The Causes and Consequences of HIV-Related Enacted and Internalized Stigma: a Comment on Takada et al.

Alongside of the global HIV/AIDS crisis runs a parallel pandemic of AIDS stigma. Prejudice, discrimination, and social isolation are driven by stigmatizing beliefs, adversely impact the lives of people living with HIV infection and propagate the spread of the virus. The social construction and mental representations of HIV as a stigmatized condition create barriers to HIV testing, protective behaviors, treatment access, medication adherence, and disease management. Fears of discrimination and rejection stemming from stigma lead people to conceal their HIV status, even when nondisclosure is stressful, illegal, or places others at risk. (1) Stigmas extend beyond the diagnosed person to their social communities, networks, and close relationships, contributing to the burden of AIDS. The extent and ramifications of AIDS stigma are unprecedented in terms of impact on global health. And yet, there are few conceptual models to explain the social processes of HIV-related stigma that extend beyond the earliest theory of stigma offered by Erving Goffman (2) decades before the first cases of HIV infection. The lack of contemporary models for studying HIV-related stigma has also stymied innovation in research design and methodology. More than 30 years since the first behavioral studies in AIDS and 50 years since Goffman’s seminal work, we are only now seeing the emergence of new ideas, new models, and ground breaking methodologies in the study of HIV-related stigma. (3–5) In this issue, Takada et al. (6) present findings from a Ugandan cohort of people living with HIV that demonstrates temporal associations between discrimination experiences, or enacted stigma, and emotional and instrumental support garnered from the relationships of people living with HIV. Takada et al. also report that a lack of instrumental support is associated with increased experiences of subsequent enacted stigma. Furthermore, when people with HIV adopt society-held stigmatizing beliefs, or internalized stigma, they experience diminished emotional support. The reciprocally determinant associations between internalized stigma and emotional support is reminiscent of the dynamic processes between depression and social support. However, these relationships have not previously been tested in relation to HIV-related stigma. Indeed, there are surprisingly few longitudinal studies of the relationship between stigma experiences and social support in reference to any health condition. The social and relational consequences of internationalized stigma in people living with HIV therefore may mirror the well-established reciprocity of depression and social support and may generalize to other stigmatized illnesses. Although conceptually distinct, internalized stigma and depression share important common features including self-deprecation, shame, and diminished social relations. Takada et al. provide evidence for the mechanisms underlying internalized stigma, which may be shared with depression. This important finding pushes forward our understanding of mental health, emotional adjustment, and coping in people living with a stigmatized condition. In addition to their conceptual contributions, Takada et al. (6) exploit the use of time-lagged modeling, approaching a causal relationship between enacted and internalized dimensions of HIV-related stigma and emotional and instrumental social support. This unprecedented precision in measurement is coupled with data analytic strategies that offer answers to questions that have until now been left to speculation. The now empirically validated reciprocal relationship between stigma, social support, and adjustment must be translated into strategies for breaking the detrimental cycle of stigma and maladjustment. Conceptual clarity and methodological precision offered by Takada et al. will surely advance research. We must now develop models for translating these important findings into interventions to ameliorate HIV-related stigmas to improve the lives of those affected by AIDS.