Predictors of HIV-Related Stigmas Among African American and Latino Religious Congregants

More than 30 years into the HIV epidemic, HIV-related stigma remains a barrier to prevention and treatment efforts (Earnshaw, Bogart, Dovidio, & Williams, 2013). The U.S. National HIV/AIDS Strategy holds that stigma reduction is essential to reducing HIV-related disparities (White House Office of National AIDS Policy, 2010). African Americans and Latinos continue to be disproportionately affected by HIV, accounting for 65% of new infections in 2010 while representing only 28% of the population (Prevention, 2012). Faith-based organizations (FBOs) have been suggested as key community partners in addressing HIV disparities (Nunn, et al., 2013; Sachs, 2008; Sutton & Parks, 2013; UNAIDS, 2009; Woldehanna, Ringheim, & Murphy, 2005), but their roles in addressing HIV stigma are unclear. Prior literature on congregation-based HIV prevention interventions has focused almost exclusively on African American churches (Agate, et al., 2005; Baldwin, et al., 2008; Berkley-Patton, et al., 2010; Berkley-Patton, Moore, Hawes, Thompson, & Bohn, 2012; Griffith, Pichon, Campbell, & Allen, 2010; MacMaster, et al., 2007; Marcus, et al., 2004; Tyrell, et al., 2008; Wingood, Simpson-Robinson, Braxton, & Raiford, 2011). Although these and many community initiatives such as The Balm in Gilead (http://www.balmingilead.org/index.php/hiv.html) aim to work with congregations to reduce stigma as part of HIV education and testing programs, there have been few published evaluations of the extent to which such efforts actually reduce stigma. Further, few studies have measured HIV stigma in church-affiliated populations (Berkley-Patton, et al., 2013; Berkley-Patton, Thompson, et al., 2012; Bluthenthal, et al., 2012; Lindley, Coleman, Gaddist, & White, 2010; Muturi & An, 2010), despite being noted consistently as a barrier to congregation-based HIV programming (Williams, Palar, & Derose, 2011). HIV stigma in congregational settings is often attributed to religious taboos on homosexual contact between men, multiple sex partners, and drug use, which are likely to be viewed through a moral lens, facilitating stigmatization and the casting of blame (and shame). However, no previous church-based studies to our knowledge have measured these related stigmatizing attitudes (regarding homosexuality and drug addiction) and how they might contribute to HIV stigma. To develop effective HIV stigma reduction interventions in collaboration with FBOs, it is important to explore dimensions and predictors of HIV stigma among church-affiliated populations. We therefore explored HIV stigma and associated stigmas regarding same-sex sexual relations and drug addiction, using baseline data from an intervention study that aimed to reduce HIV stigma among congregants from three Latino and two African American churches in high HIV-prevalence communities. Background on HIV Stigma Previous research has identified two types of stigma relevant to HIV: instrumental stigma refers to concern about the potential consequences of interacting with a stigmatized person, such as becoming infected with HIV, while symbolic stigma refers to concern about what the stigmatized condition, such as HIV, symbolizes (Bos, Schaalma, & Pryor, 2008; Herek & Capitanio, 1998). Instrumental stigma can play out in feelings of discomfort about interacting with HIV-positive individuals, while symbolic stigma encompasses both an HIV-positive individual’s feelings of shame for having HIV as well as non-infected individuals’ rejection and blame towards those with HIV. To understand the predictors of stigma in our study, we draw on the seminal work of Goffman (1963), who described stigmatization as a social process involving the discrediting of members of an entire group based on one or more attributes. We also use the work of Herek (1999), who identified four characteristics of HIV that are likely to evoke stigma: 1) the cause is perceived to be the bearer’s responsibility; 2) the condition is unalterable or degenerative; 3) the condition is perceived to be contagious or to place others in harm’s way; and 4) the condition is readily apparent to others. We also draw upon previous work on the predictors of HIV stigma in general (i.e., not specifically HIV-positive) U.S. populations, as well as the few studies of HIV stigma among religious congregants. The most consistent individual-level, independent factors associated with lower instrumental and symbolic HIV stigma among general U.S. populations have been younger age, higher education, personal contact with people with HIV or AIDS, greater knowledge about HIV transmission, and more favorable attitudes towards gays (Herek, 1999). The two previous U.S. church-based studies of which we are aware that quantitatively measured HIV stigma focused on African Americans and were somewhat limited in terms of how much they explored the predictors of stigma. Berkley-Patton et al. (2013) found that an HIV education and testing intervention did not reduce HIV stigma among congregants and community members served by outreach programs at four African American churches, and found that only greater HIV knowledge and income (but not age, gender, or religiosity) were predictive of lower HIV stigma score at baseline. Lindley et al. (2010), in a study of congregants, pastors, and pastoral care lay leaders from 20 African American churches, found that male gender, older age, and lower HIV knowledge were associated with higher HIV stigma. Focus of this Study In order to inform African American and Latino church-based interventions to reduce HIV stigma, we focused this study on factors that might be associated with stigma. First, we examined whether personally knowing someone with HIV was associated with lower HIV stigma (Herek & Capitanio, 1997; Mall, Middelkoop, Mark, Wood, & Bekker, 2013; Nambiar & Rimal, 2012). Such an association would support the contact hypothesis (Pettigrew & Tropp, 2006), which suggests that intergroup contact can reduce prejudice. We also examined whether stigmas related to drug addiction and homosexuality were associated with higher HIV stigma (Capitanio & Herek, 1999; Herek & Capitanio, 1999; Price & Hsu, 1992; St. Lawrence, Husfeldt, Kelly, Hood, & Smith, 1990). Finally, since research has found that individuals who have never discussed HIV with anyone have more negative attitudes toward people with HIV (Genberg, et al., 2009), we also explore whether specific types of communication about HIV within and outside church are associated with HIV stigma. In this paper, we: 1) describe HIV stigma scales that we adapted from previous work to characterize four HIV stigma dimensions (discomfort, shame, rejection, and blame); 2) assess the extent to which these HIV stigma scales tap into different components of HIV stigma and examine their relationships to stigmas regarding drug addiction and homosexuality; and 3) test the following hypotheses: a) African American and Latino religious congregants who know someone with HIV will express lower HIV stigma, controlling for other factors; and b) Congregants with higher drug addiction and homosexuality stigmas will have higher HIV stigma after controlling for other factors. No previous studies have examined HIV-related attitudes among Latino congregants, the ways in which multiple dimensions of HIV stigma compare across congregants of different races and ethnicities, the extent to which attitudes regarding homosexuality and drug addiction are associated with HIV-related attitudes in congregational settings, or whether knowing someone with HIV influences HIV-related attitudes in congregational settings.