Public health services and intersectional stigma: a social sciences perspective with implications for HIV service design and delivery

Abstract

Purpose of reviewUnderstanding stigma is important for improving HIV care services and gaps in HIV service delivery have been attributed to stigma. This review article synthesizes recent evidence on stigma and its implications for HIV service design and delivery. Given the intersectional nature of stigma, we will focus on HIV stigma as well as related forms of stigma based on one's race, sexual identity, gender identity and other identities.Recent findingsStigma remains a barrier to achieving equity in HIV services. Individualistic measures of stigma remain influential and are associated with barriers to accessing HIV health services. Recent work also highlights stigma measured at a structural level and its impact on HIV services contexts. Individuals situated at intersections of marginalized identities continue to face greatest injustices, and although intersectional approaches have been adapted to design services at a micro level, few focus on structural change. Recent evidence for mitigating stigma indicates some success for psychosocial interventions that target internalized stigma. Furthermore, community-led approaches show promise in addressing stigma that manifests in HIV health services settings.SummaryInterventions that address individual-level stigma and structural stigma are needed. Theoretical and applied antistigma research is needed to make HIV services more equitable.

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“…We established that stigma associated with HIV and same-sex intercourse increases negative experiences with testing and dissuades GBMSM from testing. Consistent with previous studies, participants’ accounts show how stigma at the healthcare-, community-, and individual levels affects testing experiences and discourages GBMSM from testing [ 20 , 27 ]. At the community level, GBMSM recount the association of HIV with sin, same-sex intercourse, and sex work; at the healthcare level, they experience negative comments and intrusive questioning around sexual behavior.…”

HIV Late Presenters in Asia: Management and Public Health Challenges

“…HIV stigma may also be structural; in many countries in the region, laws criminalising the transmission of HIV are still in force, many of which enforce a heavy penalty even in situations of inadvertent transmission or failure to disclose one's HIV serostatus to one's sexual partners [ 26 ]. These manifestations of stigma, whether anticipated or experienced (or both), have been shown to have a range of deleterious effects on the lives of people living with HIV in Asia, including delayed access to testing services, poorer linkage to specialist care, suboptimal adherence to daily antiretroviral therapy, and an increased risk of loss to follow-up [ 27 , 28 ]. In resource-limited environments across Asia and Africa, fear of stigmatisation is a significant barrier to both testing and accessing treatment [ 8 , 29 – 34 ].…”