HIV STIGMA:
FROM GLOBAL TO
LOCAL
Brandon Brown, PhD
UCR SOM
Department of Social Medicine and Population
Health
Outline
1. HIV Background
2. HIV stigma
3. New epidemics
4. Positive outlook
UNAIDS Goals
zero new HIV infections
zero discrimination
zero AIDS-related deaths
Human Immunodeficiency virus
 Virus
 Causes-transfer of:
◦ Blood
◦ Semen
◦ vaginal fluid
◦ pre-ejaculate
◦ breast milk
 Destroys immune system
◦ Helper T-cells cant help
◦ Develop AIDS

What do you die from?
 Opportunistic
diseases
History/Emergence of HIV

Developed countries



Sub-Saharan Africa –



(e.g. U.S.)- 1980s
First identified among MSM
Moved into drug-using populations
 leading to transmission via heterosexual sex
mid-1990s to present
Majority of HIV/AIDS burden
Transmission attributed to heterosexual sex
Southeast Asia, India, China & former Soviet Union


Started primarily among intravenous drug users
Male drug users subsequently infected FSWshetero
HIV
■ 37 million with HIV
– 60% Sub Saharan Africa
– >50% don’t know +
■ Prevention methods
– PREP
– Mother to child
■ Labor
■ breastfeeding
– Condoms
– Microbicides
–
–
–
–
Counseling and testing
Prevention with positives
Blood testing
ABCs
Issues with HIV eradication
■ Sometimes difficult to recognize HIV infection
– Common cold or flu
■ Issues with testing
– Window period
– People don’t think they are at risk-stigma
■ No vaccine-all failed
■ Sexual behavior difficult to control
■ Our best prevention-condoms
– Don’t always work
– Negotiation sometimes difficult
■ Cultural factors
AIDS and Behavior
■ 5 million ppl. infected per year
– Majority heterosexual
■ 9/10 HIV+ children born in SSA
■ Issue-difficult to change behavior
– Depends on:
1. background characteristics
2. societal norms
3. attitudes towards new behavior
Context on changing behavior
■ Former President of South Africa (Mbeki)
– Denying HIV problem
■ ‘there is no such thing as HIV’
– HIV testing legally banned
HIV: Local
In the US
• 1.1 million people living with HIV
• HIV is an urban disease
• African Americans most affected by HIV
– 12% of population, but 44% of new infections
– Rate 8 times that of whites
http://www.washingtonpost.com/national/health-science/southern-states-are-now-epicenter-of-hivaids-in-the-us/2014/09/22/9ac1525a-39e6-11e4-9c9f-ebb47272e40e_story.html
HIV: a higher impact on women
• 80% of new infections in Southern US
• Particularly black women
• What are the reasons for women being more prone?
• Where are they getting HIV from?
• Higher burden among women not unique globally
Women: Sub-Saharan Africa
• Nature of the transactional / polygamous
relationships
• Older male partners with resources
• Women have limited rights & social power
• cannot insist on condom
• Stigma and blame in HIV testing
• Virgin myth
• If you have HIV, sex with a virgin will cure you
HIV continues to
spread at high rates!
HIV prevalence in
young pregnant women
in rural Vulindlela,
South Africa (2009-2012)
Age Group
(Years)
HIV Prevalence
(N=1029)
≤16
8.4
17-18
18.6
19-20
25.4
21-22
32.8
23-24
44.8
Young
Women
HIV in 15–24
year old men
and women
(2008–2011)
women 8 X more
HIV than men
Zimbabwe
Source: Adapted from
UNAIDS 2012
World map
--countries by land area
15
HIV/AIDS Deaths Globally
http://www.worldmapper.org/display_extra.php?selected=374
Origin of HIV: revisited

Developed countries (e.g. U.S.)- 1980s
 First identified among MSM
Most believe still believe HIV is a
disease of MSM and hyper sexual
What is the face of HIV?
■ Sex workers?
18
■ Only among gay men?
■ Injection drug users
■ Or……….
– Mothers, teachers, students
21
What is HIV Stigma?
■ “An attribute that is deeply discrediting”
■ Prejudice & Discrimination
■ Negative Perceptions & Attitudes
■ Abuse & Neglect
■ Maltreatment
■ …directed towards people living with HIV & AIDS and
the groups and communities they associate with
Why is there HIV stigma?
■ HIV/AIDS is a life-threatening disease
■ People believe HIV infection is associated with
behaviors that are already stigmatized
– homosexuality, drug addiction, promiscuity
■ Most people become infected through sex
– Personal responsibility
■ Inaccurate information about HIV transmission
– http://www.youtube.com/watch?v=Ke2QKx26iNc
Stigma in the News…cont
Pastor Michael Jordan-Alabama
Talking about the news
■ Charlie Sheen out as HIV+
– How does this impact HIV stigma?
Charlie Sheen + goddesses
Impact of HIV-Stigma
 Social isolation
 Gender based violence
 Decreased Access to Services
 Reduced status Disclosure
 Avoidance of Healthcare
 Decreased HIV Testing
 Mental Health Pathologies
 Loss of employment
Larry Dunn and Cicely Bolden - Dallas
 Decreased Negotiation of Safe Sex Practices
 DEATH
HIV Stigma reduction-Photovoice
■ Recruited 10 women of color living with HIV
■ Award winning photojournalist trained participants
on photography and ethics
■ Participants reflect on experiences with stigma
– Took photos to bring reflections to life
■ Discussed photos during focus groups &
structured interviews
Led by UCI PH Doctoral candidate Mariam Davtyan
Hospital visit-stethoscope
“Stay clear of my kids’ bathroom!”
“Taking labels off HIV pill bottles!”
“HIV-Stigma & Decay!”
“Pennies are more valuable than me!”
Inspot.org- confidential
Report official STD results and find partners who accept the ones you have
Visual Story of HIV-stigma
■ Gay men’s CBO in Lima, Peru (Epicentro)
houses our clinical studies
“Peru was recently voted as the most
Homophobic country in Latin America”
http://uctv.tv/shows/HIV-Stigma-Personal-Stories-from-Gay-Men-andTransgender-Women-in-Peru-A-UCI-GHREAT-Initiative-25898
■
Opens up door to stigma globally
HIV-Stigma in the News
Senator Morgan Femai




64 countries: adult same-sex conduct is legal and protective laws in place
115 countries: adult consensual same-sex conduct is not a criminal offense
78 countries: adult consensual same-sex conduct is criminalized
7 countries: adult consensual same-sex conduct is illegal-punishable by death
*Source: UNAIDS, 2013
Stigma in the news: Nigeria
■ Last year
– President Goodluck
Jonathan signs same
sex marriage ban bill
into law
■ Lynching, stoning MSM
• One man recently confessed to forced sodomy 7 years ago
• Judge spared him death sentence by stoning
• Lashed 20 times
Nigeria-new legislation
 The Same Sex Marriage (Prohibition)
Act prohibits same sex marriage or
civil union, and carries up to 14 years
imprisonment
 Up to 10 years imprisonment for
any persons who "support the
registration of gay clubs, societies,
organizations, processions or
meetings".
 This provision poses a threat HIV
organizations providing services to
the LGBTI population
Not picking on Nigeria
Ebola and HIV stigma
 Current Ebola epidemic raises HIV stigma
similarities
 Both divine retribution for past sins
 propagandas for population control
 Misconceptions that only (migrants,
homosexuals, and sex workers) at risk
 HIV stigma reduction programs may be
applied to Ebola education programs
HIV and Ebola
■ Recent Ebola seminar on HCW experience in Liberia
– Children orphaned by Ebola shunned
– Similar to HIV+ children shunned from orphanages in past
■ Old news?
– Last week Sierra Leone
■ Ebola free then 2 more cases-stigma continues
– New epidemics
■ Zika virus
Study of MDs in Coachella Valley
■ Provided HIV tests to 3% patients in past month
■ How do we help them test more?
– HIV testing literature for patients
– better understanding of CDC recommendations
■ Barriers?
– other priorities at the patient visit (time)
– discomfort on broaching the HIV topic
■ What is the HIV testing recommendation by CDC?
– Less than 50% agreed critical test
http://www.ncbi.nlm.nih.gov/pubmed/26627106
New HIV prevention focus (PrEP)
More on PrEP
■ Clinical trials around the world results 2010
– 99% effective at preventing HIV if taken daily
■ FDA approved in the US since 2012
– Most other countries not available not approved
■
Even though studied there
■
Just this year South Africa and Kenya
■ Stigma for new intervention!
– Party drug
http://www.huffingtonpost.com/news/michael-weinstein-truvada-party-drug/
Stigma Trumps Prevention Options and
Reachable Goals !!!!
zero new HIV infections
zero discrimination
zero AIDS-related deaths
Male
circumcision
Microbicides
for women
Auvert B, PloS Med 2005
Gray R, Lancet 2007
Bailey R, Lancet 2007
Treatment of
STIs
Grosskurth H, Lancet 2000
Abdool Karim Q, Science 2010
Female Condoms
Pre-exposure
prophylaxis
Grant R, NEJM 2010 (MSM)
Baeten J , 2011 (Couples)
Paxton L, 2011 (Heterosexuals)
Choopanya K, 2013 (IDU)
HIV
PREVENTION
Male Condoms
HIV Counseling
and Testing
Coates T, Lancet 2000
Post Exposure
prophylaxis (PEP)
Scheckter M, 2002
Treatment as
prevention
Donnell D, Lancet 2010
Cohen M, NEJM 2011
Behavioural
Intervention
- Abstinence
- Be Faithful
- Condoms
Note: PMTCT, Screening transfusions, Harm reduction, Universal precautions, etc.
have not been included – this is focused on reducing sexual transmission
Hope/Progress
•
•
•
•
•
PrEP and now PEP
New better drug therapy
People living longer
More availability-tests, therapy
More media
■
https://www.youtube.com/watch?v=9eXlNn-C8BY
■
Kami (HIV positive muppet)
Lifting Ban on lifetime blood donations
We are on the right track
(UNAIDS)
■ New HIV infections among adults and children were 2.3 million in
2012, a 33% reduction since 2001
■ New HIV infections among children have been reduced to 260 000 in
2012, a reduction of 52% since 2001
■ AIDS-related deaths have also dropped by 30% since the peak in 2005
as access to antiretroviral treatment expands
■ By the end of 2012, some 9.7 million people in low- and middle-income
countries were accessing antiretroviral therapy, an increase of nearly
20% in just one year
■ Between 2005 and 2014, HIV diagnoses fell 40% among women,
including 42 percent among black women. Diagnosis rate dropped 35%
in heterosexuals and 63 percent among injection drug users (IDUs).
Preliminary Discussion Items
1. What can you do to help reduce HIV stigma?
2. What are some of your choices for HIV testing?
3. Challenge-come pick up a condom
Thank you
Lookup: Great American condom campaign!!
http://amplifyyourvoice.org/gacc/