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. Author manuscript; available in PMC: 2022 Apr 1.
Published in final edited form as: Soc Sci Med. 2021 Mar 6;275:113824. doi: 10.1016/j.socscimed.2021.113824

Intersecting internalized stigmas and HIV self-care among men who have sex with men and who use substances

Abigail W Batchelder a,b,c, Jacklyn D Foley a,b, Jane Kim a, Aron Thiim c, John Kelly a,b, Kenneth Mayer c, Conall O’Cleirigh a,b,c
PMCID: PMC8009855  NIHMSID: NIHMS1683192  PMID: 33721745

Abstract

Rationale.

Men who have sex with men (MSM) are disproportionately affected by HIV, substance use, and stigma related to co-existing or intersecting identities that are stigmatized or devalued by society (e.g., being a sexual minority male, a person living with HIV, or a person who uses substances). Evidence indicates that when stigma is internalized it may act as a barrier to engagement in self-care behaviors.

Objective.

Gaining a better understanding of how intersecting internalized stigmas affect HIV self-care among MSM who use substances.

Methods.

To investigate these relationships, we conducted semi-structured qualitative interviews until we reached thematic saturation (n=33) with HIV+ MSM who use substances and were sub-optimally engaged in HIV care. Interviews inquired about identity, internalized stigmas, substance use, HIV self-care behaviors, and interrelationships between concepts.

Results.

Our sample was 63% African American and 76% reported annual incomes of ≤$20,000. Approximately half of the participants explicitly described how intersecting internalized stigmas impacted their sense of self and their behavior. The overwhelming majority conveyed that internalized stigma related to substance use was the most burdensome and was considered a barrier to HIV self-care behaviors. Participants also described internalized stigmas related to HIV and sexual orientation, as well as race, effeminateness, poverty, and housing instability, which together impacted their psychological wellbeing and HIV self-care.

Conclusions.

Our results indicate a need for clinicians to consider and address intersecting internalized stigmas, particularly internalized stigma related to substance use, to reduce substance use and improve HIV self-care among MSM who use substances and are sub-optimally engaged in HIV care.

Keywords: HIV, men who have sex with men (MSM), substance use, stigma, internalized stigma, substance use stigma, gay, bisexual

Introduction

HIV treatment has improved greatly over the years, including advances in antiretroviral medications and the identification that an undetectable viral load effectively eliminates the risk of HIV transmission (Rodger et al., 2019). These advances have reduced HIV transmission and improved the quality of life for many individuals living with HIV. Regardless, these benefits require individuals living with HIV to engage in self-care behaviors, including regularly attending HIV care appointments and adhering to antiretroviral therapy (Center for Disease Control and Prevention, 2019; Dieffenbach, 2009; Dodd et al., 2010; Granich et al., 2009; Kay et al., 2016). Yet, among gay, bisexual, and other men who have sex with men (MSM) living with HIV, estimates suggest that only 57% are consistently seen for HIV appointments and 58% are virally suppressed (Centers for Disease Control and Prevention, 2017).

Further, evidence indicates that among MSM who report active substance use, engagement in HIV self-care, including antiretroviral adherence, is often sub-optimal (Batchelder et al., 2017; Jin et al., 2018). Specifically, inconsistent patterns of accessing HIV services have been identified among MSM with substance use disorders (Klinkenberg et al., 2004). Additionally, MSM who use stimulants have particular difficulty navigating HIV treatment, including adhering to antiretrovirals (Jin et al, 2018) and maintaining consistent adherence patterns (Carrico et al, 2011).

The negative impacts of HIV, sexual minority status, and substance use stigmas, or negative societal beliefs, on health are well documented (Chambers et al, 2015; Crapanzano et al., 2018; Flentje et al., 2019). Nevertheless, the impact of internalizing, or accepting or adopting, these negative beliefs about one’s identity is less well understood (Berger et al., 2001; Earnshaw et al., 2013). Some evidence suggests that internalized stigma can be a significant barrier to HIV self-care (Bennett et al., 2016; Levi-Minzi & Surratt, 2014; Sayles et al., 2009; Turan et al, 2016). While substantial research has focused on HIV-related internalized stigma, recently internalized stigma related to sexual orientation and substance use have also been identified as potential barriers to HIV treatment (Batchelder et al., 2020a; Bauermeister et al, 2019; Stringer et al, 2019). Substance use in particular has been identified as one of the most stigmatized characteristics globally (Room, 2005). Further, the moralization of addiction, self-inflicted nature of addiction, and often-described cyclical relationship between shame and addiction (i.e., “the shame addiction cycle” Frank & Nagel, 2017; Luoma, Chwyl, & Kaplan, 2019; Wiechelt, 2007) may lead to the internalization of substance use stigma acting as a barrier to self-care behaviors.

Many individuals living with HIV have multiple stigmatized identities in addition to being a person living with HIV, including identifying as MSM and being a person who uses substances, yet the effects of intersecting internalized stigmas on engagement in HIV self-care are not well understood. The intersectionality framework describes how identities interlock at the individual level and interact with social and structural contexts of privilege and oppression to contribute to one’s sense of self (Bowleg, 2012; Crenshaw, 1991; Hill Collins, 2000; Warner, 2008). According to this framework, identity is configured, not by adding two identities together, but rather by the experience of dual and triple levels of subjugated social identities at their intersection (Hankivsky et al, 2010). Emerging evidence indicates that the impact of intersectional stressors can lead to negative health outcomes, including through avoidance of engagement in HIV self-care (Earnshaw et al., 2015; English et al., 2018). However, little work has explored the intersection of internalized HIV, sexual orientation, and substance use stigmas in relation to HIV self-care. As the impact of intersecting internalized stigmas can be difficult to assess (Bowleg & Bauer, 2016), thoughtful qualitative investigation is needed to ascertain how intersecting internalized stigmas may contribute to sub-optimal engagement in HIV self-care.

The role of intersecting internalized stigmas concerning HIV self-care among MSM who use substances has not been thoroughly investigated. To effectively intervene on HIV self-care, an intersectional understanding of the relationship between internalized stigmas related to living with HIV, being MSM, and being a person who uses substances, is needed (Mereish & Bradford, 2014). In this study, we sought to better understand how these intersecting stigmatized identities impact HIV-related self-care among MSM who use substances and were sub-optimally engaged in their HIV care.

Methods

Procedures

We conducted semi-structured qualitative interviews with MSM living with HIV who use substances and were sub-optimally engaged in HIV care (N= 33) between 2017 and 2018 in Boston, Massachusetts and the surrounding area. Eligibility criteria included: (1) living with HIV, (2) reported substance use, including alcohol, in the past 3 months (3) being gay, bisexual, or straight-identified MSM; and (4) being sub-optimally engaged in HIV self-care which included either being viral detectable, reporting <90% antiretroviral adherence in the past month, or missing ≧2 HIV-related medical appointments in the past year and not rescheduling them.

Participants were recruited in-person through advertising and outreach at community and clinical settings, substance use clinics, shelters, and HIV and sexual and gender minority-oriented support services in the greater Boston area. Participants were also recruited through Boston-focused online websites and apps (i.e., Craigslist, Scruff, Facebook). All interviews lasted 30-75 minutes and were conducted by a trained qualitative interviewer in a private room.

Interviews included questions about: participants’ identity/ies broadly, specific identities, substance use, HIV self-care behaviors, and relationships between these topics. Specifically, participants were first asked broadly about their identities (“How do you think about yourself?” and “How would you describe yourself to someone who didn’t know you and couldn’t see you?”). After participants initially replied to these two questions, they were probed with followup questions related to age, race, ethnicity, and sexual orientation (i.e., “What about in relation to age?”). Next, all participants were asked “Do you think about yourself as a person living with HIV?” and “Do you think about yourself as a person who uses substances?” All participants were then asked, “Does the way you think about yourself impact your behavior(s)?” and if so, they were asked how. Participants were then asked how well they engaged in self-care behaviors and more specifically HIV-related self-care behaviors. Finally, participants were asked how different parts of their identity related to one another and to their behaviors. Interviews were conducted until thematic saturation was reached. Additional demographics and information regarding substance use were collected including a revised version of the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST; Babor, 2002). All procedures were approved by the Fenway Health institutional review board.

Qualitative data analyses

We used thematic analysis (Braun & Clarke, 2006), informed by grounded theory (Glaser & Strauss, 1967), to deductively analyze the results, informed by the intersectionality framework to explore the relationships between specific intersecting identities (i.e., being a person living with HIV, a sexual minority, and a person who uses substances) and HIV-related self-care behaviors, while inductively identifying additional themes and sub-themes that emerged from the interviews. This process involved three trained coders reading and open-coding all transcripts, meeting to discuss the initial codes, then collating the codes into themes and sub-themes. Over several meetings and re-reviews of the transcripts, themes were iteratively refined and defined. Themes related to the initial deductive plan were defined including specific aspects of identity (e.g., sexual orientation, HIV-status, and race), internalized stigmas related to aspects of identity inquired about in the interviews, discrimination, intersectionality, avoidance-coping, and HIV-related self-care. Additional themes were inductively identified based on the open-coding of the transcripts (e.g., effeminophobia and religiosity). Several transcripts were then double-coded by the trained coders to facilitate finalizing the thematic coding structure and definitions, which were refined based on discussions of discrepant interpretations. Finally, all 33 interviews were double-coded by the same coders using the final thematic coding structure. N-Vivo 12 was used for analyses (NVivo Qualitative Data Analysis Software, 2018).

Results

Sociodemographic characteristics

Our sample included 33 participants with a mean age of 51.3 (SD=11.03; range 26-68). The majority (60.6%) identified as Black/African American and 36% reported having a high school education or less. More than half (57.6%) identified as gay or homosexual and reported an annual income of ≤$20,000 (75.7%). Participants reported being diagnosed with HIV between 1980 and 2017, with 14 (42%) being diagnosed before the advent of antiretroviral medication in 1996 and 19 (58%) being diagnosed after 1996. Almost all participants reported polysubstance use in the past three months, with the majority reporting recent stimulant use (78.8%). Additionally, 84.8% of our sample reported recent alcohol use, 66.7% of our sample reported using marijuana, 75.8% reported using tobacco, and 39.4% reported using club drugs in the past three months. In terms of problematic use, 54.5% reported problematic stimulant use, 36.4% reported problematic alcohol use, 33.3% reported problematic use of alcohol to intoxication, 12.1% reported problematic opioid use, 21.2% reported problematic cannabis use, and 45.5% reported problematic use of more than one substance. (See Table 1 for demographics and Table 2 for details regarding recent substance use).

Table 1.

Demographics (n = 33).

Characteristics
Age (years)
 Mean (±SD) 51.3 11.0
 Range 26-68
Years Living with HIV
 Mean (±SD) 19.2 9.8
 Range 0-38
n %
Race
 Black/African American 20 60.6%
 White 12 36.4%
 Other 1 3%
Ethnicity
 Hispanic/Latino 1 3%
Education
 ≤ Highschool graduate 12 36.4%
 Some college/college graduate 15 45.5%
 > College 5 15.2%
Sexual Orientation
 Gay/homosexual 19 57.6%
 Bisexual 9 27.3%
 Other (includes both participants who selected “straight” or “other”) 5 15.2%
Income
 $10,000 or less 14 42.2%
 $10,001 to $20,000 11 33.3%
 $20,001 and above 8 24.2%
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Table 2.

Substance use (n = 33).

Substance Use in the Past 3 Monthsa n %
Alcohol only 6 18.2%
Alcohol + stimulants (cocaine/crack + amphetamines) 12 36.4%
Alcohol + stimulants + sedatives/benzos 5 15.2%
Alcohol + stimulants + opioids + sedatives/benzos 4 12.1%
Alcohol + stimulants + opioids 2 6.1%
Stimulants + sedatives/ benzos 2 6.1%
Alcohol + opioids + sedatives/ benzos 1 3.0%
Stimulants 1 3.0%
Marijuana 22 66.7%
Tobacco 25 75.8%
Club drugs 13 39.4%
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a

Assessed using a modified version of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST; Babor, 2002).

Summary of results

Although the majority of participants conveyed experiencing some form of internalized stigma, or the internalization of negative beliefs about one’s identities, only half explicitly described different types of internalized stigmas intersecting with one another. Almost all described internalized stigma related to substance use, including indicating that the internalized stigma associated with substance use was the most burdensome. Further, the majority described how internalized substance use stigma directly and indirectly acted as a barrier to their HIV self-care behaviors. In addition to internalized substance use stigma, participants also described internalizing stigmas related to HIV, sexual orientation, race, effeminateness, poverty, and housing status as impacting their HIV self-care. First, we describe how participants conveyed a) intersecting internalized stigmas and their implications on their health and well-being. Second, we describe how the majority of participants conveyed how b) internalized substance use stigma is bidirectionally related to substance use. Finally, we describe how participants conveyed that c) internalized substance use stigma and substance use itself were significant barriers to HIV-related self-care.

a) Intersecting Internalized Stigmas

While the majority of participants described experiencing some type(s) of internalized stigma (i.e., internalized stigmas related to substance use, HIV, or sexual orientation stigma, as well as effeminateness, poverty, and housing instability), a smaller proportion explicitly conveyed experiencing intersecting internalized stigmas. Across participants who explicitly conveyed intersecting internalized stigmas, there were common sentiments related to the intersecting nature of their multifaceted identities. Participants described how multiple enacted stigmas compounded their experiences of feeling judged or marginalized, which led to the internalization of one or more types of stigma. Additionally, many participants attributed the lack of belonging and interpersonal challenges to intersecting stigmas that they had internalized.

Across these interviews, participants emphasized how the components of their identities could not be separated or experienced singularly. One participant exemplified this:

“Being HIV-positive and being gay.. that sticks with me every moment of the day because it’s just like, that’s part of me. That’s who I am… I can’t take that away.”

-68-year-old Black gay male

Among those who described intersecting internalized stigmas, participants conveyed how the stigmas they experienced compounded one another and influenced how they were interpreted or judged by society. One participant conveyed this:

“I’m HIV-positive. I’m gay. I’m black. So it’s like, those are like the three strikes against me. Oh, no, excuse me, four strikes, because I’m a drug-user too.”

-54-year-old Black bisexual male

Participants’ consistently described how the various components of their identities, including race among participants of color, interlocked and together contributed to how others treated them and how they thought about themselves.

The majority of these participants conveyed how enacted stigma, discrimination, and oppression resulted in internal tension and ultimately contributed to the internalization of one or more types of stigma. One participant captured how feeling judged led to internal tension:

“The society -- they judge you. They judge you for the way you’re dressed, the colors you wear, the way you wear your hair. So you have all these things that’s not condoned, so, inside you’re hiding and covering up. So it takes it to… you don’t want to be exposed, but you want to be accepted, so you have all these things fighting with you inside you. Sometimes I want to take a stand publicly- then the fear of being exposed or ostracized or revealed or whatever- I don’t do it. Then I feel ashamed. Some part of me feels ashamed.”

-68-year-old Black gay male

Another participant described how he internalized the intersecting stigmas he anticipated from others, a sentiment expressed by many of the participants who endorsed internalized stigma:

“They think… you’re not only HIV, but you’re gay, you’re an addict… and it’s like, why are you even existing on life? ..That’s what my mind tells me…”

-55-year-old Black straight-identified male

Together, participants conveyed how their experiences of enacted stigma and discrimination related to multiple components of their identities contributed to the internalization of stigma, self-judgment, and shame.

Many participants reported feeling a lack of belonging in their families, with friends, or in religious or other communities due to their intersecting stigmatized identities. For many, this sense of not belonging exacerbated feelings of marginalization and internalized stigma. One participant conveyed how enacted and anticipated stigma impacted his willingness to be open about his identities:

“I’m HIV-positive. I’m gay. I’m a drug user. My family doesn’t accept me. I’ve got to tip-toe around society. -- I don’t have a problem telling anybody that I’m HIV-positive or that I’m gay, but they reject you and all that, and I hate rejection.”

-54-year-old Black gay male

Other participants described feeling stigmatized within the gay and HIV-positive communities due to personal characteristics such as effeminateness, housing instability, or financial hardship resulting in feeling even more marginalized. Across interviews, the stigma and discrimination experienced related to their intersecting stigmatized identities led many participants to feel othered by family, friends, and among others with whom they felt in-group, which contributed to the internalization of stigmas related to specific identities particularly being a person living with HIV, a person who uses substances, and a sexual minority.

Among some participants who described themselves as religious, particularly participants of color, the internalization of stigma associated with being a person living with HIV and being a sexual minority was described as exacerbated by their religious community.

“…the culture specifically that I largely identify with, the black community and the black church; those are two communities that are much of my identity. But, both of these have a lot of stigma around HIV, around sex, around sexuality.”

-53-year-old Black straight-identified male

Notably, while racial discrimination was described as challenging among almost all participants who identified as Black, being a part of the Black community and the Black church was also a source of strength and belonging.

Several participants also conveyed how their intersecting internalized stigmas affected their interpersonal behavior, including pushing others away when they felt badly about themselves. One participant conveyed this sentiment concerning becoming frustrated with others:

“I let things get to me because of who I am, my lifestyle, my HIV diagnosis, and everything… So if I’m exploding on somebody, it’s usually because I’m feeling pain, or I’m feeling unworthy or unclean.”

-54-year-old Black bisexual male

Across descriptions of intersecting internalized stigmas, participants conveyed the interlocking nature of their identities and the ways in which enacted and anticipated stigmas contributed to the internalization of specific stigmas and more general forms of self-judgment, shame, and isolation.

b) Internalized Stigmas & Substance Use

While few participants described internalized stigma related to their HIV status or sexual orientation being related to their substance use, almost all participants described internalized substance use stigma as contributing to their substance use. Several participants explicitly conveyed that their substance use was a result of their internalized substance use stigma and negative self-conscious emotions (e.g., shame and guilt) related to their internalized substance use stigma. Others described their substance use perpetuating their internalized substance use and other stigmas (e.g., internalized stigma related to HIV and sexual orientation). Nevertheless, the majority described bidirectional relationships between internalized substance use stigma and substance use. Across interviews, sub-themes of fear of judgment and social isolation were conveyed in relation to internalized substance use stigma and substance use as well.

The bidirectional relationship between internalized substance use stigma and related emotions and substance use was conveyed across almost all interviews. One participant captured this sentiment:

“A little bit of shame, a lot of self-hatred. Why? It’s like very negative things, and it’s all because I’ll put myself off… Like, I’m a okay person, but when I get involved with drugs and alcohol, I’m doing that because I do not like myself. I’m not feeling good about myself. I’m lonely. I’m angry.”

-55-year-old White non-Hispanic gay male

Several described the cyclical nature of the relationship between using substances and negative emotions:

“You use drugs because you’re miserable. But you’re miserable because you use drugs. It’s like a Catch-22”

-53-year-old White non-Hispanic bisexual male

Another participant captured the cyclical relationship conveyed by many, including a desire to avoid stigma-related emotions and vulnerability.

“I think what happened to me when I started using was the reason I’ve plummeted more into it… I was trying to numb every aspect of my emotions… I was trying to kill anything that felt vulnerable, like emotions. And I went from just puffs to at one point using the needles.”

-30-year-old Black bisexual male

Across interviews, internalized substance use stigma was highlighted as most associated with participants’ substance use, beyond internalized stigmas associated with other aspects of their identities (e.g., being a person living with HIV or being a sexual minority).

Within the context of describing the relationship between internalized stigma related to substance use and other stigmatized identities and substance use itself, most participants expressed fear of judgment or rejection, or anticipated stigma, associated with one or more aspects of their identities. This fear of judgment or rejection was frequently described as perpetuating and being perpetuated by substance use. One participant exemplified this sentiment:

“Why can’t they just accept me for who I am? … and from there, it’s.. downhill, because I start feeling bad about myself. I don’t want to feel that pain, so I’m going out to use. I’m going out to drink.”

-54-year-old Black bisexual male

Others reported isolation and avoidance in response to fear of judgment or stigma related to their substance use or other stigmatized identities (e.g., HIV status). One participant conveyed this commonly reported sentiment:

“I didn’t want anyone to know that I was using crack and I didn’t want anybody to know that I was HIV positive. So I was going home and locking doors and I was pushing people away”

-68-year-old Black gay male

Across interviews, participants overwhelmingly reported internalized substance use stigma as being associated with their substance use, far more than other types of internalized stigmas. However, multiple participants also described anticipated stigma related to other aspects of their identity as perpetuating their substance use.

c) Internalized Stigma, Substance Use, & HIV Self-Care

In response to questions about HIV self-care, most participants reported that internalized substance use stigma, and to a lesser extent other forms of internalized stigmas related to HIV status and sexual orientation, as well as substance use itself contributed to sub-optimal engagement in HIV self-care. Further, most of these participants described bidirectional or cyclical relationships between internalized stigmas, substance use, and sub-optimal engagement in HIV self-care. For example, one participant conveyed how internalized stigma related to living with HIV and his sexual orientation, substance use, and sub-optimal HIV self-care interrelate:

“Sometimes … I don’t even like pills. I’ll do crack. That’ll solve it. (laughs) I’ll do alcohol. In my mind, that’ll solve it. But in reality, it doesn’t… Because I don’t have to think about anything. It takes me away from thinking about me and my life, and living with HIV, being gay, all that… It takes me away from myself so I don’t have to deal with myself.”

-54-year-old Black gay male

Other participants conveyed how a cascade starting with substance use then leads to sub-optimal HIV self-care, isolation, and related negative psychological ramifications including internalized stigma. One participant expressed this:

“I’ll go get high and I won’t take my meds, and it’s just like, I’ll destroy– because …people will be calling me and I’ll avoid people. And then I won’t care. I won’t care about myself, …”

-50-year-old Black bisexual male

Across interviews, participants conveyed that internalized stigmas related to substance use, and to a lesser extent related to HIV status, and sexual orientation interfered with their HIV self-care at times. The majority of participants expressed that internalized stigmas often led to substance use, which then interfered with HIV self-care resulting in a cyclical relationship perpetuating substance use and sub-optimal HIV self-care behaviors.

Discussion

As far as we are aware, this study is the first to assess intersecting internalized stigmas among gay, bisexual, and other MSM living with HIV who are using substances concerning HIV-related self-care behaviors. While the majority of participants described some internalized stigma, as expected, the explicit description of intersecting internalized stigmas was not consistently conveyed by participants. Among those who did describe intersecting, or interlocking, aspects of their identities, participants described compounding experiences of feeling judged or marginalized. For many, the resulting feelings exacerbated beliefs that they did not belong in their social networks and communities. Regardless, teasing apart aspects of one’s identity is not necessarily intuitive and in and of itself is of questionable public health utility (Bowleg, 2008; Turan et al., 2019). Rather, while not all participants explicitly described intersecting identities or related internalized stigmas, the synthesis of the impact of internalized stigmas on HIV-related self-care behaviors among this sample of MSM living with HIV who use substances offers the most substantive contribution to the literature. Our most notable finding, consistent with emerging quantitative literature (Batchelder et al., 2020a; Stringer et al., 2019), was that while multiple forms of internalized stigma were reported by participants across interviews, internalized stigma related to substance use was described by almost all interviews as the most burdensome and cyclically related to substance use and sub-optimal HIV self-care.

The predominance of descriptions of internalized substance use stigma compared to internalized stigma related to other identities (e.g., HIV status or sexual orientation) was notable in the sample, given the existing literature demonstrating a relationship between HIV stigma and sub-optimal engagement in HIV self-care behaviors (Rueda et al, 2016). While there is substantially less research on the role of internalized substance use stigma among MSM living with HIV, substance use has been identified as more stigmatized than mental illness (Barry et al, 2014). Further, emerging results have identified that anticipated substance use stigma is associated with lower adherence to ART (Stringer et al., 2019), with missed HIV appointments in a similar sample (Batchelder, 2020a). The predominance of substance use stigma may be due to the moralization of addiction (Frank & Nagel, 2017), which many attribute to the self-inflicted nature of substance use disorders (Room, 2005) or as threatening to interpersonal interactions (Pachankis et al., 2018), resulting in a lack of empathy and compassion by providers for people who use substances, thereby reducing engagement in HIV self-care. Our findings indicate a need to consider and address the impact of internalized substance use stigma to improve engagement in HIV self-care among MSM living with HIV who use substances.

Additionally, avoidance of negative self-conscious emotions related to stigma (e.g., shame), judgment, and rejection was described across interviews. For many, these avoidance behaviors led to isolation and a lack of social support, which perpetuated internalized stigma, substance use, and sub-optimal HIV self-care. This pattern of avoidance is consistent with the concepts of rejection sensitivity and concealment within minority stress theory (Meyer, 2003). Sexual minority stress contributes to stressors including prejudice, expectations of rejection, and concealment, which can lead to internalized stigma (Meyer, 2003). The developmental trajectory of sexual minority men may contribute to internalized stigmas via the perpetuation of stigma at the societal and policy levels against sexual minorities (Herek, Gillis, Cogan, 2009; Meyer, 2003). Together, these pathways may elicit avoidance responses that instigate or perpetuate substance use (Batchelder et al, 2019; O’Clerigh et al., 2019). Recent efforts have been made to intervene on intersecting internalized stigmas as barriers to self-care, such as those by Batchelder and Flentje (e.g., Batchelder et al., 2020b and Flentje, 2020) by using strategies such as self-compassion (Germer & Neff, 2013), cognitive restructuring, and emotion regulation. Additionally, interventions such as acceptance and commitment therapy (e.g., Luoma & Platt, 2015) may be beneficial in reducing substance use and improving HIV self-care.

Further, themes related to other types of stigma emerged throughout the interviews related to intersecting aspects of participants’ identities including race and effeminateness. While some of these themes have not been addressed substantially in the literature (e.g., effeminateness), norms related to racial discrimination and masculinity have been expansively addressed (Choi, Paul, Ayala, Boylan, & Gregorich, 2013; Fleming, Lee, & Dworkin, 2014; Krill et al., 2019; Wong et al., 2017). Nevertheless, to fully appreciate perceived barriers to HIV self-care among this population, it is imperative to continue to work to understand how these additional intersecting internalized stigmas affect behavior.

Limitations

While this is the first study we are aware of to explicitly investigate how intersecting stigmatized identities affect engagement in HIV self-care among MSM living with HIV who use substances, there are several limitations. First, while we reached thematic saturation, the sample was heterogeneous in terms of sexual orientation (including gay, bisexual and straight-identified MSM), type of substance use, and substance use severity. Given these variabilities, internalized stigma may differ by sexual orientation, type of substance use, and degree of substance use severity. Additionally, the sample was predominantly men over 50 years old, which may have influenced the results. Further, we did not assess whether substance use proceeded HIV acquisition or vice versa. Finally, the sample was all from the greater Boston area, which has unique medical access and may have impacted the results.

Conclusions

While more work is needed to better understand and address intersecting internalized stigmas among MSM living with HIV who use substances, this work provides needed insight into how internalized stigmas perpetuate substance use and sub-optimal engagement in HIV self-care. Across interviews, internalized substance use stigma was identified as the most burdensome and behaviorally influential internalized stigma. Most participants described bidirectional relationships between internalized stigmas, particularly internalized substance use stigma, substance use, and sub-optimal engagement in HIV self-care. Further, our results indicate that avoidance of stigma-related emotions, judgment, and rejection lead to cycles of isolation and loneliness, which for some perpetuate internalized stigma, substance use, and sub-optimal engagement in HIV self-care. Clinical efforts to convey acceptance related to an individuals multifaceted identity, focusing on being a person who uses substances, may lead to reductions in substance use and improvements in HIV self-care. Emerging strategies that focus on cultivating self-compassion and self-acceptance generally (e.g., Luoma & Platt, 2015), and concerning intersecting stigmatized identities (e.g., Batchelder et al., 2020b) may reduce substance use and improve HIV self-care. Finally, societal and policy-level interventions are needed to reduce stigma and discrimination more broadly, including stigma related to HIV, sexual minorities, and substance use.

Highlights.

  • Internalized substance use stigma described as a barrier to engagement in HIV care.

  • Stigma, substance use, and poor engagement in HIV care perpetuate one another.

  • Intersecting internalized stigmas compound one another as barriers to HIV care.

Acknowledgements:

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). The authors thank Elsa Sweek, MA and Eric Lam, MPH for their assistance coding these interviews; additionally, they are grateful to participants in this study.

Footnotes

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Disclosures: The authors have nothing to disclose.

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