Abstract
The objective of this paper is to describe the long-term evolution of HIV-related public stigma and the misconceptions around HIV transmission in Spain. A repeated cross-sectional study was conducted using data from three surveys with random sampling carried out in 2008, 2012, and 2021 with a total of 4,836 participants aged ≥ 16 residing in Spain. The temporal variation of public stigma and discrimination indicators between 2008 and 2021 and 2012–2021 was analyzed adjusting for possible sociodemographic differences among the samples calculating adjusted differences using multivariable Poisson regressions with robust variance and multivariable linear regressions. Most stigma indicators and misconceptions about HIV transmission decreased during the analyzed period. However, the degree of proximity of the participants with people with HIV and their willingness to establish relationships with them did not improve. HIV-related stigma remains a significant issue in Spain although most of the public stigma and discrimination indicators improved between 2008 and 2021.
Keywords: HIV, AIDS, Public stigma, Discrimination, Trend
Resumen
El objetivo de este artículo es describir la evolución a largo plazo del estigma relacionado con el VIH y de las ideas equivocadas sobre la transmisión del VIH en España. Se llevó a cabo un estudio transversal repetido con datos de tres encuestas con muestreo aleatorio realizadas en 2008, 2012 y 2021 con un total de 4.836 participantes ≥ 16 años residentes en España. La variación temporal del estigma público y los indicadores de discriminación entre 2008–2021 y 2012–2021 se analizó ajustando por posibles diferencias sociodemográficas entre las muestras calculando diferencias ajustadas con modelos de regresión de Poisson multivariable con varianza robusta y regresiones lineales multivariable. La mayoría de los indicadores de estigma y las ideas equivocadas sobre la transmisión del VIH descendieron en el periodo analizado. Sin embargo, el grado de proximidad de les participantes con personas con VIH y su voluntad de establecer relaciones con elles no mejoró. El estigma relacionado con el VIH sigue siendo un problema significativo en España aunque la mayoría de indicadores de estigma público y discriminación hayan mejorado entre 2008 y 2021.
Palabras Clave: VIH, SIDA, Estigma público, Discriminación, Tendencia
Introduction
People with HIV (PHIV) face significant stigma and discrimination in a lot of areas of their lives [14]. Stigma and discrimination negatively affect them, impacting their health behaviors and psychological adjustment [15], making them internalize stigma, increasing depression, anxiety, and suicidal ideation [1, 21], while decreasing their quality of life [21] and delaying their enrollment in care [22]. Stigma also negatively affects prevention efforts, hindering HIV response [7]. UNAIDS has clearly established that ending stigma and discrimination related to HIV is instrumental to ending AIDS.
Stigma has various drivers and facilitators and intersects with several sociodemographic factors, leading to different manifestations among individuals experiencing it [18]. When an intersectional approach is considered, women [8], LGBTIQ + individuals [14], migrants [14], people living in rural areas [8], and those aging with HIV [8, 13], experience more perceived stigma.
Public stigma refers to the social and psychological reactions of those who stigmatize [4]. It is influenced by individual perceptions, such as the misconceptions about HIV transmission, perceived threat of the infection, attributions of responsibility and blame to PHIV, stereotypes, and the intersection between stigma and other forms of social exclusion [9, 16].
In Spain, HIV-related stigma remains a significant challenge [2], and worldwide, zero stigma is a priority of UNAIDS strategy [23]. Therefore, efforts to reduce stigma are crucial in numerous interventions to improve the lives of PHIV. During the Spanish Presidency of the Council of the European Union in the second half of 2023, the elimination of HIV-related stigma was a political priority [2].
However, there is limited information on the evolution of stigma in recent years, and findings are not uniform. In Spain, attitudes towards PHIV improved between 2008 and 2012, but misconceptions about HIV transmission persisted during that period [11]. Stigma and discrimination are closely tied to social contexts; therefore, it is important to study these trends in different geographical and temporal settings. Moreover, comprehensive data on the evolution of various dimensions of stigma are essential to inform effective interventions and strategies aimed at eliminating HIV-related stigma.
Therefore, the aim of this study is to describe the long-term evolution of HIV-related public stigma in its different dimensions, and the misconceptions around HIV transmission in Spain between 2008 and 2021.
Methods
Study Design and Population
A repeated cross-sectional study was conducted using data from three surveys carried out in 2008 [9], 2012 [11], and 2021 on individuals aged 16 years or older living in Spain. A random sampling of landline phone numbers was used to obtain a representative sample of the population, with a margin of error of 2.48% for a confidence interval (CI) of 95.5% in a scenario of maximum dispersion. Computer Assisted Telephone Interviews (CATI) were conducted, in which a household was randomly selected stratifying by regions and size of municipalities. Within each household, a participant was selected based on gender and age quotas. Response rates were 25.0% in 2008, 11.6% in 2012 and 15.9% in 2021. The number of participants was 4,836 globally; 1,607 in 2008, 1,619 in 2012, and 1,610 in 2021.
Measures
Only participants who knew what HIV/AIDS is were included in the surveys. Those who did not respond or gave an incorrect answer were excluded.
The surveys included questions regarding sociodemographic factors (age, gender, size of their municipality of residence, maximum level of education attained, and employment status).
The surveys portraited a battery of questions related to public stigma against PHIV. These included questions about feelings of discomfort and the intention to avoid hypothetical situations involving contact with PHIV: sending their child to a school with students with HIV, working with a colleague with HIV, and regularly shopping in a store with an employee with HIV. These items had a Likert scale format ranging from 1 (not uncomfortable/would not avoid) to 4 (extremely uncomfortable/would definitely avoid).
The surveys also included questions about agreement with discriminatory policies, such as making a public list of names of PHIV or legally segregating P HIV in certain spaces. Additionally, participants were asked whether they consider PHIV “are to blame for their disease” and whether those who were infected through sexual relations or substance use “deserve it”. Responses had a Likert scale ranging from 1 (strongly disagree) to 4 (strongly agree).
In addition, participants were asked about their beliefs regarding the ways HIV can be transmitted or not: by sharing a glass, using public restrooms, coughing or sneezing, mosquito bites, having sex without a condom, sharing needles or razors, and breastfeeding. Responses were also on a Likert scale ranging from 1 (very unlikely transmission) to 4 (very likely transmission).
Participants were also asked about the highest degree of relationship they could have with a PHIV: none, neighbor, study or work colleague, friend, occasional sexual partner, or stable romantic partner. Finally, the degree to which respondents felt closeness, sympathy, fear, anger, disgust, and pity towards PHIV, as well as the perceived severity of HIV, was explored using a Likert scale ranging from 0 to 10.
A composite indicator, the Public Stigma Index, was created by integrating questions about discomfort, avoidance, discriminatory policies, and blame attribution, adding one point for each affirmative answer, resulting in a range from 0 to 10.
The wording of all the questions reported here was maintained among all three surveys.
Data Analysis
A descriptive analysis of the sociodemographic characteristics of the three samples was performed. Questions about discomfort, intention to avoid, agreement with discriminatory policies, blaming, and beliefs about routes of infection were evaluated dichotomously by calculating the percentage of people who responded affirmatively. Discomfort or intention to avoid were considered affirmative if the response indicated any degree other than “none”. Agreement with the rest of statements was considered if the Likert scale response was 3 or 4 (agree and strongly agree). For the highest degree of relationship, the percentage of participants choosing the extreme values, none and stable romantic partner, was presented.
To analyze the temporal variation of discrimination indicators between 2008 and 2021 and 2012–2021, differences adjusted for possible confounding sociodemographic factors, along with their 95% confidence intervals, were calculated using multivariable Poisson regressions with robust variance. The transformation of the regression coefficients into adjusted differences was performed using Stata’s margins command, which predicts results based on the fixed values obtained in the corresponding Poisson regressions, integrating the covariates [19].
Indicators measuring feelings towards PHIV (closeness, sympathy, fear, anger, disgust, and pity), as well as the perceived severity of HIV and the Public Stigma Index, were presented as means of the 0 to 10 scales. The temporal variation of these indicators between 2008 and 2021 and 2012–2021 was calculated with differences adjusted for possible variations of the common sociodemographic factors specified in the measures section using multivariable linear regressions.
All calculations were performed using Stata v. 17 (StataCorp). Statistical significance was set at p < 0.05 for all calculations. Missing data were treated as such, with no imputations, for all calculations.
Results
The gender distribution was similar between both binary genders, with women representing between 49.8% and 51.3% in the surveys. The 2008 sample was younger than the 2021, with the 19–29 years old group representing 31.4% in the first and 18.8% in the latest. The most common size of municipality of residence was under 20.000 inhabitants in the three samples, ranging from 23.8 to 31.9%. Most of the participants were working in all three samples. The proportion of people with university studies was 30.1% in 2008, 34.4% in 2012 and 49.2% in 2021 (Table 1).
Table 1.
Sociodemographic characteristics of the 2008, 2012 and 2021 samples (N = 4,836)
| 2008 | 2012 | 2021 | ||||
|---|---|---|---|---|---|---|
| n = 1,607 | n = 1,619 | n = 1,610 | ||||
| n | % | n | % | n | % | |
| Gender | ||||||
| Man | 787 | 49.0 | 788 | 48.7 | 808 | 50.2 |
| Woman | 820 | 51.0 | 831 | 51.3 | 802 | 49.8 |
| Age (years) | ||||||
| 16–29 | 504 | 31.4 | 328 | 20.3 | 302 | 18.8 |
| 30–44 | 369 | 23.0 | 513 | 31.7 | 501 | 31.1 |
| 45–64 | 571 | 35.5 | 520 | 32.1 | 490 | 30.4 |
| 65 or more | 163 | 10.1 | 258 | 15.9 | 317 | 19.7 |
| Size of municipality of residence (inhab.) | ||||||
| Under 20.000 | 383 | 23.8 | 494 | 30.5 | 514 | 31.9 |
| 20.000–50.000 | 367 | 22.8 | 242 | 15.0 | 254 | 15.8 |
| 50.000-200.000 | 292 | 18.2 | 367 | 22.7 | 364 | 22.6 |
| 200.000-500.000 | 314 | 19.5 | 244 | 15.1 | 216 | 13.4 |
| Over 500.000 | 251 | 15.6 | 272 | 16.8 | 262 | 16.3 |
| Employment status | ||||||
| Working | 356 | 45.4 | 681 | 43.8 | 940 | 58.9 |
| Unemployed | 59 | 7.5 | 275 | 17.7 | 130 | 8.2 |
| Retired | 21 | 2.7 | 287 | 18.5 | 336 | 21.1 |
| Homemaker | 138 | 17.6 | 181 | 11.6 | 78 | 4.9 |
| Student | 210 | 26.8 | 131 | 8.4 | 111 | 7.0 |
| Maximum level of education attained | ||||||
| None | 24 | 3.1 | 70 | 4.4 | 23 | 1.5 |
| Primary | 146 | 18.8 | 471 | 29.3 | 183 | 11.8 |
| Secondary | 374 | 48.1 | 513 | 31.9 | 585 | 37.6 |
| University | 234 | 30.1 | 553 | 34.4 | 767 | 49.2 |
inhab inhabitants
Missing values were under 5% for all variables except for employment status and educational level in 2008 (51%)
There were no missing values for gender, age and size of municipality of residence
The level of discomfort around PHIV significantly reduced between 2008 and 2021 for all situations, adjusted by sociodemographic factors. These reductions were remarkable regarding their children having a classmate with HIV [−21.4% (95% CI −28.8;−14.0)], and shopping at a store with an employee with HIV [−22.6% (95% CI −29.3;−15.9)]. Between 2012 and 2021, the decrease in discomfort levels was only significant for having a coworker with HIV, [−5.2% (95% CI −8.8;−1.6)], and for regularly shopping in a store with an employee with HIV [−21.4% (95% CI −28.8;−14.0)] (Table 2).
Table 2.
Adjusted evolution of discomfort around people with HIV (PHIV), intention to avoid PHIV, agreement with discriminatory policies against PHIV, blame attribution to PHIV and degree of relationship they could have with a PHIV
| Prevalence (%) | |||||||
|---|---|---|---|---|---|---|---|
| 2008 | 2012 | 2021 | A.Diff 08–21 |
95% CI | A.Diff 12–21 |
95% CI | |
| Discomfort in hypothetical scenarios | |||||||
| Child’s school with student PHIV1 | 58.2 | 39.3 | 36.6 | −21.4 | (−28.8; −14.0) | −1.0 | (−5.7; 3.5) |
| Work colleague PHIV2 | 30.2 | 26.0 | 19.5 | −10.9 | (−16.4; −5.4) | −5.2 | (−8.8; −1.6) |
| Store with employee living with HIV3 | 45.0 | 39.3 | 23.5 | −22.6 | (−29.3; −15.9) | −14.7 | (−18.9; −10.5) |
| Any of the above | 66.9 | 44.3 | 42.1 | −26.6 | (−34.7; −18.6) | −0.5 | (−5.4; 4.5) |
| Intention to avoid | |||||||
| Child’s school with student PHIV | 22.9 | 15.2 | 11.4 | −9.3 | (−14.0; −4.6) | −2.5 | (−5.3; 0.3) |
| Work colleague PHIV | 8.8 | 6.2 | 4.8 | −2.0 | (−4.7; 0.8) | −0.7 | (−2.5; 1.0) |
| Store with employee living with HIV | 23.9 | 19.9 | 10.4 | −12.4 | (−17.3; −7.5) | −8.8 | (−11.8; −5.9) |
| Any of the above | 35.1 | 26.2 | 17.8 | −15.6 | (−21.5; −9.7) | −7.0 | (−10.6; −3.4) |
| Agreement with discriminatory policies | |||||||
| Public list of names of PHIV | 18.4 | 13.1 | 5.5 | −9.6 | (−13.3; −5.8) | −5.3 | (−7.5; −3.1) |
| Segregation of PHIV | 19.2 | 13.3 | 7.7 | −6.9 | (−10.6; −3.1) | −3.8 | (−6.2; −1.4) |
| Blame attribution | |||||||
| PHIV are to blame for their infection | 21.5 | 16.0 | 9.7 | −9.1 | (−13.5; −4.8) | −5.0 | (−7.7; −2.3) |
| PHIV deserve it if sex/drugs4 | 18.2 | 16.6 | 8.4 | −4.7 | (−8.3; −1.1) | −7.2 | (−9.8; −4.5) |
| Could have some kind of relationship | |||||||
| None | 19.2 | 8.5 | 11.6 | −1.9 | (−5.8; 2.0) | 5.5 | (2.9; 8.2) |
| Romantic partner | 8.0 | 18.8 | 13.8 | 8.6 | (5.4; 11.8) | −5.7 | (−8.8; −2.6) |
A.Diff Adjusted difference, 95% CI 95% Confidence Interval, PHIV people living with HIV
1Own child attending a school where another student lives with HIV
2Working at a place where a colleague lives with HIV
3Shopping at a store with an employee that lives with HIV
4People with HIV deserve it if they contracted the virus though sex or drug use
The intention to avoid sharing one’s child’s school and a store reduced significantly between 2008 and 2021, with reductions of −9.3% (95% CI −14.0;−4.6) and − 12.4% (95% CI −17.3;−7.5), respectively. However, only the intention to avoid regularly shopping in a store with an employee with HIV reduced from 2012 to 2021 [−8.8%;95% CI −11.8;−5.9)]. The intention to avoid having a coworker with HIV did not change significantly (Table 2).
Agreement with HIV discriminatory policies and the blame attribution significantly reduced both between 2008 and 2021, and between 2012 and 2021. In 2021, 5.5% of participants supported the publication of names of PHIV, a reduction of −9.6% (95% CI −13.3;−5.8) compared to 2008, and − 5.3% (95% CI −5.5;−3.1) compared to 2012. Agreement with the sentence “PHIV who contracted the virus through sex or the use of drugs get what they deserve” decreased by −4.7% (95% CI −5.5;−3.1) in 2021 compared to 2008 and by −7.2% (95% CI −5.5;−3.1) compared to 2012 (Table 2).
The percentage of people who would not have any kind of relationships with PHIV did not decline significantly between 2008 and 2021; furthermore, it significantly increased between 2012 and 2021 by 5.5% (95% CI 2.9;8.2). Those who would have a romantic relationship with a PHIV significantly increased between 2008 and 2021 by 8.6% (95% CI 5.4;11.8), but significantly decreased from 2008 to 2021 by −5.7% (95% CI −8.8;−2.6) (Table 2).
The only incorrect belief about HIV transmission that significantly Changed between 2008 and 2021 was that of HIV being transmitted by mosquito bites, with an adjusted difference of −10.8% (95% CI −17.0;−4.6). Between 2012 and 2021, the incorrect beliefs about HIV transmission using public restrooms, coughing or sneezing, and mosquito bites was significantly reduced, with adjusted differences ranging from − 3.3% to −11.5%. However, one correct belief, transmission by breastfeeding, also significantly reduced when comparing 2021 to both 2008 and 2012, by −19.9% (95% CI −26.9;−12.9) and − 20.1% (95% CI −25.3;−14.9), respectively (Table 3).
Table 3.
Adjusted evolution of incorrect and correct beliefs around HIV transmission
| Prevalence (%) | |||||||
|---|---|---|---|---|---|---|---|
| 2008 | 2012 | 2021 | A.Diff 08–21 |
95% CI | A.Diff 12–21 |
95% CI | |
| Incorrect beliefs | |||||||
| Sharing glass | 15.2 | 14.5 | 11.5 | 0.1 | (−3.4; 3.7) | −0.1 | (−2.9; 2.7) |
| Public restrooms | 17.7 | 14.6 | 9.4 | −3.0 | (−6.5; 0.5) | −3.3 | (−6.0; −0.7) |
| Cough/sneezing | 15.3 | 15.9 | 9.0 | −3.6 | (−7.2; 0.1) | −4.7 | (−7.3; −2.0) |
| Mosquito bite | 39.6 | 40.5 | 25.2 | −10.8 | (−17.0; −4.6) | −11.5 | (−16.1; −6.9) |
| Any wrong | 54.1 | 53.2 | 36.1 | −11.1 | (−18.3; −3.4) | −11.8 | (−17.2; −6.4) |
| Correct beliefs | |||||||
| Condomless sex | 97.3 | 97.5 | 96.5 | −1.0 | (−10.8; 8.9) | −1.2 | (−8.5; 6.2) |
| Needle or razor | 93.1 | 98.0 | 97.0 | 2.3 | (−7.4; 12.1) | −1.3 | (−8.6; 6.1) |
| Breastfeeding | 57.1 | 51.6 | 29.3 | −21.0 | (−28.3; −13.8) | −19.8 | (−25.2; −14.4) |
| All correct | 51.2 | 49.5 | 27.2 | −19.9 | (−26.9; −12.9) | −20.1 | (−25.3; −14.9) |
A.Diff Adjusted difference, 95% CI 95% Confidence Interval
The degree to which participants perceived proximity to PHIV did not significantly change. The perceived severity of HIV decreased by −1.07 points (95% CI −1.23;−0.91) between 2008 and 2021, and − 0.68 points (95% CI −1.80;−0.56) between 2012 and 2021. The feeling of sympathy towards PHIV significantly increased when comparing 2021 to both 2008 and 2012. All negative feelings significantly decreased between 2008 and 2021, and between 2012 and 2021, particularly the feelings of fear, which reduced − 1.76 points (95% CI −2.06;−1.46) compared to 2008 and − 0.82 (95% CI −1.05;−0.59) compared to 2012; and pity, with − 1.55 points (95% CI −1.87;−1.23) compared to 2008 and − 1.20 (95% CI −1.45;−0.96) compared to 2012. The Public Stigma Index also decreased significantly by −0.98 points (95% CI −1.19;−0.78) and by −0.54 (95% CI −0.70;−0.38) when comparing 2021 to both 2008 and 2012, respectively (Table 4).
Table 4.
Adjusted evolution of HIV perceived proximity, perceived severity, negative feelings towards people with HIV and public stigma index
| Mean* | |||||||
|---|---|---|---|---|---|---|---|
| 2008 | 2012 | 2021 | A.Diff 08–21 |
95% CI | A.Diff 12–21 |
95% CI | |
| Proximity | 2.27 | 2.22 | 2.06 | −0.08 | (−0.39; 0.23) | −0.23 | (−0.47; 0.00) |
| Severity | 9.19 | 8.88 | 8.12 | −1.07 | (−1.23; −0.91) | −0.68 | (−0.80; −0.56) |
| Sympathy | 7.60 | 8.14 | 8.32 | 0.81 | (0.56; 1.05) | 0.20 | (0.03; 0.37) |
| Negative feelings | |||||||
| Fear | 4.01 | 3.14 | 2.03 | −1.76 | (−2.06; −1.46) | −0.82 | (−1.05; −0.59) |
| Anger | 2.78 | 1.87 | 1.03 | −1.42 | (−1.67; −1.17) | −0.62 | (−0.81; −0.44) |
| Disgust | 2.04 | 1.40 | 0.67 | −1.04 | (−1.25; −0.84) | −0.60 | (−0.76; −0.44) |
| Pity | 6.73 | 6.32 | 4.95 | −1.55 | (−1.87; −1.23) | −1.20 | (−1.45; −0.96) |
| Public Stigma Index | 2.60 | 2.03 | 1.36 | −0.98 | (−1.19; −0.78) | −0.54 | (−0.70; −0.38) |
A.Diff Adjusted difference, 95% CI 95% Confidence Interval
*Mean in a 0 to 10 scale
Discussion
Spanish attitudes towards PHIV have showed a considerable improvement as a significant number of the HIV-related public stigma indicators analyzed in this study showed substantial decrease over the observed period, both when comparing 2021 with 2008 and with 2012.
Levels of discomfort about sharing public spaces with P HIV have notably decreased since 2008. However, since 2012, there has been little variation in the discomfort about participants having children attend school with students with HIV, with more than a third of respondents in 2021 still feeling uncomfortable in that situation. Between 2012 and 2021, the only hypothetical scenario where participants’ intention to avoid PHIV significantly decreased was shopping in a store with employees with HIV. It is worth mentioning that, in 2021, less than 5% of people would have avoided a work environment because of having a coworker with HIV. Both agreement with discriminatory policies and the attribution of blame to PHIV also decreased significantly.
All negative feelings towards PHIV were significantly reduced, as did the perceived severity of HIV, although it remained above 8 out of 10 in 2021. Sympathy towards PHIV increased, and the Public Stigma Index synthetic indicator significantly decreased, falling to less than 1.5 out of 10 in 2021.
The improvement of these indicators over time shows that a significant portion of the HIV related stigma has reduced in the last decade in Spanish society. Although this study does not evaluate the possible casual effect of specific activist or institutional actions and policies on these indicators, the observed evolution suggests that these strategies are effective and may be having an impact on reducing public stigma. In Spain, the Social Pact for Non-Discrimination and Equal Treatment associated with HIV was approved in 2018, it included awareness campaigns, legal reforms, and scientific research initiatives like this one [10, 17]. In addition, Spain joined the UNAIDS Global Partnership for Action to Eliminate all Forms of HIV-Related Stigma and Discrimination in 2023.
However, several indicators that improved still remain at levels that are not acceptable in any society that seeks the well-being of all its members. Therefore, it is essential that all social actors understand the great importance of ending stigma and take actions aimed at achieving the zero-stigma objective [23].
Despite the improvement in these indicators and the fact that the number of PHIV in Spain has not significantly decreased during the last years (Unidad de vigilancia del VIH, ITS y hepatitis B y C [24, 25], respondents, on average, did not feel a greater degree of proximity to PHIV. This is not just because respondents do not know anyone with HIV, but also because people with HIV in their immediate environment are not visible and open about it. Additionally, the highest degree of relationship that participants would have with a PHIV did not improve. In fact, the percentage of people who would not have any relationship increased significantly between 2012 and 2021. Moreover, the percentage of those who would have a PHIV as a stable romantic partner significantly decreased, remaining below 15% in 2021.
PHIV continue to be perceived as distant strangers by Spanish society. This perception, combined with the significant portion of society’s reluctance to form meaningful relationships with them, can impose important barriers to the stigma reduction. It is because, contact with stigmatized groups has been demonstrated a powerful strategy for stigma reduction [26]. Also, it makes it complex for individuals to be open about living with HIV [3]. In Spain, around 70% of PHIV disclosed this information with some of their closest relationships, but only 11.2% is publicly visible about it [10]. It is essential for public campaigns and strategies to focus on this aspect of stigma, because the reduction of discrimination in certain areas has not been accompanied by an ease of visibility for PHIV nor by society imagining lives where HIV is present. Attitudes towards HIV have improved during the period analyzed, but these improvements were found mostly in theoretical or more distant scenarios, not in the intimate spheres of life.
Most misconceptions about HIV transmission have decreased, particularly those related with social contact. Reducing these misconceptions is important, as they are related to stigmatization towards PHIV, both in terms of the intention to avoid them and the agreement with discriminatory policies [9]. In this line, increasing the population knowledge of the message Undetectable = Untransmittable (U = U) will help reduce fear and stigma.
These findings align with previous studies, indicating that HIV-related stigma does not evolve uniformly across all its facets and in every context. Similar to previous research in the Netherlands [20], stigma decreased in most dimensions in recent years, but not in all. Additionally, unlike the data from India [5] and sub-Saharan African countries [6], both negative feelings of fear and the intention to avoid PHIV in many scenarios decreased in Spain. These differences should be analyzed in future research, considering both cultural differences and the possible effects of activist and institutional campaigns targeting HIV-related stigma carried out in the different countries.
Reducing stigma requires multi-level interventions. In the case of public stigma, which is the focus of this research, the literature points to the importance of education, contact, advocacy, and activism [12]. Studies conducted in Spain consistently show that it is crucial to restructure misconceptions about transmission routes, reduce stereotypical images of HIV, decrease the attribution of responsibility and blame to PHIV, and increase contact with them. Therefore, education on HIV, sexuality, and values, along with fostering empathy towards individuals with HIV and promoting contact, are key elements for effective interventions.
A vital aspect of reducing the perception of HIV as a threat would be to disseminate evidence to the population that when HIV is undetectable in the blood, it cannot be transmitted sexually, even without protective measures. However, it is essential to simultaneously improve the legal protection of P HIV and empower them to deal with stigma. They are active individuals that can successfully cope with stigma if they are supported in building resilience and provided with empowerment tools. In Spain, within the framework of the Social Pact against Discrimination against PHIV, work is being done on a multi-level response, which we believe may be behind the positive developments observed and which we hope will bear more fruit in the future.
This study has certain limitations. It did not analyze the relationship between different policies and campaigns and the variations in public stigma levels. Future research should measure the impact of specific programs or actions. Additionally, the analysis was not pre-registered, the fact that the surveys were conducted by interviewers could have introduced certain social desirability bias resulting in some underestimation of stigma levels, and response rates could have affected the results also underestimating stigma levels as people more motivated by the topic of the survey, and therefore probably more aware, are more likely to participate. However, the study also has significant strengths, such as analyzing the evolution of HIV-related stigma over a very long period with representative random samples of Spanish society. Moreover, it measures a large number of indicators related to different aspects of stigma, providing relevant information on which factors should be prioritized in interventions addressing HIV-related stigma.
Conclusions
During the analyzed period, most of the HIV-related stigma indicators decreased, suggesting that interventions by both activist groups and institutions are making an impact on something so crucial for the lives of PHIV. However, there is still significant work to be done, particularly towards fostering a society where individuals feel closer to those with HIV, form meaningful relationships with them, and where people do not feel compelled to conceal that they live with HIV. Interventions such as campaigns aimed at reducing HIV-related stigma should consider this information to effectively address these aspects of stigma too.
Funding
This study was supported by the Spanish Ministry of Health (EC11-204) and the Pacto Social por la No Discriminación y la Igualdad de Trato Asociada al VIH.
Data Availability
Data is available from the corresponding author on reasonable request.
Declarations
Competing Interests
The authors declare no conflicts of interest.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Gonzalez-Recio Paule and Fuster-RuizdeApodaca María José have contributed equally to this work.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data is available from the corresponding author on reasonable request.