HIV-related Stigma as a Determinant of Health Among Sexual and Gender Minority Latinxs

SEXUAL AND GENDER MINORITY LATINXS (SGML) continue to be disproportionately impacted by HIV. While new HIV diagnoses stabilized for gay and bisexual men from 2012–2016, they increased by 12% during this period for Latinx gay and bisexual men.¹ According to U.S. epidemiological data, Latinx transgender individuals are also disproportionately impacted by HIV.^2–5 These disparities among SGML are the products of, and exacerbated by, social and structural conditions, including poverty, HIV-related stigma, discrimination, documentation status, lack of access to healthcare, and anti-immigration rhetoric.^6–9

Among these conditions, HIV-related stigma serves as a determinant of health among SGML.^{10, 11} HIV-related stigma includes negative attitudes and beliefs directed at people living with HIV (PLWH) and and/or associated with PLWH. It is the prejudice that comes with labeling an individual as part of a group that is believed to be socially unacceptable.^{12, 13} Given the pervasive impact of HIV-related stigma on overall health, we urge researchers, clinicians, health and social service providers, policy makers, and multi-sectoral community stakeholders to implement programs and interventions that address HIV-related stigma and disparities in HIV/AIDS.

Intersectional Stigma

A discussion on HIV-related stigma should be framed within an intersectional approach. The concept of intersectional stigma examines the juncture of multiple stigmatized identities that fall across categories, such as co-occurring health conditions (HIV, mental illness and substance use); sociodemographic characteristics (racial, ethnic, gender, sexual orientation and immigration status); and behaviors/experiences (substance use, sex work, and pre-and-post migration experience).^14,15

Through syndemics theory, research has documented that pervasive psychosocial (depression, substance use, experiences of childhood sexual abuse) and structural/ social conditions (discrimination, HIV-related stigma, violence, history of incarceration) exist among SGML, and that the interplay of these conditions exacerbate HIV risk and HIV transmission.^2,6,7 Syndemics theory posits that multiple risk factors interact synergistically to increase vulnerability; diseases and social conditions not only co-occur, but also interact with one another, making the cumulative impact of co-occurring conditions greater than the impact of each condition alone.¹⁶

A participant from one of our studies mentioned, “As trans individuals, we are constantly challenged by discrimination, stigma, violence, homelessness, and lack of comprehensive trans care. Support is needed to navigate through legal and medical systems, like name change and access to hormones and affirmation surgery” (Laritza, Latinx, 30). Another participant further expanded on the role of stigma amongst healthcare providers “When I changed my name, a nurse insisted on calling me ‘he’ when that made me uncomfortable. I consider myself a woman” (Jen, Latinx, 26).

In particular, our research has documented the detrimental impact of the processes of immigration on health and wellness.^17–19 For sexual and gender minority immigrants, anti-immigration rhetoric is often linked with HIV acquisition and transmission, delays in HIV prevention and treatment, substance use, negative mental health outcomes, and isolation. One participant commented “Many people won’t go and seek out services because they are afraid it will affect their immigration status...for fear of being found out as undocumented individuals, they don’t seek help” (Alex, Latinx, 45).

Programs, Interventions and Initiatives to Address HIV-Related Stigma

Several programs and interventions have proven to be feasible and acceptable, efficacious and/or effective at reducing HIV-related stigma and disparities in HIV/AIDS among SGML. Some of the programs and interventions include Contacto, Connecting Latinos en Pareja, SOMOS, Trans Equity Project and HOLA en Grupo.

Contacto is an individual-level HIV stigma reduction intervention for SGML living with HIV in Puerto Rico. Delivered by a trained health educator using motivational interviewing techniques, this intervention helps participants manage the negative impact of stigma related to HIV-status and/or sexual orientation. The intervention also helps participants identify challenges and create a plan to overcome the negative impact of stigma when accessing healthcare services. More information about the intervention can be found at: https://apha.confex.com/apha/143am/webprogram/Paper331684.html.

Connecting Latinos en Parejas is a couple-based bio-behavioral HIV prevention and treatment intervention for Latino men and their same-sex partners.²⁰ Connecting Latinos en Pareja consists of four sessions with content, scenarios, and examples that adapt to each couples unique circumstances and HIV status. It incorporates biomedical prevention methods such as pre-exposure prophylaxes (PrEP); promotes engagement in care, adherence to HIV treatment regimens, and viral suppression; and encourages routine HIV testing as indicated by the couple’s serostatus.

SOMOS is a three-component, theory-based HIV prevention intervention targeting Latino gay men that includes: group sessions, social marketing, and community presentations.²¹ The group sessions consist of five meetings which address family dynamics, gay identity, homophobia, body image, and sexual health. The social marketing campaigns consist of testimonials that mirror participants’ learning during the sessions. Community presentation topics emerge from the group sessions, these-range from community activism to sexual health.

Trans Equity Project is a homegrown, community-level HIV prevention and treatment intervention for transgender men and women.²² Trans Equity Project consists of six peer-led hybrid individual- and group-based intervention sessions that emphasize leadership, social and structural interventions, and HIV risk reduction using evidence-based practices for HIV prevention and care. Trans Equity Projects peer-led model includes peer activities ranging from peer service delivery (such as peerled rapid HIV testing or referral to peer-led needle and syringe program) to peer health promotion (such as peer-developed and peer-implemented stigma reduction campaigns or community development, including the Trans March in Philadelphia) and peer leadership (such as peers taking leadership roles in their community, their sector, or participating in policy and law reform).

HOLA en Grupo is a Spanish-language, group-level HIV prevention intervention for Latino gay, bisexual and other men who have sex with men.²³ Module 1 introduces the intervention purpose, describes the impacts of HIV and STIs on Hispanic/Latino MSM, and summarizes HIV and STI facts, including transmission, prevention strategies, HIV testing, and healthcare access. Module 2 includes activities that teach participants HIV and STIs prevention/ protection methods, including negotiating condom use and correct condom use. It concludes with a homework activity in which participants are given different brands and types of male condoms and an internal condom (also known as a female condom) and asked to examine them on their own to determine their preferences. Module 3 explores Latino cultural values and their impact on sexual health. Module 4 reviews all previously covered concepts. This last module includes a DVD developed by the partnership that uses a testimonial from Latino men with HIV to begin a discussion about the experience of living with HIV.

In order to address HIV-related stigma and disparities in HIV/AIDS among SGML, it is critical to increase the rates of implementation for existing interventions and programs. An implementation science framework could guide the uptake of effective HIV programs and interventions. Implementation science is a multidisciplinary scientific field that seeks generalizable knowledge about the magnitude of, determinants of, and strategies to close the gap between evidence and routine practice for health in real-world settings.²⁴ Special attention should be given to facilitating and encouraging academic-community partnerships as platforms for implementation science projects to reduce HIV-related stigma and disparities. Community-based organizations are also critically important to reduce stigma and ensure long-term success of these programs, interventions, and initiatives.HIV

Biography

Omar Martinez, JD, MPH, MS is an Assistant Professor at Temple University’s School of Social Work. He completed his MPH in Health Policy and JD in Health Law at Indiana University-Bloomington. He later went on to obtain an MS in Clinical Research Methods at Columbia University. Mr. Martinez completed his postdoctoral research fellowship in Behavioral Science Research and HIV Prevention at Columbia University. His research interests lie in addressing health disparities affecting Latinxs, people living with HIV, immigrants, and sexual and gender minorities. His past and current research has pertained to syndemic factors and HIV risk among sexual and gender minorities, development and implementation of HIV prevention and treatment interventions, and health inequalities research. He is currently developing and testing several interventions, including couples-based and peer-led interventions, to reduce HIV/STI risk and psychosocial and social-structural vulnerability among sexual and gender minorities.