“You’re an Open Target to Be Abused”: A Qualitative Study of Stigma and HIV Self-Disclosure Among Black Men Who Have Sex With Men

Abstract

The HIV/AIDS epidemic is a health crisis among Black men who have sex with men (MSM). HIV-related stigma presents a primary barrier to sexual communication and effective HIV prevention. Using in-depth, qualitative interviews conducted with 20 HIV-positive Black MSM between 2007 and 2008 in Chicago, Illinois, we explored the themes related to HIV-related stigma and the underlying messages HIV-positive Black MSM receive regarding their status. Stigmatizing messages stem from family, churches, and the gay community and from negative, internalized, beliefs HIV-positive Black MSM held about infected individuals before their own infection. HIV stigma influences sexual silence around HIV disclosure, especially to sexual partners.

Black Americans, compared with Whites, are disproportionately affected by HIV, accounting for 44% versus 32% of the newly diagnosed cases in 2009^1,2 and comprising approximately 13% versus 65% of the US population.^2,3 Furthermore, HIV is a serious health crisis among Black men who have sex with men (MSM), who represented 73% of the recorded new HIV diagnoses among Black men and 37% of new cases among MSM in 2009.^1,4,5 One explanatory theory is that Black MSM are more likely than are White MSM to engage in sexual networks in which there is a higher prevalence of HIV-positive individuals,^6–8 which increases the likelihood of HIV exposure. Additionally, national HIV surveillance data for the general population suggest that approximately 18% of those infected with HIV are unaware of their infection, with Black Americans less likely to know their HIV status than are Whites (19% vs 15%).⁹ Moreover, among MSM, studies indicate that MSM of color are less likely to know their HIV status (44% vs 54%)⁵ and may therefore be more likely to unknowingly transmit HIV to their sexual partners.^{4–6,8,10,11}

Because of the high percentage of people who are unaware of their infection and persistent infection rates among MSM,^1,5 prevention strategies have been shifting toward routine HIV testing¹² and interventions aimed at HIV-positive individuals.¹³ Underlying many of these strategies is the belief that HIV is becoming less stigmatized and that infected individuals are now more likely to be out about their positive status with family, friends, and sexual partners. However, although there have been positive shifts toward reducing stigma in some medical and other health care settings, negative views of HIV-infected individuals continue to persist, especially in Black communities.¹⁴ Challenges to discussing one’s positive status arise from multiple sources, including direct and indirect experiences with HIV-related stigma and discrimination. These experiences may occur across various groups and settings (e.g., sexual networks, family, friends, churches). A better understanding of how these barriers develop and challenge HIV disclosure, especially with sexual partners, would greatly inform future HIV-prevention strategies. Consequently, we explored the beliefs about and experiences with HIV-related stigma in a cohort of HIV-positive Black MSM.

According to Goffman, stigma is a deeply discrediting attribute that marks an individual as both different and less desirable than are those without that attribute.¹⁵ Same-sex sexual activity remains highly stigmatized and strongly condemned in many Black communities in the United States. Therefore, Black HIV-positive MSM may experience a variety of stigmatizing messages from multiple sources, including community organizations, family, friends, and certain segments of the gay community.^16–19 Both HIV stigma and stigma about homosexuality may increase mental and social stress and impair interpersonal interactions,^{16,17,20–22} creating a norm of silence around issues of sexuality and decreasing sexual communication before or during sexual encounters.^{6,8,19,21–25}

Recent findings document that Black MSM were less likely than were their White counterparts to disclose their HIV status to sexual partners, regardless of their sexual partner’s HIV status.²⁶ This finding may suggest that Black and White MSM experience being HIV positive differently and have varied challenges related to disclosure. For example, Wilson et al. found that gay-related stigma perpetuated through Black churches had the potential to increase silence around matters of sexuality and thereby negatively affect community response and HIV-prevention efforts for Black MSM.¹⁴ Therefore, community-based stigma related to homosexuality might be a more significant influencing factor in HIV disclosure for Black MSM than for White MSM.

We have had almost 30 years of concerted public health campaigns aimed at increasing HIV knowledge and decreasing HIV-related stigma. However, there is a dearth of recent studies on how HIV-related stigma may influence disclosure practices for Black MSM. In a qualitative study, we sought to better understand how beliefs about and experiences with HIV-related stigma among Black MSM influence HIV disclosure to sexual partners, family, and friends.

METHODS

We used convenience sampling to recruit Black MSM participants from a community center in Chicago, Illinois, that provided services to HIV-positive clients. Participants were eligible if they self-identified as being HIV positive and Black; reported engaging in sexual risk with a male sexual partner who was HIV negative or whose HIV status was unknown in the past 6 months; were not currently in a monogamous, long-term relationship (as determined by a duration of ≥ 6 months); and provided written informed consent.

We collected qualitative information regarding perceptions about and experiences of HIV-related stigma through individual, semistructured, open-ended interviews.²⁷ The average interview length was approximately 2 hours and 40 minutes. We compensated participants $20 for the study visit.

The interview guide covered 4 primary domains: (1) first or early experiences with HIV disclosure (e.g., “Who were the first people you told?” “How did the first people you talked to respond?”); (2) social norms among Black MSM regarding practices and expectations of HIV disclosure (e.g., “What are some of the ways your friends who have HIV talk about or don’t talk about this information with their sexual partners?”); (3) experiences of disclosure or nondisclosure with sexual or potential sexual partners (e.g., “What were some of the reasons for disclosing or not disclosing your HIV status?” “How did you share this information with your sexual partner?”); and (4) strategies used in assessing the HIV status of sexual partners (e.g., “How do you determine whether someone is HIV positive or not?”).

We transcribed audio recordings verbatim and entered all transcriptions into qualitative data management software²⁸ to facilitate data organization and analysis. We partially analyzed the interviews throughout the data collection process to inform data collection and assess data saturation, which occurs when new interviews cease adding unique information regarding the categories and themes of interest.^27,29 We achieved data saturation in the 20 interviews.

Strauss and Corbin’s grounded theory framework informed our data analysis, which included 3 primary processes: open coding, axial coding, and selective coding.^27,29 During the open coding phase, we examined the data for initial themes related to sexual communication and broadly coded the data to capture the breadth of the participants’ responses. We then reduced the raw data to major themes that were pertinent to the participants’ experiences of being HIV positive and were explicitly connected to HIV communication.

We explored the relationships and interconnections between the primary themes during the axial coding phase; we further developed, defined, explained, and refined these themes and constructs through the selective coding stage.^27,29 The principal investigator (J. D. P. B.) was the initial and primary coder for this analysis. We discussed emergent themes and patterns with a second data analyst and presented them to a qualitative working group for further investigation and review. This provided the opportunity for us to discuss alternative interpretations of the themes and to identify and select representative quotations. We identified the quotations we have included in the article by a unique pseudonym to protect the participants’ identity.

RESULTS

The study sample (n = 20) had a mean age of 40 years, with a median age of 41 years and a range between 23 and 58 years. The participants reported a mean of 9.2 years since their HIV diagnosis (median = 10; range of 1–20 years). The majority of the participants (n = 12) reported their sexual identity as “gay” with 4 participants identifying as “bisexual” and 2 participants reporting no label, although their friends and family were aware of their same-sex sexual activity. Only 2 of the participants identified their sexual identity as “same gender loving.” Two of the participants always disclosed their status, 3 never disclosed, and 15 reported disclosing their HIV status depending on the circumstances.

Almost all the participants expressed a heightened awareness of HIV stigma and concerns about being stigmatized, stereotyped, or discriminated against because of their HIV status. These perceptions about how they would be treated and scrutinized were often intensified by their own past, preinfection beliefs about HIV-positive individuals, which gave some of the men a foundation from which to expect negative reactions from others. Our analysis identified 3 main sources or influences on the participants’ HIV disclosure behaviors: stigmatization from family, friends, and society; stigmatization from within the gay community; and internalized stigmatization.

Stigmatization From Family, Friends, and Community

Concerns about the negative views that otherwise supportive networks, such as family, friends, and community members, held toward HIV-positive individuals was 1 prominent theme. Participants expressed these negative views through 3 primary subthemes: (1) HIV as judgment for immorality, (2) HIV as a death sentence, and (3) HIV-positive individuals as diseased and contagious.

HIV as judgment for immorality.

You’re looked down upon—you’re discriminated against … there’s no support system. [You] don’t wanna say anything because there’s no place to turn to for relief. So if I say somethin’—I’m gonna get talked about, I’m gonna get exiled—that same stereotype … all those years ago … still very much exists. (Steve, 51 years)

One key subtheme expressed by participants was the fear of negative judgments and the belief that they would be viewed unfavorably postdisclosure. Participants indicated a concern that being openly HIV positive made people targets of discrimination and isolated them from community support. Some of the men feared that, on disclosure, the HIV-positive status would become a dominant identity, expose them to uncomfortable scrutiny, change the dynamics of important social relationships, and discredit former accomplishments.

The belief that others would judge an HIV-positive status as punishment for immoral or incorrect behavior was the most persistent fear about judgment. These negative judgments partly stemmed from the assumptions and stereotypes about why an individual became HIV positive in the first place, namely homosexual behavior. Participants identified these beliefs as being tightly associated with religious tenets and community norms against homosexuality, expressing a concern that disclosing an HIV-positive status would raise questions about the personal character of the HIV-infected individual as morally corrupt and undeserving of either support or compassion. Consequently, remaining silent about their HIV status was 1 way to avoid social conflict and negative judgments around HIV, especially when the infection occurred through homosexual activity (see the box on p. 2195).

Representative Quotations: HIV Disclosure in Casual Sexual Encounters for HIV-Positive African American Men Who Have Sex With Men: Chicago, IL, 2007–2009

Sexual Silence: Stigmatization From Family, Friends, and Community

HIV as judgment for immorality

“His close family knows, like his mom … but … fraternity brothers don’t know. And, I think what happens is he has been the breadwinner in his family, is the first one to go to college, and do all these things. So, I think there’s a great deal of responsibility. And, I think it’s kind of what I went through back then, afraid of people judging you differently now.” (Jake, 36 years)

“Families are being silent, number one, they don’t want people to know that their children are getting this … other people in the family are just judgmental … and mean … some of ’em just feel like you just got what you deserve for being that way, you know?” (Jack, 32 years)

“HIV is considered … a manifestation of gay. If you aren’t gay, you wouldn’t be HIV positive… . But because it was the gay man’s disease … and it’s still sort of perceived that way … then they’ve done something wrong to deserve it… . If someone comes out as positive, they’ve definitely done something wrong.” (Eric, 45 years)

“I guess it’s kinda hard to explain. Black people see AIDS as like, you know, in a church realm, like you[’re] being punished by God for … something in your life that you’re doing, you’re being punished, you’ve been stricken with this … you can get hurt, you know, so I really kept it hid ’cause I didn’t want people to know.” (Tyrone, 36 years)

“[Avoiding HIV disclosures to] … avoid confrontations, yeah, because I didn’t wanna hear, ‘I told you so. I told you so. I told you so.’ And I knew that sometimes my family could be that way: ‘That’s what you get for going and having sex with men,’ and all that kinda craziness.” (Rodney, 40 years)

HIV as a death sentence

“A lot of people [are] scared to talk about HIV and AIDS… . It’s a disease… . People hear AIDS and … [it means] you gay and you gonna die and it’s a terrible thing.” (Kevin, 44 years)

“When it come down to your family… . It’s like you just automatically told them, you’re gonna actually be planning a funeral right then and there. Don’t nobody like funerals at all.” (Tim, 25 years)

HIV-positive individuals as diseased and contagious

“There’s stigma attached to having an STD [sexually transmitted disease] … there’s a stigma attached because people think you’re a disease.” (David, 23 years)

“I was in the South at the time when I found out … people had a mindset of, you know, they need to be isolated on an island somewhere. That kind of just really being an outcast in society.” (Eric, 45 years)

“It makes you an outcast. It makes you feel uncomfortable … you can assume that—it makes the other person feel uncomfortable… . It runs you away… . You’re unworthy.” (Charles, 45 years)

Unexpected Adversaries: HIV-Related Stigma in the Gay Community

“[HIV-negative individuals] … consider you to be unnormal ’cause you’re HIV… . Non-AIDS people … don’t like the AIDS people because they figure they going around infecting everybody. They just dead and sick to the community… . They just feel like you’re dying… . You’re going around to help people die.” (Ben, 28 years)

“In the gay life, that’s what everybody do… . They try to sabotage you … it all boils down to one thing, jealously.” (Ben, 28 years)

“We have to really watch who we disclose that to. We have to just kinda protect that in a sense. And it’s just because people can be so vicious… . So I’m very protective of that.” (Rodney, 40 years)

“And I just feel like in the Black gay community, a lot of times they get that information, and that information just goes to everybody.” (Rodney, 40 years)

“[If you disclosed an HIV status], it woulda been hard for you to even get a drink. You know, hell, they probably wouldn’t even let you in the club. So, that was like taboo.” (Tyrone, 36 years)

Internalized Stigma: The Legacy of Preseroconversion Stigma

“I used to think they [HIV-positive individuals] were disease-ridden people. And that they just gonna die and go to hell… . Because I was not one of them … I thought of them as a problem in our society.” (Tim, 25 years)

“[I] was with this guy that I was dating, and when he told me that he was positive, I froze, because … I was uneducated about HIV/AIDS. And I broke off the date and all that, so when I found out [about being HIV positive] … I was shocked that, wow, this is going on with me now… . And the first thing crossed my mind is the way that I treated the young man… . And then by me treating him like that, you know, made me feel rejection a whole lot more than, than I probably would normally have felt.” (Richard, 43 years)

HIV as a death sentence.

It’s difficult for some people because they interpret the disease as the way everybody else does… . Doom and gloom. You’re gonna die. (Jack, 32 years)

This silence around HIV was further strengthened by perceptions of HIV as a fatal disease or a death sentence, which was another barrier to disclosing one’s HIV status. Participants expressed a concern that people would automatically equate HIV with death, even in the face of medical advances and concerted public health messages that attempt to reframe HIV as a chronic, treatable disease. Some of the participants reported that, even in cases in which an HIV disclosure produced a supportive response from family or friends, it still negatively changed the social dynamic so that the HIV-infected individual was perceived as damaged and no longer a whole person. The future prospects of that person became overshadowed by the negative labeling and a perception of imminent mortality. This refocusing served to further isolate the individual, casting him as someone to be taken care of and pitied. This pitying response from others often conflicted with the individual’s own perception of the disease as manageable and not interfering with his ability to remain healthy and productive. Because of this, many of the participants chose to remain silent about their HIV status to avoid having external constraints placed on their life goals and objectives (see the box on p. 2195).

HIV-positive individuals as diseased and contagious.

Afro-Americans still think it’s a plague. If I touch you, I’m gonna give it to you… . This guy I know … for almost 33 years. I told him that and he ain’t came back and seen me since. And I thought this was one of my best friends. (Charles, 45 years)

Another prominent theme was that infected individuals would be viewed as a physical manifestation of their infection. In this regard, HIV was viewed not merely as harmful to the infected person but also as a dangerous attribute that put others at risk. A handful of the participants argued that the absence of comprehensive HIV education in the Black community fueled these uninformed fears of contagion. This focus on the individual as a danger to the Black community, rather than focusing on the behaviors through which infection is spread, may further discourage HIV status disclosure and serve to further socially isolate HIV-positive individuals from community support.

These beliefs and fears about HIV as a contagion coupled with the moral judgments attached to anal sex transmission behaviors resulted in feelings of isolation and rejection. Several participants expressed feeling that HIV-positive individuals were not only disliked but also treated as “outcasts.” This concern about being treated as an outcast further promoted silence around HIV and encouraged some participants to choose nondisclosure over possible social isolation and negativity. Furthermore, fear of being treated as an outcast decreased self-esteem and complicated social relationships (see the box on p. 2195).

Overall, this desire to avoid conflict contributed to an environment of silence within community and family networks. This HIV silence was facilitated both by the individual’s anticipation of stigma and through direct experiences within community organizations (such as churches) and family members. Richard argued that his experience with a former pastor was a major reason for his separating himself from the church, despite his having had a strong and long connection to his faith:

Now the pastor that I had was real tight. We were tight like family, and I was gonna announce to the church at this time about my HIV. But he told me that would not be a wise decision, because “the people will ridicule you … make fun of you, and that would [put] stress on you … you don’t need the stress—that type of a stress.” (Richard, 43 years)

The pastor’s response, although appearing to protect Richard, confirmed his fears that HIV was a discrediting attribute and that the people with whom he was engaged in worship would respond negatively and would ridicule him. For Richard, the anticipation of HIV stigma was solidified through this experience, with the pastor strengthening the environment of HIV silence for Richard and, potentially, for all those who attended his church. Consequently, the pastor’s decision to warn Richard away from disclosure resulted in his eventual disassociation from the church as a general system of support.

In regard to family networks, our participants stated that HIV disclosure to families was complicated because there was no automatic expectation of support; rather, there was the fear that the family (e.g., parents, siblings, and other relatives) could become an additional site of intolerance. Moreover, it was believed that the family itself sometimes enforced silence around HIV disclosure to circumvent HIV-related and sexuality-based stigma being directed toward the family from others in the community. The fear of direct judgments from family and a desire to avoid exerting further stigma on to families were another avenue through which HIV silence was learned. To summarize, men’s fears about negative moral judgments, reinforced through persistent beliefs of HIV as a death sentence and HIV-infected individuals as contagious, generated considerable pressure to remain silent about HIV status among our sample.

HIV-Related Stigma in the Gay Community

Significant concerns about HIV stigma and distrust within gay communities was another key theme participants raised. Although one might expect gay communities to be more accepting of HIV-positive MSM, participants identified an ideological separation between HIV-positive and HIV-negative individuals that was maintained through active discrimination and gossip. Gay communities and sexual networks were seen as being a complex mix of sexual competitiveness, intimacy, and companionship. In such environments, an HIV-positive status was viewed as diminishing the individual’s sexual and social desirability. This divide between HIV-positive and HIV-negative individuals appeared to correspond to some of the previously discussed concerns, specifically the belief that HIV was perceived as a fatal disease and that HIV-positive individuals were viewed as diseased and contagious.

Because HIV was seen as a liability within the gay community, numerous participants discussed how information about an HIV-positive status could be a powerful means of excluding individuals from the sexual community. For instance, participants explained that, because HIV was seen as “taboo” and there was a lack of confidentiality within gay communities, there was a concern that HIV status information could be spread through gossip. It was believed that the widespread disclosure of an HIV-positive status would be a barrier to going to certain gay bars or clubs because of the perception that HIV-positive individuals would be unwelcome in these environments. These types of concerns were a significant barrier to disclosing one’s HIV status.

Although the “outing” of HIV-positive individuals to others was occasionally used among friends and in risky sexual environments to purportedly decrease potential HIV transmission, participants generally viewed others’ unwanted disclosure of HIV information as a malicious act, happening in a context of jealousy or spitefulness. The following quotation is an illustration of this theme:

If the wrong person gets your information, you know, they have power … they get so into the thrill of knowing somebody else’s business that, you know, they’ll spread it everywhere… . Information has power … I don’t wanna give that power, because to me, it’s like them having power over me. (Jack, 32 3years)

Expanding on this notion of HIV status information as a way to exert power over HIV-positive individuals, some participants described their fears that the information could be used as a weapon to discredit and sabotage HIV-positive individuals who were disliked. This particular risk appeared to generate an explicit message, shared between HIV-positive individuals, that disclosure was not only unwarranted but dangerous, opening them up to mistreatment. This in turn appeared to create a norm against disclosure among casual social and sexual relationships for some of the participants (see the box on p. 2195).

Preseroconversion Stigma

The negative beliefs participants held about HIV-positive people before their own seroconversion often reinforced notions of stigma within the gay community. Participants often internalized the negative attitudes, misinformation, and stereotypes about HIV-positive individuals that they had held when they were HIV negative and then used them as templates in shaping the expectations about how others would treat them. For example, Steve stated:

I discriminated like everybody else did. I … thought that you transfer the virus just by bein’ in the same room—all the ignorant, paranoid, unsupported, idiotic thoughts that went along down the line, I was one of them people … once I found out, you know, it was heartbreaking… . All the stereotypes that were associated with HIV and AIDS were inside my head … I went into denial for a long period of time. (Steve, 51 years)

This fear and anticipated mistreatment appeared to contribute to the participants’ disclosure decisions. Overall, few participants reported never or always disclosing their HIV status to sexual partners. The majority of the participants reported that HIV disclosure decisions depended on the type of relationship (e.g., anonymous, casual, long term). Men tended to consistently disclose in long-term relationships or with sexual partners who had the potential to be long term; less disclosure occurred with anonymous and casual sexual partners. There may be numerous underlying factors related to how disclosure decisions were made. For some of these participants, however, whether they could trust the sexual partner to keep HIV status information in confidence was important. In other words, some of the men in this study saw the perceived and experienced discrimination of HIV-positive individuals as contributing to distrust in the Black gay community and decreased communication about HIV. This dynamic created an atmosphere of secrecy and conflicting tensions between negotiating self-protection and protecting others through disclosure.

DISCUSSION

We explored how beliefs about and experiences with HIV-related stigma among Black MSM influence patterns of HIV disclosure, especially to sexual partners. During the past decade there have been efforts to understand HIV-related stigma.²¹ However, few recent studies have explored how HIV stigma influences HIV disclosure, especially among Black MSM.

The participants in this study reported that HIV-related stigma continues to be a major concern for them within Black communities, arguing that judgmental attitudes about homosexuality and HIV misinformation fuel these discriminatory attitudes. Furthermore, there was concern that HIV-related stigma extended into both the Black and gay communities. HIV-related stigma was considered a significant barrier to candid discussions about HIV with family, friends, and sexual partners, and there appeared to be general agreement that protecting HIV status information was of primary importance. Participants generally appeared very skeptical that the people in their communities would receive their HIV status favorably and seemed to expect that most people would respond negatively, using their HIV status to single them out as deviant or morally corrupt. These fears were supported by explicit messages from clergy, family, and friends that they should practice discretion around discussing their HIV status with others. Furthermore, the implicit message that one’s HIV status would generate stigma for an infected individual’s family imposed an additional responsibility to remain silent.

More concerning, though, was the presence of HIV stigma within White and Black gay communities. Considering the history of HIV advocacy in gay communities, one might expect more tolerant attitudes about people who are HIV positive. Notably, numerous participants themselves came to anticipate negative reactions from potential partners on the basis of their own devaluation of HIV-positive individuals before their seroconversion. Participants expressed apprehension about being judged as deficient, treated as outcasts, and isolated from supportive and intimate sexual relationships. These apprehensions were important in shaping their beliefs about and strategies for HIV disclosure. This anticipated discrimination also appeared to intensify the participants’ desire to carefully control to whom they disclosed and resulted in a belief that an HIV-positive status must remain secret to maintain positive social functioning.

Two potential mechanisms related to the generation of HIV-related stigma might be extrapolated from these findings. One mechanism is related to the general fear of HIV, which is a pervasive risk for gay men and has created a ubiquitous focus on sexual safety, condoms, and sexual negotiation within the gay community. Several participants indicated that HIV status information was sometimes used to “sabotage” people who are HIV positive. In these cases, HIV status information was publically disclosed as a means of isolating the individual from social networks. In addition to stigmatizing individuals, disclosing the positive status of others may be a mechanism that uninfected men use to “out and isolate” those men they see as capable of transmitting the virus and exclude them from their sexual networks. This reliance on setting up a dichotomized sexual environment that separates HIV-positive and HIV-negative men serves to further isolate HIV-infected men and, ironically, enforces greater norms of sexual silence as a strategy for avoiding both the stigma and the social consequences of disclosure. As norms of sexual silence intensify, the dependence on nonverbal assumptions about a sexual partner’s HIV status, which are often derived from inaccurate stereotypes or knowledge, may actually increase HIV transmission risks.^30–34

A second mechanism may be that HIV-infected Black MSM are seen as manifestations of the belief that HIV is a punishment for immoral sexual behavior (e.g., homosexuality). In this specific case, Black HIV-positive MSM may be seen as dangerous to both the broader Black community and gay communities, not only because they comprise a risky and contagious group but also because they represent the perceived immorality of same-sex sexual behavior. In other words, for gay communities, those individuals who are HIV positive confirm the stereotypical beliefs of the broader community that all gay men become HIV infected and challenge the argument that same-sex sexuality is a legitimate and acceptable identity that should be integrated as a valid identity within the larger Black community.

Limitations

As in all studies there are several limitations that warrant mention. First, recruiting nonclinical samples of HIV-positive Black MSM into research studies is challenging. Therefore there is a possibility of sample bias because we drew the sample from individuals receiving services from a gay-identified community center and a majority of the participants reported being gay, bisexual, or “out” about their same-sex sexuality. It is probable that study participants had prior experience discussing issues related to HIV treatment and prevention, which may have shaped their views on disclosure. Potential sample bias may also mean that the findings underestimate the degree of fear and stigma experienced by Black MSM and Black men who have sex with men and women, who may be more secretive about their same-sex sexual activity and less likely to utilize gay-identified services than were the men we interviewed.

Second, study participants were familiar with research, and many were engaged in HIV support and treatment at gay-identified clinics. Consequently, study participants were more likely to be out about their HIV status to a greater number of people. Finally, we conducted the study with a limited number of participants and although we achieved data saturation, future studies will need to explore the themes we identified in this study with a larger, more diverse sample of Black MSM.

Conclusions

Despite these limitations, this study has several important implications for HIV prevention among Black MSM and future research with this population. Previous research suggests that HIV disclosure may be related to better sexual communication and safer sex negotiation,³⁵ HIV treatment compliance,³⁶ and psychological well-being (e.g., increased self-esteem and lower rates of depression).³⁷ Considering the relationships between HIV-related stigma and nondisclosure of HIV status we have documented, increased efforts to reduce HIV-related stigma are warranted. For instance, public health campaigns and HIV-prevention interventions should explicitly address issues related to HIV stigma, misperceptions about HIV-infected individuals, and the negative consequences of discriminatory behavior toward people who are HIV positive.

It is also important to examine how perceptions of HIV (e.g., HIV as a judgment for immoral behavior and HIV-positive individuals as diseased and contagious) within both gay communities and broader social networks influence norms of sexual silence and concerns about being out as HIV positive. HIV-positive and HIV-negative Black MSM may hold very different beliefs and assumptions about both HIV and what it means to be HIV positive. Further research on how HIV stigma is produced, deployed, manipulated, and sustained would be useful in determining potential points of intervention. For example, nearly all the participants in this study stated that finding ways for HIV-positive individuals to be more visible in their communities would be useful in counteracting negative images and stereotypes. However, nearly all the participants also argued that they were not yet ready to make this decision themselves. Because of this, working through influential community leaders and institutions, such as schools, social clubs, and fraternities, may assist in reshaping beliefs and attitudes about HIV-positive individuals and could be a powerful alternative to requiring HIV-positive individuals to out themselves.

Developing antidiscrimination and antistigma campaigns in respected and established institutions, such as Black churches, may be an effective strategy for reducing HIV-related stigma. Ultimately, decreasing the degree to which HIV-infected individuals are stigmatized across multiple communities could be critical, and necessary, to increasing sexual communication about HIV. This, in turn, could result in more accurate sexual risk assessments and decreased rates of new HIV infections among Black MSM.