Stigma is a well-documented barrier to health seeking behavior, engagement in care and adherence to treatment across a range of health conditions globally. In order to halt the stigmatization process and mitigate the harmful consequences of health-related stigma (i.e. stigma associated with health conditions), it is critical to have an explicit theoretical framework to guide intervention development, measurement, research, and policy. Existing stigma frameworks typically focus on one health condition in isolation and often concentrate on the psychological pathways occurring among individuals. This tendency has encouraged a siloed approach to research on health-related stigmas, focusing on individuals, impeding both comparisons across stigmatized conditions and research on innovations to reduce health-related stigma and improve health outcomes. We propose the Health Stigma and Discrimination Framework, which is a global, crosscutting framework based on theory, research, and practice, and demonstrate its application to a range of health conditions, including leprosy, epilepsy, mental health, cancer, HIV, and obesity/overweight. We also discuss how stigma related to race, gender, sexual orientation, class, and occupation intersects with health-related stigmas, and examine how the framework can be used to enhance research, programming, and policy efforts. Research and interventions inspired by a common framework will enable the field to identify similarities and differences in stigma processes across diseases and will amplify our collective ability to respond effectively and at-scale to a major driver of poor health outcomes globally.

ObjectiveTo conduct a systematic review and series of meta-analyses on the association between HIV-related stigma and health among people living with HIV.Data sourcesA structured search was conducted on 6 electronic databases for journal articles reporting associations between HIV-related stigma and health-related outcomes published between 1996 and 2013.Study eligibility criteriaControlled studies, cohort studies, case-control studies and cross-sectional studies in people living with HIV were considered for inclusion.Outcome measuresMental health (depressive symptoms, emotional and mental distress, anxiety), quality of life, physical health, social support, adherence to antiretroviral therapy, access to and usage of health/social services and risk behaviours.Results64 studies were included in our meta-analyses. We found significant associations between HIV-related stigma and higher rates of depression, lower social support and lower levels of adherence to antiretroviral medications and access to and usage of health and social services. Weaker relationships were observed between HIV-related stigma and anxiety, quality of life, physical health, emotional and mental distress and sexual risk practices. While risk of bias assessments revealed overall good quality related to how HIV stigma and health outcomes were measured on the included studies, high risk of bias among individual studies was observed in terms of appropriate control for potential confounders. Additional research should focus on elucidating the mechanisms behind the negative relationship between stigma and health to better inform interventions to reduce the impact of stigma on the health and well-being of people with HIV.ConclusionsThis systematic review and series of meta-analyses support the notion that HIV-related stigma has a detrimental impact on a variety of health-related outcomes in people with HIV. This review can inform the development of multifaceted, intersectoral interventions to reduce the impact of HIV-related stigma on the health and well-being of people living with HIV.

BackgroundSocial and structural factors are now well accepted as determinants of HIV vulnerabilities. These factors are representative of social, economic, organizational and political inequities. Associated with an improved understanding of multiple levels of HIV risk has been the recognition of the need to implement multi-level HIV prevention strategies. Prevention sciences research and programming aiming to decrease HIV incidence requires epidemiologic studies to collect data on multiple levels of risk to inform combination HIV prevention packages.DiscussionProximal individual-level risks, such as sharing injection devices and unprotected penile-vaginal or penile-anal sex, are necessary in mediating HIV acquisition and transmission. However, higher order social and structural-level risks can facilitate or reduce HIV transmission on population levels. Data characterizing these risks is often far more actionable than characterizing individual-level risks. We propose a modified social ecological model (MSEM) to help visualize multi-level domains of HIV infection risks and guide the development of epidemiologic HIV studies. Such a model may inform research in epidemiology and prevention sciences, particularly for key populations including men who have sex with men (MSM), people who inject drugs (PID), and sex workers. The MSEM builds on existing frameworks by examining multi-level risk contexts for HIV infection and situating individual HIV infection risks within wider network, community, and public policy contexts as well as epidemic stage. The utility of the MSEM is demonstrated with case studies of HIV risk among PID and MSM.SummaryThe MSEM is a flexible model for guiding epidemiologic studies among key populations at risk for HIV in diverse sociocultural contexts. Successful HIV prevention strategies for key populations require effective integration of evidence-based biomedical, behavioral, and structural interventions. While the focus of epidemiologic studies has traditionally been on describing individual-level risk factors, the future necessitates comprehensive epidemiologic data characterizing multiple levels of HIV risk.

Mona Loutfy and colleagues used focus groups to examine experiences of stigma and coping strategies among HIV-positive women in Ontario, Canada.

Background ‘Intersectional stigma’ is a concept that has emerged to characterize the convergence of multiple stigmatized identities within a person or group, and to address their joint effects on health and wellbeing. While enquiry into the intersections of race, class, and gender serves as the historical and theoretical basis for intersectional stigma, there is little consensus on how best to characterize and analyze intersectional stigma, or on how to design interventions to address this complex phenomenon. The purpose of this paper is to highlight existing intersectional stigma literature, identify gaps in our methods for studying and addressing intersectional stigma, provide examples illustrating promising analytical approaches, and elucidate priorities for future health research. Discussion Evidence from the existing scientific literature, as well as the examples presented here, suggest that people in diverse settings experience intersecting forms of stigma that influence their mental and physical health and corresponding health behaviors. As different stigmas are often correlated and interrelated, the health impact of intersectional stigma is complex, generating a broad range of vulnerabilities and risks. Qualitative, quantitative, and mixed methods approaches are required to reduce the significant knowledge gaps that remain in our understanding of intersectional stigma, shared identity, and their effects on health. Conclusions Stigmatized identities, while often analyzed in isolation, do not exist in a vacuum. Intersecting forms of stigma are a common reality, yet they remain poorly understood. The development of instruments and methods to better characterize the mechanisms and effects of intersectional stigma in relation to various health conditions around the globe is vital. Only then will healthcare providers, public health officials, and advocates be able to design health interventions that capitalize on the positive aspects of shared identity, while reducing the burden of stigma.

HIV-related stigma may negatively impact the health, quality of life, social support and well-being of people living with HIV (PLHIV). Previous studies have used diverse samples and a multitude of measurement instruments to examine demographic and health correlates of HIV-related stigma, highlighting the importance of synthesizing findings across different studies to gain a better understanding of these associations. This study examined the relationships between HIV-related stigma and a range of demographic, social, physical and health characteristics. A meta-analysis was conducted to assess the overall strength and direction of these relationships. Twenty-four studies of PLHIV, conducted in North America and published in peer-reviewed journals between January of 2000 and November of 2007, were examined and their findings integrated. The heterogeneity of reported results was also assessed and examined. Our review revealed substantial variability in the ways researchers measure participants' HIV-related stigma as well as their physical, emotional and mental health. In spite of this variability, high stigma level was consistently and significantly associated with low social support (r = -0.369, p<0.0005), poor physical health (r = -0.324, p<0.0005), poor mental health (r = -0.402, p<0.0005), age (-0.066, p<0.05) and income (-0.172, p<0.005). These correlations were of a medium size, which would be recognized by the individual in daily life. Health and mental health professionals working with individuals and families impacted by HIV could benefit from an enhanced understanding of correlates of HIV-related stigma, which will inform assessments, interventions and treatment plans. The association between HIV-related stigma and physical health has potential implications for treatment, care and support for people at different stages of HIV infection. AIDS Service Organizations are also encouraged to integrate findings into HIV stigma interventions and social support programs. Additionally, HIV-related stigma scales should be developed and validated, so that future studies using them are able to report findings that are operationally and conceptually consistent.

We are not being invaded. The body is not a battlefield. The ill are neither unavoidable casualties nor the enemy. We-medicine, society-are not authorized to fight back by any means whatever. -Sontag (1 p. 180) Sontag's quotation above from 'AIDS and its metaphors' [1] reminds us to expose, and disengage from, constructions of illness that propagate fear. We are called to address the fear of COVID-19 by correcting misinformation [2,3]. While misinformation is indeed a driver of fear and stigma, other underlying facilitators produce stigma [4,5] and need to be considered in stigma mitigation. HIV research and an understanding of the historical construction of illness can be leveraged to mitigate COVID-19 stigma. COVID-19 public health responses-essential for prevention and containment [6,7]-also have the potential to exacerbate stigma [8]. We outline four tensions between COVID-19 containment and stigma mitigation, and offer possible ways forward.

ObjectiveTo examine factors associated with parents’ uptake of human papillomavirus (HPV) vaccines for their children.DesignSystematic review and meta-analysis.Data sourcesCochrane Library, AIDSLINE, CINAHL, EMBASE, PsycINFO, Social Sciences Abstracts, Ovid MEDLINE, Scholars Portal, Social Sciences Citation Index and Dissertation Abstracts International from inception through November 2017.MethodsWe included studies that sampled parents and assessed uptake of HPV vaccines for their children (≤18 years) and/or sociodemographics, knowledge, attitudes or other factors associated with uptake. Study risk of bias was assessed using the Effective Public Health Practice Project tool. We pooled data using random-effects meta-analysis and conducted moderation analyses to examine variance in uptake by sex of child and parent.ResultsSeventy-nine studies on 840 838 parents across 15 countries were included. The pooled proportion of parents’ uptake of HPV vaccines for their children was 41.5% (range: 0.7%–92.8%), twofold higher for girls (46.5%) than for boys (20.3%). In the meta-analysis of 62 studies, physician recommendation (r=0.46 (95% CI 0.34 to 0.56)) had the greatest influence on parents’ uptake, followed by HPV vaccine safety concerns (r=−0.31 (95% CI −0.41 to −0.16)), routine child preventive check-up, past 12 months (r=0.22 (95% CI 0.11 to 0.33)) and parents’ belief in vaccines (r=0.19 (95% CI 0.08 to 0.29)). Health insurance-covered HPV vaccination (r=0.16 (95% CI 0.04 to 0.29)) and lower out-of-pocket cost (r=−0.15 (95% CI −0.22 to −0.07)) had significant effects on uptake. We found significant moderator effects for sex of child.ConclusionsFindings indicate suboptimal levels of HPV vaccine uptake, twofold lower among boys, that may be improved by increasing physician recommendations, addressing parental safety concerns and promoting parents’ positive beliefs about vaccines, in addition to expanding insurance coverage and reducing out-of-pocket costs. Limitations of this meta-analysis include the lack of intervention studies and high risk of bias in most studies reviewed. Further studies should disaggregate HPV vaccine uptake by sex of child and parent.