV-related stigma in at least one of the studies (p < 0.001, X2 = 73.1, 18 degrees of freedom). Most studies involved people living with HIV (PLH) alone as intervention recipients and as intervention implementers. Community members with unknown HIV status were involved in only 2 studies. The intervention strategies were largely information sharing through workshops and training as well as individualized counselling. In few studies, additional support in the form of referrals, nutritional supplements, and adherence support was provided to PLH during the interventions. Most studies were judged to be of moderate to high cost except in 3 where the intervention implementers were PLH within the community, volunteering in the home-based support approach. The involvement of community members in the design of intervention strategies was not seen in all the studies.

CONCLUSION

Community-based interventions appear to be effective in reducing HIV-related stigma. However, more robust randomized trials are needed to provide stronger evidence for this effect. Although these interventions have been multifariously developed in Sub-Saharan Africa, comprehensive strategies involving the stigmatized and the "stigmatizers" in a social change approach are lacking. The application of strategies without the involvement of community members in their design takes away a sense of community responsibility, and this threatens the sustainability of such interventions.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42023418818.

Community-based psychosocial support interventions to reduce stigma and improve mental health of people with infectious diseases: a scoping review

BACKGROUND

Stigma experienced by people with infectious diseases impedes access to care, leading to adverse psychosocial consequences. Community-based interventions could prevent or mitigate these consequences but lack robust evidence. This scoping review aimed to identify and critically appraise community-based psychosocial support interventions to reduce stigma and improve mental health for people affected by stigmatizing infectious diseases including tuberculosis (TB), HIV/AIDS, and leprosy.

METHODS

This was a scoping review of literature indexed in PubMed, Web of Science, Elton B. Stephens Company (EBSCO) database, as well as reports in the World Health Organization repository, published from January 2000 to June 2023. We included research articles and reports addressing stigma and mental health disorders among individuals with TB, HIV/AIDS, or leprosy and/or their household members in low- and middle-income and/or high TB burden countries. We extracted information regarding types of psychosocial interventions and their reported impact on health and psychosocial indicators.

RESULTS

Thirty studies were included in this review: 21 (70%) related to HIV/AIDS, seven (23%) leprosy, and two (7%) TB. Of these, eleven were quantitative studies, nine qualitative, and ten mixed-methods. Eleven community-based interventions were reported to reduce infectious disease-related stigma, predominantly internalized and enacted stigma, and improve adherence to medication, quality of life, health-related knowledge, depression symptoms, and psychosocial wellbeing. Most studies involved lay people in the community as supporters of those affected. The predominant reported mechanism of intervention effect was the ability of supporters to enable those affected to feel seen and listened to, to accept their diagnosis, to improve their self-esteem, and to facilitate continuation of their daily lives, and thereby reducing anticipated stigma, self-stigma, and mental illness. Adequate training for lay people was reported to be essential to ensure success of interventions.

CONCLUSIONS

This review identified a paucity of high-quality evidence relating to community-based interventions to reduce stigma for infectious diseases. However, such interventions have been reported to reduce stigma and improve mental health among people with HIV/AIDS, leprosy, and TB. Engaging affected communities and peers, through the conception, planning, training, implementation, and evaluation phases, was reported to be essential to optimise intervention uptake, impact, and sustainability.

Reported impact of creativity in the Wakakosha ('You're Worth It') internal stigma intervention for young people living with HIV in Harare, Zimbabwe

Internal stigma (negative judgements towards oneself) continues to be a barrier to HIV treatment, management and care, and has global public health consequences. People living with HIV (PLHIV) who report internal stigma are less likely to seek care, adhere to treatment and can experience increased depression and lower quality of life. The Wakakosha ('You're Worth It') programme sought to reduce internal stigma among young PLHIV using inquiry-based stress reduction (IBSR), a cognitive and awareness-based methodology. This sub-study focused on creativity, exploring how it promotes young PLHIV's well-being. We analysed individual interviews (n = 14), focus groups (n = 3), poems (n = 5), songs (n = 2) and self-compassion letters (n = 38) and 23 activity journals from November 2021 to March 2022, utilising inductive thematic analysis to identify themes across the data. Creativity saturated the Wakakosha intervention through modalities such as drawing, colouring, body mapping, music and letter writing. These engaged participants and gave them a space in which to shift their internal stigmatising beliefs, and helped them in multiple ways including: facilitating emotional regulation, self-acceptance, self-compassion, self-worth and body positivity. Creativity also enhanced participants' self-image and allowed them to see their own abilities. Music improved the therapeutic environment by helping participants focus, emote, retain messages and connect within the group setting. Letters to self/others allowed participants to let go of stigma towards themselves and the circumstances of their infection. Tools such as drawing and body mapping assisted participants with emotional recognition and expression. This sub-study provided insight into the potential of creativity, when integrated into an IBSR intervention, in counteracting internal stigma. Ongoing replication is needed to continue to evolve best practices for internal stigma interventions. Future work should use more structured and specific interviews with participants regarding their creative processes.

Piloting "From the Inside Out" - a toolkit addressing tuberculosis-related self-stigma

BACKGROUND

Self-stigma among people who have tuberculosis (TB) can contribute to non-adherence to medication and disengagement from care. It can manifest in feelings of worthlessness, shame, and guilt, leading to social withdrawal and disengagement from life opportunities. Self-stigma may also affect families of those who have TB, or healthcare workers who treat them. However, few interventions addressing TB self-stigma exist to date.

METHODS

We piloted the delivery of a toolkit of psychosocial interventions using a "training-of-trainers" approach with six staff members of a TB-focused NGO (Non-Governmental Organisation) and partner organisations in Jakarta, Indonesia. These trainers could then disseminate the toolkit among community partner organisations. Local staff involvement throughout the study supported translation and adaptation to enhance cultural and language appropriateness. Over a 2-day training-of-trainers workshop, the NGO staff were familiarised with the mode of delivery of the toolkit, which they then delivered via a four-day participatory workshop with 22 people who have TB/TB survivors, who were representatives of partner organisations working among communities affected by TB.

RESULTS

The newly-trained local facilitators delivered the toolkit to the participants, who self-reported significant increases in knowledge and efficacy around TB self-stigma post-intervention compared to baseline (Z = 1.991, p = 0.047, Wilcoxon signed-rank test). The participants' levels of self-compassion were also significantly higher post-workshop (Z = 2.096, p = 0.036, Wilcoxon signed-rank test); however, these effects were not maintained at 3-month timepoint. There was also a significant increase post-workshop in one of the participants' Ryff dimensions of psychological wellbeing, that of positive relationships with others (Z = 2.509, p = 0.012, Wilcoxon signed-rank test) but this was also not maintained at the 3-month timepoint.

CONCLUSIONS

The observed changes in recipients' self-reported levels of knowledge and efficacy, self-compassion, and psychological wellbeing may warrant further investigation into the best modalities for toolkit delivery (frequency, dose, duration) and support for individuals as they progress through the TB treatment journey.

Factors associated with HIV-positive status awareness among adults with long term HIV infection in four countries in the East and Southern Africa region: A multilevel approach

Antiretroviral treatment (ART) appropriately and regularly used decreases the human immunodeficiency virus (HIV) viral load in the bloodstream, preventing HIV-infected people from spreading the infection to others. Disparities in ART adoption persists in East and Southern Africa, with low HIV-positive status knowledge being the primary factor. We investigated individual and household characteristics of HIV-positive status awareness among adults with long-term HIV infection in four East and Southern African countries: Eswatini, Malawi, Tanzania, and Zimbabwe. The study analyzed data from surveys conducted in Eswatini, Malawi, Tanzania, and Zimbabwe in 2015-2016. Only individuals who tested positive for HIV through rapid tests were included in the analysis. Those who already knew they were HIV-positive were categorized as aware, while those who reported being negative, never tested, or didn't know their status were categorized as unaware. Statistical models were used to examine various factors related to HIV awareness. Pooled and country-specific odds ratios were computed. The percentage of people who knew they had HIV ranged from 58% (Tanzania and Malawi) to 87% (Eswatini). After adjusting for other variables, young persons in all countries were less likely to be aware of their HIV-positive status. Gender, marital status, education, working status, household wealth, and urbanization level of households were also associated with HIV-positive status awareness but inconsistent across countries. HIV-positive status awareness in these four East and Southern African nations remained unsatisfactory as compared to the United Nations' 95% guideline, indicating that testing and knowledge of HIV testing in this region still has a lot of potential for improvement. The observed variations among nations may be attributable to differences in HIV pandemic culture and policies. The findings of this study will assist governments determining which subpopulations to target to boost adoption of HIV testing services, as well as in designing and development of policies.

Addressing the unmet mental health needs of people living with HIV: a scoping review of interventions in sub-Saharan Africa

Some mental health interventions have addressed mental health among people living with HIV (PLWH) using a variety of approaches, but little is known about the details of such interventions in sub-Saharan Africa (SSA), a region that bears the largest burden of HIV in the world. The present study describes mental health interventions for PLWH in SSA regardless of the date and language of publication. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) reporting guidelines, we identified 54 peer-reviewed articles on interventions addressing adverse mental health conditions among PLWH in SSA. The studies were conducted in 11 different countries, with the highest number of studies in South Africa (33.3%), Uganda (18.5%), Kenya (9.26%), and Nigeria (7.41%). While only one study was conducted before the year 2000, there was a gradual increase in the number of studies in the subsequent years. The studies were mostly conducted in hospital settings (55.5%), were non-pharmacologic (88.9%), and interventions were mostly cognitive behavioural therapy (CBT) and counselling. Task shifting was the primary implementation strategy used in four studies. Interventions addressing the mental health needs of PLWH that incorporates the unique challenges and opportunities in SSA is highly recommended.

Wakakosha "You are Worth it": reported impact of a community-based, peer-led HIV self-stigma intervention to improve self-worth and wellbeing among young people living with HIV in Zimbabwe

Introduction

Self-stigma-negative self-judgements or core beliefs-can result in feelings of shame, worthlessness and self-blame, and impacts social interaction, mental health and health service utilization among people living with HIV (PLHIV). Few interventions target self-stigma among PLHIV and, to our knowledge, none until now for adolescents and young people LHIV (AYPLHIV) in sub-Saharan Africa. We present qualitative findings on the perceived impact of a self-stigma intervention (Wakakosha, "You are Worth it").

Methods

The Wakakosha intervention adopted inquiry-based stress reduction (IBSR) at its core-a unique way of identifying and questioning deeply rooted self-stigma, combined with mindfulness, meditation and creativity. The intervention consisted of 16 × 3 hour group sessions. Supporting the intervention was a 156-page activity journal. We utilized a qualitative enquiry to explore the perceived impact of the intervention at various time points between November 2021 and November 2022, with 62 participants (n = 32 female). Discussions explored experiences of being involved in the intervention and any reports on changes in relation to self-stigma and shame. Additionally, we reviewed intervention documentation and creative elements. A thematic analysis guided generation of themes across all data sources.

Results

Both intervention participants and coaches described the transformative effect of the intervention, detailing their experiences before and after. Main themes that emerged were positive changes around: self-confidence, self-agency, sense of purpose/meaning, body positivity, improved communication and personal/family relationships and, forgiveness. The intervention also transferred a set of practical skills on self-inquiry, mindfulness, meditation and creativity that continued to be used in participants' daily lives.

Conclusion

The Wakakosha intervention, using IBSR supported by music, creativity, writing and mindfulness techniques, showed potential for reducing self-stigma and improving self-worth among AYPLHIV. It also transferred practical skills to intervention participants and peer coaches, building their capacity to support others and deal with life challenges beyond HIV. The next phase is to continue supporting the young people to ensure fidelity as the peer coaches deliver the intervention to others. Study results indicate that culturally and practically, interventions to reduce self-stigma and/or improve self-worth operate at various levels and need to be designed and assessed at each level.

Exploring the beliefs, experiences and impacts of HIV-related self-stigma amongst adolescents and young adults living with HIV in Harare, Zimbabwe: A qualitative study

Background

HIV-related self-stigma is a significant barrier to HIV management. However, very little research has explored this phenomenon, particularly in sub-Saharan Africa. This study explored the beliefs, experiences, and impacts of HIV self-stigma amongst adolescents and young adults (AYALHIV) in Harare, Zimbabwe to inform future interventions. It aimed to capture the lived experience of self-stigmatization among AYALHIV and its impact on their social context using Corrigan et al (2009) self-stigma framework of ‘awareness’, ‘agreement’, and ‘application’.

Methods

Virtual semi-structured key informant interviews were conducted between June and July 2020 with adolescents and young adults (Female = 8; Male = 8) living with HIV (18–24 years) in Harare, Zimbabwe. We conducted the interviews with a purposive sample of AYALHIV enrolled in Africaid’s ‘Zvandiri’ program which provides HIV support services. Interviews were mainly conducted in English and with three in Shona, the main indigenous language. Audio-recorded qualitative data were transcribed, translated into English (where necessary) and deductively coded using Corrigan et al.’s self-stigma framework. The outbreak of SARS-CoV-2 coincided with the commencement of data collection activities, which impacted on both the sample size and a shift from in-person to virtual interviewing methods.

Results

Sixteen respondents (50% male) took part in the interviews. The mean age of respondents was 22 years. All respondents reported HIV-related self-stigma either occasionally or frequently. Three main themes of self-stigmatizing experiences emerged: disclosure, relationships, and isolation. These themes were then analyzed within the self-stigma development framework by Corrigan et al. (2009) known as ‘the three As’: awareness, agreement, and application of self-stigmatizing thoughts. Respondents’ experiences of self-stigma reportedly led to poor well-being and decreased mental and physical health. Gendered experiences and coping mechanisms of self-stigma were reported. Data suggested that context is key in the way that HIV is understood and how it then impacts the way people living with HIV (PLHIV) live with, and experience, HIV.

Conclusions

HIV-related negative self-perceptions were described by all respondents in this study, associated with self-stigmatizing beliefs that adversely affected respondents’ quality of life. Study findings supported Corrigan et al.’s framework on how to identify self-stigma and was a useful lens through which to understand HIV-related self-stigma among young people in Harare. Study findings highlight the need for interventions targeting PLHIV and AYALHIV to be context relevant if they are to build individual resilience, while working concurrently with socio-political and systemic approaches that challenge attitudes to HIV at the wider societal levels. Finally, the gendered experiences of self-stigma point to the intersecting layers of self-stigma that are likely to be felt by particularly marginalized populations living with HIV and should be further explored.

Investigating the effect of inquiry-based stress reduction on mortality awareness and interpersonal problems among intensive care unit nurses

INTRODUCTION

Caring for dying patients is one of the job stressors. Nurses in intensive care units are among the medical staff who have a close interaction with dying patients. Studies have shown that psychological interventions are very helpful in improving thinking about death and its problems. Therefore, this study was conducted to investigate the effect of Inquiry-Based Stress Reduction on mortality awareness and interpersonal problems among intensive care unit nurses in southeastern Iran.

MATERIALS AND METHODS

This was a Quasi-experimental study with a pretest-posttest design in southeast of Iran in 2021. Nurses were selected using the convenience sampling method and divided into intervention (n = 32) and control (n = 35) groups using the block randomization method. The intervention group received a two-hour Inquiry-Based Stress Reduction counseling session every week for 6 weeks. Data were gathered using Multidimensional Mortality Awareness Measure and Inventory of Interpersonal Problems before, immediately after, and 6 weeks after the intervention. IBM SPSS Statistics software version 25 was used for data analysis.

RESULTS

In the intervention group, the mean scores of Mortality Awareness before, immediately after, and 6 weeks after the intervention were 130.41 ± 5.91, 164.47 ± 8.66, and 163.91 ± 9.29, respectively. Therefore, in the intervention group, the increase of Mortality Awareness mean score was statistically significant (P < 0.001). In the control group, the mean scores of Mortality Awareness before, immediately after, and 6 weeks after intervention were 129.63 ± 5.59, 135.26 ± 11.14, and 132.66 ± 5.62, respectively. Difference between the two groups was significant (P < 0.001). The results also showed that in the intervention group the mean scores of Interpersonal Problems immediately after and 6 weeks after the intervention were lower than before the intervention (P < 0.001). In the control group, Interpersonal Problems increased over time (P < 0.001). Accordingly, the difference between the two groups in terms of Interpersonal Problems during the study was statistically significant (P < 0.001).

CONCLUSION

The study results suggest that the Inquiry-Based Stress Reduction is an appropriate intervention method to improve mortality awareness and reduce interpersonal problems in intensive care unit nurses.

HIV-AIDS Stigma in Burundi: A Qualitative Descriptive Study

HIV/AIDS stigma is a global issue and a serious problem in African countries. Although prevalence remains high in this region, no detailed study has yet been carried out to determine and characterize this problem in Burundi. Using a qualitative analysis based on an extensive series of 114 interviews, we describe the main characteristics of HIV stigma in the country. The results of our study indicate that the problem of HIV/AIDS stigma is widespread in Burundian society, as all participants in the research reported having experienced some kind of HIV stigma. The seven dimensions of stigma identified in people living with HIV/AIDS (PLWHA) in Burundi are physical violence, verbal violence, marginalization, discrimination, self-stigma, fear and insecurity, and healthcare provider stigma. These dimensions of stigma can be experienced through different manifestations, which have been characterized in this study, revealing that the problem of stigma in PLWHA is still an important issue in Burundi.

Role of Self-Stigma in Pathways from HIV-Related Stigma to Quality of Life Among People Living with HIV

This study examined the relationships between perceived public stigma, experienced stigma, and quality of life in people living with HIV (PLHIV), and whether self-stigma mediates these relationships. Cross-sectional data were analyzed from 1704 PLHIV in care at OLVG hospital in the Netherlands. We measured different types of stigma (perceived public stigma, experienced stigma, and self-stigma), and various quality-of-life outcomes (disclosure concerns, depression, anxiety, sexual problems, sleeping difficulties, self-esteem, general health, and social support). Structural equation modeling was used to test the paths from different types of stigma to quality-of-life outcomes. All direct effects of self-stigma on quality-of-life outcomes were significant. The final mediation model showed that the effects of both perceived public and experienced stigma on quality-of-life outcomes were mediated by self-stigma. These findings highlight the importance of addressing self-stigma in PLHIV, and call for (psychosocial) interventions that reduce the harmful effects of HIV-related stigma.

"My Friend with HIV Remains a Friend": HIV/AIDS Stigma Reduction through Education in Secondary Schools-A Pilot Project in Buea, Cameroon

The universal access to treatment and care for people living with HIV (PLWHIV) is still a major problem, especially in sub-Saharan Africa, where 70% of HIV-infected people live. Equally important is the fact that HIV/AIDS-related stigma is recognized to be a major obstacle to successfully control the spread of this disease. We devised a pilot project (titled “My friend with HIV remains a friend”) to fight the HIV/AIDS stigmatization through educating secondary school students by openly HIV-positive teachers. In a first step, we have measured the amount and type of stigma felt by the PLWHIV in Buea/Cameroon using the “The people living with HIV Stigma Index” from Joint United Nations Programme on HIV/AIDS. Gossiping and verbal insults were experienced by 90% of the interviewees, while 9% have experienced physical assaults. Using these data and material from the “Toolkit for action” from the “International Centre for the Research on Women,” the teachers educated the students on multiple aspects of HIV/AIDS and stigma. The teaching curriculum included role-plays, picture visualizations, drawing, and other forms of interactions like visits to HIV and AIDS treatment units. Before and after this intervention, the students undertook “True/False” examinations on HIV/AIDS and stigma. We compared these results with results from students from another school, who did not participate in this intervention. We were able to show that the students taking part in the intervention improved by almost 20% points in comparison to the other students. Their results did not change.

Pathways for reduction of HIV-related stigma: a model derived from longitudinal qualitative research in Kenya and Uganda

INTRODUCTION

The rollout of antiretroviral therapy (ART) has been associated with reductions in HIV-related stigma, but pathways through which this reduction occurs are poorly understood. In the newer context of universal test and treat (UTT) interventions, where rapid diffusion of ART uptake takes place, there is an opportunity to understand the processes through which HIV-related stigma can decline, and how UTT strategies may precipitate more rapid and widespread changes in stigma. This qualitative study sought to evaluate how a UTT intervention influenced changes in beliefs, attitudes and behaviours related to HIV.

METHODS

Longitudinal qualitative in-depth semi-structured interview data were collected within a community-cluster randomized UTT trial, the Sustainable East Africa Research in Community Health (SEARCH) study, annually over three rounds (2014 to 2016) from two cohorts of adults (n = 32 community leaders, and n = 112 community members) in eight rural communities in Uganda and Kenya. Data were inductively analysed to develop new theory for understanding the pathways of stigma decline.

RESULTS

We present an emergent theoretical model of pathways through which HIV-related stigma may decline: internalized stigma may be reduced by two processes accelerated through the uptake and successful usage of ART: first, a reduced fear of dying and increased optimism for prolonged and healthy years of life; second, a restoration of perceived social value and fulfilment of subjective role expectations via restored physical strength and productivity. Anticipated stigma may be reduced in response to widespread engagement in HIV testing, leading to an increasing number of HIV status disclosures in a community, "normalizing" disclosure and reducing fears. Improvements in the perceived quality of HIV care lead to people living with HIV (PLHIV) seeking care in nearby facilities, seeing other known community members living with HIV, reducing isolation and facilitating opportunities for social support and "solidarity." Finally, enacted stigma may be reduced in response to the community viewing the healthy bodies of PLHIV successfully engaged in treatment, which lessens the fears that trigger enacted stigma; it becomes no longer socially normative to stigmatize PLHIV. This process may be reinforced through public health messaging and anti-discrimination laws.

CONCLUSIONS

Declines in HIV-related stigma appear to underway and explained by social processes accelerated by UTT efforts. Widespread implementation of UTT shows promise for reducing multiple dimensions of stigma, which is critical for improving health outcomes among PLHIV.

What determines employment quality among people living with HIV: An empirical study in China

At the intersection of research areas on health and employment, little attention has been paid on employment quality among people living with HIV (PLWH). The objective of the current study is to identify critical factors and empirically examine their effects on employment quality among PLWH. Based on the social-ecological perspective, we identified negative self-image, workplace discrimination, social support, and policy support as critical factors associated with employment quality among PLWH. Thereafter, a questionnaire survey was conducted to gather information from 339 employed PLWH in China. Hierarchical regression analyses were further performed to analyze the effects of the identified factors on employment quality among PLWH. We obtained three main findings. First, negative self-image and workplace discrimination are detrimental to employment quality among PLWH; whereas social support and policy support are conducive to their employment quality. Second, older, male, and highly educated PLWH can better leverage the undesirable effects of negative self-image and workplace discrimination on employment quality compared with their peers. Third, male, and highly educated PLWH can better utilize social support and policy support to advance employment quality compared with their peers. However, the employment quality effects of the identified factors did not differ by marital status. Our findings provided some useful implications for PLWH, employers, community service providers, and policy makers to promote employment quality among PLWH.

The push of stigma: a qualitative study on the experiences and consequences of sexuality stigma among same-sex attracted men in Harare, Zimbabwe

This paper describes experiences of sexuality stigma among same-sex attracted men in Zimbabwe and analyses the consequences of such experiences for healthcare seeking. It draws on qualitative research carried out in Harare in 2017, which included in-depth interviews with sixteen gay and bisexual men, and key informant interviews with three representatives of organisations that work with gay men. There were numerous stories about sexuality stigma in the study participants´ social environments, including at home, in local communities and in healthcare facilities. We first offer a description of these and then go on to trace the implications of stigma on the relations between men who have sex with men on the one hand and the healthcare sector on the other. We conceive of stigma as a pushing force that exerts pressure on and in these relations, and identify five types of consequences of this. Stigma works to (1) produce geographical shifts in healthcare, (2) promote private over public care, (3) compartmentalise healthcare (with dedicated providers for queer persons), (4) deprofessionalise care, and (5) block access to appropriate healthcare altogether for some same-sex attracted men. Most of these consequences have negative implications for preventive or treatment-focused HIV programming.