To Disclose, Not Disclose, or Conceal: A Qualitative Study of HIV-Positive Men with Multiple Concealable Stigmatized Identities

Abstract

People living with HIV (PLHW) and other concealable stigmatized identities (CSIs) face continual decisions about the degree of openness they are willing to allow for their identities in different social contexts. Disclosing or concealment of CSIs describes potential stigma management strategies that may have distinct psychosocial consequences. This study aimed to examine disclosure processes in a sample of sexual minority men (SMM) with intersecting CSIs, who use substances and were suboptimally engaged in HIV care. Interviews (N = 33) were initially double coded following thematic analysis, which identified disclosure as a theme. Subsequently, content analysis and additional selective double coding were used to iteratively identify and refine subthemes related to disclosure decisions. Illustrative quotes and frequencies of the invoked subthemes and identities were recorded for each participant. The majority of participants discussed experiences of disclosure and nondisclosure (N = 31, 94%). Among these, a spectrum of related behaviors and preferences emerged, including active disclosure, passive disclosure, passive nondisclosure, and concealment. Across disclosure-related content, in addition to HIV status, the majority of participants also described navigating decisions about disclosure of sexual orientation (71%), substance use (61%), and multiple identities at once (55%). Findings from this study highlight the fluid and multi-dimensional nature of identity-related disclosure processes in SMM with multiple CSIs. Participants in this study possessed interlocking stigmatized identities and described being varying degrees of “out” across identities and time. Moreover, these findings challenge common beliefs that disclosure is a binary construct associated with positive gain.

Introduction

People living with HIV (PLWH) face ongoing, iterative decisions about the degree of openness appropriate in a given time and social context.¹ Serostatus disclosure is not a binary state or one-time occurrence, but rather a dynamic process that evolves over time and with additional social contacts to whom one may disclose or conceal aspects of their identity. Either behavior may be an adaptive response or coping mechanism for managing stressors associated with one's HIV status.² Similar dynamics are relevant for individuals with other concealable stigmatized identities (CSIs), including sexual and gender minorities, people who use drugs, and people with mental illness.³ As PLWH may simultaneously hold these and more identities, an intersectional approach has been used to conceptualize the experience of managing multiple interlocking stigmatized identities.^4–6 Nondisclosure has been described as one manifestation of the intersectional stigma some PLWH experience, and thus a key process to explore alongside other structural and identity-related factors that affect HIV-related and other health outcomes.^7,8

Promoting voluntary serostatus disclosure, whether to sexual partners or others, has been the aim of various HIV interventions, given a body of evidence suggesting individual and public health benefits.⁹ Disclosure of HIV status has been associated with decreased transmission risk behavior, decreased depression symptomatology, and increased antiretroviral adherence.^10–12 However, serostatus disclosure intervention trials have not consistently shown improvements in their behavioral, social, and psychological endpoints.^13,14 Furthermore, increased openness may conversely be associated with more frequent experiences of stigmatization.¹⁵ It thus follows that HIV nondisclosure may be adaptive in some contexts to prevent discrimination and rejection, which may further lead to internalized stigma and adverse health consequences.¹⁶

An emphasis on the assumed moral imperative for openness may obscure the complicated context in which PLWH navigate disclosure. Prior studies have not consistently distinguished between various disclosure-related constructs such as nondisclosure or concealment; the former describes a global lack of openness around a given identity, while the latter involves deliberate efforts to suppress, hide, or otherwise prevent discovery of this information by others. Decisions to disclose, passively not disclose, or actively conceal a CSI are possible strategies for managing stigma that may have distinct consequences.^9,17,18 Even so, disclosure and concealment have been described as opposite sides of the same coin and are commonly conflated in the literature.

One additional limitation of previous studies of disclosure among PLHW is inattention to the interaction of other stigmatized identities and behaviors among study participants. For example, concealment of lesbian, gay, and bisexual identity has been associated with negative psychological health outcomes.¹⁹ Concealment of HIV status alongside hepatitis C has also been discussed in the qualitative literature as layered stigmatized identities in that patients may perceive added stigma because of co-infection due to the modes of acquisition of hepatitis C (i.e., injection drug use and/or traumatic anal sex).²⁰ Furthermore, substance use stigma may have important implications for PLHW. Recent scholarship demonstrated an association between higher levels of substance use stigma and lower odds of optimal ART adherence.²¹ Relatedly, substance use stigma was found to be associated with likelihood of missing HIV-related medical appointments, whereas internalized stigma related to HIV and sexual orientation was not.²² Earnshaw et al. additionally found that the relationship between internalized HIV stigma and depressive symptomology is moderated by internalized substance use stigma.²³ Qualitative studies among PLWH have considered the interlocking effects of substance use stigma, anti-gay stigma, and transphobia.^24–27 These studies underscore how additional layers of stigma may structure heightened risk for adverse mental and behavioral health outcomes.

The role of intersecting stigmas, particularly disclosure of CSIs, has not been thoroughly studied among sexual minority men (SMM) living with HIV.²² To better understand the nuances of disclosure, and to inform future interventions to improve the psychological and physical wellbeing of PLHW who possess multiple CSIs, particularly those suboptimally engaged in care, we conducted a secondary qualitative analysis specifically focused on disclosure processes. We aimed to examine disclosure processes in a sample of SMM with intersecting CSIs endorsing recent substance use and meeting criteria for suboptimal engagement in HIV care.

Methods

Initial procedures and measures

The interview guide and methodology for the primary study were approved by the Fenway Institute's Institutional Review Board (IRB 1042713) and have been previously described.²⁷ Participants were recruited in person by presenting at various community venues, including hospitals, substance use clinics, and community centers, and by screening inquiries received through distributing flyers and utilizing online/smartphone applications (i.e., Scruff, Facebook, and Craigslist). Participants were not required to receive care at a particular location to be eligible for the study, and they may have received social, behavioral, or HIV-related services at the interview site. In-depth interviews were conducted with men who have sex with men (MSM) living with HIV, who endorsed recent illicit substance use and met criteria for suboptimal engagement in HIV care (N = 33). Participants were 18 years of age or older and identified as gay, bisexual, or otherwise MSM to be eligible for this study. Substance use may have included alcohol. Poor engagement in care related to any of the following criteria, including (1) a recent detectable viral load, (2) <90% antiviral medication adherence in the month before the interview by self-report, or (3) missing two or more HIV-related medical appointments in the prior 12 months without rescheduling. These missed appointments were not related to study visits nor did participants need to meet a definition of “lost to follow-up” to be eligible for this study.

Interviews were conducted in a private room in a metropolitan community health center focused on sexual and gender minority health by a trained qualitative interviewer with expertise in HIV, substance use, and stigma (A.W.B.). The semistructured interviews ranged from 30 to 75 min to complete and discussed topics relating to identity, stigma, self-care, and substance use behavior. Participants were initially asked broad questions about how they self-identify and later how these identities and related experiences of intersecting stigmas were thought to affect HIV self-care behaviors, substance use, and perceptions of self. There were no explicit questions related to disclosure in the original interview guide, although the interviewer probed for additional context when prior experiences with stigma and preferences for discretion around various identities were invoked.

Qualitative analysis

Audio files were transcribed and data analysis was carried out using NVivo 12.²⁸ Interviews were initially analyzed using Thematic Analysis and informed by elements of Grounded Theory.^29,30 An open coding structure was iteratively developed and refined over multiple discussions between study members to resolve discrepant interpretations. All interviews were doubled coded by at least two members of the study team after the final coding structure was established. In the original coding structure, disclosure was defined as “content related to sharing or outing elements of one's identity, including HIV status and sexual orientation.”

Disclosure was selected as a theme from the original coding structure to secondarily analyze, given the potential clinical utility of better characterizing the subthemes relating to these processes that may facilitate or protect against adverse mental and behavioral health consequences. Content analysis and additional selective double coding were used to iteratively identify and refine subthemes relating to the primary disclosure theme. Provisional conceptual definitions of the four emergent subthemes' active disclosure, passive nondisclosure, and concealment were established by three team members (J.P., J.S., and A.W.B.) over multiple meetings after each member reviewed the entirety of the content. Two research team members (J.P. and J.S.) then double coded the disclosure-related content in a subset (N = 5) of the interviews to assess inter-rater reliability and refine subthemes. Discrepant interpretations were discussed and resolved by revisiting the reference in context, attaining consensus on the predominant subtheme described in a given reference, and further refining the conceptual definitions in light of illustrative examples of each subtheme. Following another round of double coding of an additional five interviews with discussion around discrepant coding, the remaining interviews were single coded with discussion to resolve ambiguous passages. If discrepancies remained, a third team member (A.W.B.) resolved discussions regarding the predominant subthemes in a reference. Illustrative quotes and frequencies of the invoked subthemes and identities were recorded for each participant with disclosure content.

Results

Of the 33 participants in the original sample, the majority (N = 31, 94%) discussed content relating to disclosure. Table 1 presents a summary of the sociodemographic characteristics of those participants who contributed to this secondary qualitative analysis. The mean age in this sample was 51.7 (range, 26–68 years; standard deviation = 11.6 years). Most participants self-identified as “gay/homosexual” or “bisexual,” although 9.7% met inclusion criteria by identifying as a man who has sex with men, and also describing their sexual orientation as “straight/heterosexual” or “other.” Over half identified as Black (55%) and one-third (32%) as white. All participants were living with HIV. The majority of participants endorsed recent polysubstance use (81%) with the most common combination of recent substances being alcohol plus stimulant use (36%).

Table 1.

Participant Characteristics of Sample (n = 31)

Variable	N/mean	%/SD
Age (range, 26–68)	51.7	11.6
Sexual orientation
Gay/homosexual	19	61.3
Bisexual	9	29.0
Other	3	9.7
Race
Black/African American	17	54.8
White	10	32.3
Mixed race/other	4	12.9
Ethnicity
Hispanic/Latino	2	6.5
Income
$10,000 or less	13	41.9
$10,001 to $20,000	11	35.5
$20,001 and above	7	22.6
Education
≤High school graduate	11	35.5
Some college/college graduate	15	48.4
>College	5	16.1

SD, standard deviation.

A spectrum of disclosure-related behaviors and preferences emerged across these interviews. Core subthemes included active disclosure, passive disclosure, passive nondisclosure, and concealment. Definitions and illustrative quotes for these various constructs are reproduced in Table 2. These subthemes were applicable not only to discrete events describing disclosure-related decisions but also to the ongoing process of navigating disclosure. Active disclosure, passive nondisclosure, and concealment were referenced by the majority of participants (71%, 65%, and 61%, respectively), while passive disclosure was the least commonly identified construct in approximately one-third of interviews (29%).

Table 2.

Overview of Emergent Disclosure-Related Sub-themes

Subtheme	Definition	Illustrative quotes
Active disclosure	Making deliberate actions or statements that increase an individual's relative openness or visibility regarding one or more identities (e.g., sexual orientation, HIV status, and substance use), such as by “coming out” or explicitly discussing their identity with others	I go into the high schools and I speak with freshmen about my story, and I talk about my whole background, and it heals me every time I talk about it to empower these young folks.
		Someone that I thought was going to be my friend until I told them that I was HIV-positive, and then that was it. You know, like, say I'll shake their hand. They go, “Oh, no, no. I'm good”
Passive disclosure	Allowing one or more of an individual's identities to become increasingly known by others without making deliberate actions or statements to convey this identity, such as by “dropping hints” or allowing others to deduce identity status through indirect means	So, when you're around people that—whether they're providers or fellow patients—just knowing that everyone's positive makes it more relaxed in that way.
		Well, I was smoking in my place. But right now, I'm smoking outdoors… I did hide it. Not here though
Passive nondisclosure	Demonstrating a conscious decision or preference to not reveal one or more of an individual's identities without specific mention of deliberate actions to conceal that identity or limit the possibility of detection by others	I don't tell anybody that at work. It's not important. I'm quiet about it.
		I don't even have to say that I'm positive. I don't have to say it because technically I'm non-transmittable
Concealment	Actively hiding or avoiding detection of one or more of an individual's identities, such as by lying or avoiding situations in which detection by others would be possible or increasingly likely	I haven't had any really good relationships, no girlfriends really since then. I'm afraid to go out on dates because I'm going to have to divulge at some point.
		You have to be a real sneak kind of person to live that lifestyle. Not as an alcoholic. You can go on the corner and get a drink. But when you're trying to get heroin, I'm telling you that's a whole different animal

These disclosure dynamics were noted across a variety of CSIs in our sample. Every participant recounted experiences of disclosure and nondisclosure of HIV serostatus, and the majority also described navigating sexual orientation (71%), substance use (61%), and multiple identities at once (55%). Mental illness emerged as an additional CSI, with several participants (10%) either disclosing or concealing psychiatric diagnoses and trauma histories. For one participant, racial identity was concealable in the setting of a blinded application process. Most other references to racial or ethnic identity were discussed in context with other factors that influenced their disclosure of other CSIs.

Active disclosure

The majority of participants endorsed actively disclosing one or more CSI during their interview. Their descriptions of “coming out” underscore how disclosure is not a one-time event, but rather a possible action with each new romantic partner, family members, health care providers, and others. A range of recurring motivations for active disclosure was noted, including a sense of personal responsibility to protect others (in relationship to disclosure of HIV status) and a desire for closeness and relief from the pressures of hiding (in relationship to all of the CSI). While the potential benefits of active disclosure, including intimacy and catharsis, were highly valued by several participants, disclosure also resulted in increased experiences of discrimination and stigmatization. Thus, decisions to actively disclose a CSI often reflected a consideration of these potential benefits against the harms.

With regard to HIV serostatus disclosure, several participants described an expectation or responsibility to disclose in romantic or sexual contexts. Participants discussed using disclosure as a way of empowering others to protect their own health. Active disclosure was thus conceptualized as proper sexual etiquette, or a necessary courtesy to extend. One salient facilitator of these conversations was the idea of “undetectability,” the idea that someone with an undetectable viral load cannot transmit HIV sexually to a partner. This sentiment was concisely communicated by one participant:

“[It] was embarrassing to have to say to all my regulars, I guess, ‘Well, I got something to tell you,’ … Then when the undetectable thing came out, it made it so much easier.”—54-year-old white gay male

Beyond fulfilling a sense of duty, disclosure was associated with tangible positive outcomes for the individual, including closeness with others. This was seen as antithetical to maintaining secrecy around aspects of one's identity. Disclosure offered some relief from the burden of hiding and anticipatory anxiety around the reactions of others. One participant described the toll effortfully concealing his HIV status and substance use took until coming to a breaking point and disclosing multiple CSIs at once:

“But I just feel I had to tell somebody… I kept that in me for about a year. And then one day I just called my ex-wife and my daughter, and I just told them… that I have HIV and I'm still using drugs.”—61-year-old bisexual Black male

Active disclosure was not universally associated with positive outcomes for interviewees in this sample, particularly as disclosure may invite stigma from the recipients of this information. For some, an experience of rejection upon disclosing one identity may prime an expectation of rejection following disclosure of another. A frustration noted by several participants was that the good intentions behind disclosure may still lead to painful experiences of discrimination or rejection. In describing serostatus disclosure to potential sexual partners on geospatial phone applications for dating and casual sex, one participant described this dynamic:

“And it sickens me the fact that you guys hit me up asking for raw sex first, and then when I tell you my status, you guys either block or say something disrespectful. What if I didn't say my status?”—30-year-old white gay male

Passive disclosure

Passive disclosure was the least commonly identified of the disclosure-related subthemes, but was still coded in a handful of participants (29%). This subtheme was characterized by a more relaxed orientation toward managing CSIs. The process by which others come to learn about an individual's identity status unfolds naturally, without decisive action encouraging openness or closeness. Various examples of passive disclosure revealed not only a general preference for discretion but also a lack of concerted effort to have one's identity become known or remain unknown. This acceptance of potential discovery is paired with a refusal to tell outright lies or hide. One participant described how others may come to understand his sexual orientation in the absence of actively offering this information to others:

“People who know me as someone with a homosexual orientation have inferred that. It's not because I've told them … I don't do that… If they infer it, it's fine, but I don't publicly or positive identify myself as a homosexual man.”—63-year-old gay Black male

Another common setting where passive disclosure arose was in reflecting upon participation in programs tailored to PLWH. Participants described an implicit “outing” that occurs when utilizing these services. While some were concerned about the possible stigma this could invite, others felt resigned to a lack of privacy in these programs, or even relaxed and comforted by the camaraderie. One participant succinctly described how this form of coming out does not require explicit declarations of identity to others, only enrollment in services specific to PLWH:

“So anybody that came into that program, or those programs, they knew that you were HIV… You come through this door, you know who's HIV because the first two rows are HIV.”—54-year-old bisexual Black male

Passive nondisclosure

Similar to the passive disclosure subtheme, passive nondisclosure involved a preference for discretion around a given identity. This preference was articulated free from effortful prevention of others discovering one's identity status. These references were notably free from overt disclosure-related anxiety, suspiciousness, or self-critical statements. Common justifications for nondisclosure related to avoiding stigma and discrimination. Others described a belief that their identity status was not relevant to others, or that disclosure would not provide social contacts with actionable information. For example, if an individual with an undetectable plasma HIV RNA was confident in their viral suppression and planned to use a condom for the duration of a sexual encounter, some individuals noted that they not obliged to disclose their status since it would not add to the protection for their partner.

Weighing the advantages and disadvantages of allowing others to know his HIV status, one participant justified his preferences for closeness, despite the reluctance he felt in not being more open:

“People don't go around telling people they got athlete's feet, you know what I mean? So why should I go around telling people that I have HIV, you know?—68-year-old Black gay male

This reasoning was seen not only in sex and romance but also to avoid discrimination or discomfort from family members and more casual contacts. In these cases, disclosure of a CSI could cause others distress, while offering little benefit to the individual. A possible response to managing this ambiguity was alternating disclosure and nondisclosure as deemed appropriate. For example, one participant withheld certain details of a traumatic sexual experience, but not others, noting there was no need for granularity with those close to him. Different elements of this same experience demonstrate either disclosure or passive nondisclosure. He recounted as follows:

“To this day, no one knows about it. I mean, I've disclosed the general scenario, but my mother does not know to this day who this person was… And, [she] would be mortified. There's no reason for me to disclose who it is because I've forgiven them. Time's gone on.”—53-year-old Black straight male

Concealment

Participants concealed CSIs for a variety of reasons and used various methods to do so. These included intentional avoidance of social contacts, deferring medical care, and outright lying. Motivations for concealment were similar to passive nondisclosure, often centering around avoiding identity-related stigma and discrimination. Concealment also emerged in both romantic and professional settings, although this subtheme was distinguished by suspicion and effortful actions to avoid discovery of one's identity status. Negative emotion and affect appeared to be particularly common among this subtheme. One participant described the pressures avoiding coworkers finding out about various CSIs, and the toll this took over time. He noted the following:

“I worked as a waiter for years and I never told anybody that I was HIV positive. So I started using crack because I thought I was going to die.”—68-year-old Black gay male

This participant described concurrently working to prevent discovery of his substance use in addition to concealing his HIV-status. The cumulative impact appeared to be increased social isolation.

Other participants noted a necessity of concealing their identity as someone who uses substances, having to “sneak” around to avoid judgment and feelings of embarrassment around discovery. For example, another participant described feeling self-conscious that recent weight loss might reveal both his HIV status and use of alcohol and methamphetamines. The impact of this on his search for employment and self-esteem is noted when he described the following:

“I feel like I'm being watched, or I'm being judged… I applied for a dishwashing position, because I didn't want to be out in public. I always wanted to be behind the scenes now, because I'm afraid of people, because of what I used to be, and what I am now.”—45-year-old white gay male

Several participants described avoiding romantic or sexual relationships to mitigate the possibility that disclosure may become necessary and thus invite the potential for negative judgment. Others avoided medical settings due to a similar desire to avoid unwanted attention around their stigmatized identities. For one participant, this came up when describing how he left a pharmacy before picking up his antiretroviral medication out of concern that others in the waiting area would be able to deduce his HIV status. Another participant concisely described avoiding an appointment with a medical provider when his recent substance use may become apparent:

“When I'm active in my drug use, and when I'm in a program, I'll disappear for days on end. Because I don't want to go back high and get a urine.”—26-year-old white gay male

Suspicion and uncertainty around how others would react to an individual's status are evident in this example of concealment behavior and in several others as well. Concealment, or effortfully reducing the potential for discovery, was a recurrent behavioral strategy used by individuals in this sample to mitigate anticipated additional experiences of stigma.

Intersecting identities, overlapping subthemes

Most participants in this sample shared insights that did not clearly reflect just one of the aforementioned subthemes; 87% shared “nonspecific” disclosure references that were characterized as generalized, hypothetical, or related to the actions or identities of others besides the participant. This included descriptions of experiences such as forced “outing” and the disclosure decisions of close contacts. One salient example involved a participant who previously disclosed his HIV status to a friend on a bus and afterward realizing that he was outed to others on the bus. While the beginning of the quote implies active disclosure, the latter portion describes the actions of other people and the impact this had on the participant:

“We spoke and I got off at the stop and as the doors close[d] I heard him say, ‘That guy got AIDS’… The whole bus on the right hand side is looking at me and every person to me is looking at me disgustingly… I saw all the looks and because of that, I'm like, hell no I'm not telling nobody ever again my status.”—68-year-old Black gay male

This participant noted a more global nondisclosure preference resulting from this stigmatizing experience. Another succinctly described what precisely is meant to be avoided, describing potential negative ramifications of disclosure in a hypothetical sense:

“Education is a lot better now, but there are still a lot of ignorant people out there. I think if you tell too many people I think you put yourself in danger of being physically hurt.”—52-year-old multi-racial gay male

Roughly half of participants (55%) had references containing multiple disclosure-related constructs simultaneously. This may have described subthemes applying to a single moment or different points of time. These references included both multiple constructs applying to distinct CSIs (such as by disclosing one's serostatus to some, but concealing it from others), and interestingly, multiple constructs applying to a single CSI. One participant illustrated how nondisclosure may cut across various identities in a particular cultural context.

“The Black churches are not very kind. I've had to talk with my priest because I'm Catholic about the fact that, if someone was getting divorced or having an affair, these are discussions we can have in the church. But having HIV or even being homosexual is not something you can ever discuss in the Catholic church. I've told him before that it's like having a secret.”—46-year-old Black gay male

Nondisclosure content here is accompanied by implied active disclosure, in this case to the participant's priest. The participant describes a pervasive stigma that discourages discussion, and in turn disclosure of multiple CSIs at once.

Discussion

The aim of this study was to examine disclosure processes in a sample of SMM with intersecting CSIs to better understand how specific disclosure-related behaviors and beliefs may promote or detract from social and mental wellbeing. In this secondary qualitative analysis, we identified four emergent subthemes relating to the primary disclosure theme through content analysis and selective double coding. These subthemes (i.e., active disclosure, passive disclosure, passive nondisclosure, and concealment) encompassed not only HIV status but also identification as gay, bisexual, MSM, or a person who uses substances. This represented a spectrum of openness in a given identity, and effort expended to change or maintain that relative position. Our categorization is consistent with previous studies,^18,19,31 although this is the first to our knowledge that describes this spectrum of practices in a sample of SMM living with HIV who possess multiple CSIs. Examples of each of these subthemes applied to CSIs beyond HIV status, providing a more nuanced depiction of the broader social context in which some PLHW manage various forms of stigma.

The clinical implications of these findings relate to identifying which disclosure-related practices predict adverse psychological consequences, and how to more effectively explore concerns around disclosure with PLWH navigating multiple CSIs. While nondisclosure may be adaptive in some contexts to avoid identity-related discrimination, active concealment has been associated with negative cognitive processes (i.e., rumination and hypervigilance), affective states (i.e., poor subjective well-being), and depression.^1,32–35 For this reason, it may be fruitful to explore what, if any, specific actions clients are taking to avoid detection of their CSIs, and to not assume that all nondisclosure is a proxy for poor psychological health. Various participants in this study described experiences of nondisclosure in strikingly neutral terms, challenging assumptions that the “closet” is synonymous with suffering. For some of these individuals, their nondisclosure behaviors were a part of coping and were felt to make their lives more manageable. This suggests that after clinicians explore the pros and cons of disclosure with clients, nondisclosure may remain a reasonable stance in certain contexts. Promoting serostatus and other behavioral disclosure may be a logical target for intervention in clinical and public health practice. Even so, pursuit of disclosure without regard for negative consequences could jeopardize the therapeutic relationship between clinician and client or pose undue risks to overall wellbeing. The findings in this study underscore the potential adaptive benefits of nondisclosure in some settings, so providers need to understand their clients' perceptions of why they engage in concealing behaviors, if they are to assist them in feeling more comfortable in sharing sensitive information with others.

Participants in our sample reflected some, but not all, of the potential benefits of voluntary serostatus disclosure. These benefits of disclosure can include increased social support, self-esteem, and ART adherence, and decreased depression symptomatology.^12,36,37 We noted examples wherein participants described both positive and negative reactions and consequences to each of the various disclosure subthemes. Taken alongside mixed results in prior serostatus disclosure trials,^14,38 these findings suggest additional considerations are needed to determine how disclosure and nondisclosure may structure psychological health. Participants in this study recounted salient experiences navigating stigma beyond HIV status, demonstrating how screening for only serostatus concealment behaviors or experiences of HIV-related discrimination will not uncover the totality of potentially harmful experiences PLWH may have around their identities. Social isolation and poor self-esteem relating to concealing substance use and sexual orientation suggest HIV-related stigma alone is insufficient in accounting for the potential negative consequences of possessing a CSI. Which CSIs are perceived as most and least stigmatized is likely to be individually determined and contextually specific.

Future studies may benefit from complementing existing stigma scales with not only measures of disclosure but also concealment behavior. Concealment may be a better predictor of adverse psychological outcomes than passive nondisclosure and has been measured in the context of various CSIs, including HIV and sexual minority identity.^39–41 These studies would be wise to explore stigma related to multiple identities concurrently. An intersectional framework conceptualizes these additional CSIs beyond covariates to be controlled for in analysis and encourages the consideration of other nonconcealable identities. In this study, several participants noted how their racial or ethnic identity influenced decisions to disclose or not disclose HIV status such as by stating non-Black providers may be less able to understand how HIV-related stigma is experienced in Black communities or stating how this stigma may be more pronounced in these communities. Prior quantitative and qualitative studies highlight how these intersecting social identities may inform management of CSIs.^42,43 These identities and associated concerns (i.e., internalized homophobia, racism, and substance use stigma) should be considered in the design, implementation, and evaluation of behavioral HIV interventions.

Not every participant affirmed identification with one of the stigmatized identities when answering questions such as, “Do you think about yourself as a person living with HIV?” or “Do you think about yourself as a person who uses substances?” This demonstrates the shortcomings of conflating behavior for identity, such as with use of MSM in describing sexual minority status or assuming that all people who use substances perceive themselves as substance users.^44,45 While this cautions against de facto classification of HIV status, substance use, and same-sex sexual behavior as identities, the majority of individuals did answer pointed identity questions drawing on these attributes. Furthermore, this semantic distinction may be less salient than the experiences of stigma and discrimination noted across identity categories.

These findings should be interpreted in light of advances in HIV medicine, namely the understanding that a person with an undetectable viral load is unable to transmit the virus to others sexually.⁴⁶ Several participants in our sample reflected on and questioned the imperative of serostatus disclosure with this knowledge. The stigma-reducing potential of the Undetectable = Untransmittable campaign (U = U) problematizes the necessity of disclosure.⁴⁷ Historically, disclosure has been strongly guided by concern about risk of transmission to others, and legal responsibility. While some 21 states have maintained legislation that considers nondisclosure of HIV status a criminal action, many have adapted with our improved understanding of HIV transmission, risk, and the notion of treatment as prevention.⁴⁸ Even so, stigma permeates and hinders both HIV treatment and prevention efforts. Stigma related to HIV medications, for example, has been cited as a barrier to pre-exposure prophylaxis (PrEP) uptake among young MSM.⁴⁹ Similar concerns have been reaffirmed by PrEP prescribers too, demonstrating individual and interpersonal forms of HIV-related stigma that persist across the care continuum.⁵⁰

There are several limitations to this study that merit consideration. First, it should be noted that the relative frequencies of the various disclosure subthemes were partially dependent on the original interview prompts of a relatively small sample size of 31 participants. As this was a secondary qualitative analysis not initially conducted to understand disclosure dynamics, we cannot conclude which subthemes were most salient to participants generally. In addition, certain forms of disclosure involving explicit behaviors (i.e., active disclosure and concealment) are more easily identified, which may have also contributed to their relative frequencies. While discussion of these discrete behaviors and events helped define the contours of the four disclosure subthemes, such examples may be incongruent with our broader conceptualization of disclosure as a process rather than a particular moment. As with all qualitative research, these methods do not allow for external generalizability. Quantitative methods such as time-effect modeling and use of validated scales of non-HIV-related stigma and concealment behaviors may further contextualize these findings. While this was beyond the scope of this study, our qualitative approach is well suited to explore the nuance behind motivations to disclose or conceal intersecting CSIs.

Those who serve PLWA may benefit from exploring not only stigma relating to HIV, but substance use as well, which was noted to be a pervasive factor by multiple participants in this sample.^22,27 Providing clients an opportunity to discuss concealment behaviors and potential impacts on psychological health may reveal previously undisclosed barriers to social engagement and wellness. Attention to these various associated stigmas is in service of ongoing work to create affirming clinical environments and relevant interventions.

Decisions to disclose, not disclose, or conceal one's HIV status are multi-faceted and context dependent. These decisions are further complicated by the interactions of other CSIs. Behavioral interventions have sought to increase disclosure behavior with mixed results. One consistent limitation of these studies is the absence of clarity around nondisclosure behaviors and other possible mediators of poor outcomes, including internalized stigma. Understanding which disclosure-related behaviors and beliefs best predict health outcomes may strengthen future HIV interventions, including those that safely promote serostatus disclosure or improve the mental health of people navigating multiple CSIs.

Authors' Contributions

J.P. conceived the idea for this secondary qualitative analysis, lead secondary coding, and completed an initial draft of the article. J.S. contributed to secondary coding and co-wrote the initial draft of the article. C.O. and K.H.M. provided mentorship to the lead investigator throughout the primary study, contributed content on sexual minority mental health, and assisted in editing this article. A.W.B. conceived the primary study, conducted the qualitative interviews, oversaw initial coding and analysis, supervised writing of the article, and provided mentorship on this project.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

Funding for the project was provided by the Harvard University Center for AIDS Research in a Development Award (PI Batchelder), through the National Institute of Health, National Institute of Allergy and Infectious Diseases 5P30AI060354-13, and Dr. Batchelder's time was supported by the National Institute on Drug Abuse Award K23DA043418 (PI Batchelder).