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. Author manuscript; available in PMC: 2024 Feb 1.
Published in final edited form as: AIDS Educ Prev. 2023 Feb;35(1):54–68. doi: 10.1521/aeap.2023.35.1.54

Correlates of HIV-related stigmas among African American church-affiliated populations in Kansas City

Kathryn P Derose 1,2, Jannette Berkley-Patton 3, Chavon Hamilton-Burgess 1, Carole Bowe Thompson 3, Eric D Williams 4, Stephen Simon 3, Jenifer E Allsworth 3
PMCID: PMC9907009  NIHMSID: NIHMS1858722  PMID: 36735231

Abstract

HIV-related stigmas contribute to disparities and contact with HIV-positive individuals has been suggested to reduce stigma. Faith-based organizations have been recognized as important to stigma reduction efforts among African American populations, however, relatively few church-based studies have measured HIV-related stigma. This study uses baseline data (n = 1448) from a study with 14 African American churches in Kansas City, MO to examine correlates of HIV-related stigmas among church members and community members accessing church social services using two previously validated scales that measure discomfort interacting with individuals with HIV and anticipated stigma or rejection. Knowing someone with HIV was associated with lower discomfort, even after adjusting for sociodemographic characteristics and sexual risk, HIV knowledge, previous communication about HIV at church, and mean drug and homosexuality stigmas. Knowing someone with HIV was not associated with anticipated stigma or rejection after adjustment. Contact-based interventions hold promise for reducing discomfort around people with HIV among church-affiliated populations.

Keywords: HIV stigma, religious congregations, contact hypothesis, African American

INTRODUCTION

In the United States (US), African Americans are disproportionately affected by HIV, and many do not know that their status. In 2019, African Americans accounted for 13% of the population, but more than 40% of people living with HIV (CDC). In addition, an estimated 38% of all new cases overall in 2016 were transmitted by individuals that were unaware of their status (CDC, 2019). Identifying and addressing barriers to regular HIV testing is important for prevention and successful management of HIV as a chronic disease.

HIV-related stigmas contribute to HIV disparities (Earnshaw, Bogart, Dovidio, & Williams, 2013). High levels of HIV stigma are well-documented and can be a barrier to effective prevention, including HIV testing (Herek, Capitanio, & Widaman, 2003). Stigma is social devaluation and discrediting associated with a personal attribute, mark, or characteristic such as HIV (Goffman, 1963). Anticipated stigma, the type of stigma that may have the greatest impact on HIV testing, is expecting to experience prejudice, discrimination, and stereotyping from others in the future (Earnshaw & Chaudoir, 2009; Earnshaw, Quinn, Kalichman, & Park, 2013). Fear of HIV-related stigma and discrimination, a kind of anticipated stigma, has been shown to discourage African Americans from testing (Murray & Oraka, 2014). Stigma, coupled with poverty and discrimination within healthcare, can limit the extent to which African Americans living with HIV benefit from available treatment (Leddy et al., 2019). Misunderstandings and mistrust of HIV-related information (e.g., public health messages regarding HIV transmission, testing, prevention, and treatment) (Bogart & Thorburn, 2005) may underlie HIV stigma, including fears of people with HIV (PWH) and of becoming infected through casual contact.

The US National HIV/AIDS Strategy (2022–2025) emphasizes that HIV stigma reduction is essential to reducing racial-ethnic disparities in HIV prevention, testing, and care, and recognizes the involvement of faith-based organizations (FBOs) as critical (The White House, 2021). FBOs such as churches are trusted information sources, well-connected, and strategically located in diverse communities affected by HIV. Moreover, African Americans report high levels of religious affiliation (Mohammed, Cox, Diamant, & Cecewicz, 2021), and Black churches in the US have historically played an important role in social change movements (Lincoln & Mamiya, 1990). Analyses using the National Congregations Study (NCS) data from 2006–2007 found that less than 6% of congregations nationally provided support to people with HIV (Frenk & Trinitapoli, 2013; Williams et al., 2014). In the 2012 wave of the NCS, 8% of congregations reported providing support to people with HIV and 9% engaged in HIV prevention activities, 7% in awareness raising, and 8% provided donations to other organizations (Williams, Derose, Haas, Griffin, & Fulton, 2018). A systematic review focused on HIV testing efforts in historically Black churches identified 26 papers representing 24 unique projects (Pichon & Powell, 2015).

Despite previous work on faith-based HIV interventions, few have reported the extent to which their interventions reduced HIV stigma, and, among those that did, results have been mixed. Two separate pilot cluster randomized controlled trials (RCT), one in Kansas City and the other in Los Angeles, implemented interventions at the church level and assessed change among congregants generally (not just among those who participated in intervention activities) and did not find significant reductions in HIV-related stigma among the African American congregations (Berkley-Patton et al., 2013; Derose, Griffin, et al., 2016), though the Los Angeles study did find reductions among Latino congregations (Derose, Griffin, et al., 2016). Another cluster RCT of African American churches in Alabama that assessed change only among those who participated in the intervention did find statistically significant reductions in individual-level HIV stigma, but not in perceptions of stigmatizing attitudes of congregations or community members (Payne-Foster et al., 2018). Finally, another pre-post nonrandomized study of Black churches in Canada found statistically significant reductions only among congregants who were exposed to all intervention components (Husbands et al., 2021).

Low involvement of religious congregations in addressing HIV has been attributed to stigmatization of behaviors associated with HIV, lack of perceived need, insufficient resources, and lack of clergy training (Williams, Palar, & Derose, 2011). HIV stigma in congregational settings is often attributed to religious taboos on homosexual contact between men, multiple sex partners, and drug use, which are likely to be viewed through a moral lens, facilitating stigmatization and the casting of blame (and shame) (Fullilove & Fullilove, 1999; Williams et al., 2011). However, to our knowledge, only two previous church-based studies have measured these related stigmatizing attitudes (regarding drug addiction and/or homosexuality) and examined how they might contribute to HIV stigma (Derose, Kanouse, et al., 2016; Kerr et al., 2021).

Previous research has identified two aspects about stigma that are relevant to HIV: instrumental stigma refers to concern about the potential consequences of interacting with a stigmatized person, such as becoming infected with HIV, while symbolic stigma refers to concern about what the stigmatized condition, such as HIV, symbolizes (Bos, Schaalma, & Pryor, 2008; Herek & Capitanio, 1998). Instrumental stigma can play out in feelings of discomfort about interacting with HIV-positive individuals, while symbolic stigma can encompass how people with HIV feel about themselves and how they are or might be treated by others, as well as how people who do not have HIV imagine they might be treated by others if they had HIV (anticipated stigma or rejection).

Although previous studies with church-affiliated populations have examined factors associated with HIV stigma, the studies had few numbers of churches (Berkley-Patton et al., 2013; Derose, Kanouse, et al., 2016; Kerr et al., 2021), had limited measures of HIV stigma (Berkley-Patton et al., 2013), or did not adjust for covariates known to affect HIV-related attitudes (Lindley et al., 2010). To develop effective HIV stigma reduction interventions in collaboration with FBOs, it is important to explore further the dimensions and correlates of HIV stigma among church-affiliated populations and the communities they serve. We therefore examined two different types of HIV-related stigma (discomfort interacting with people with HIV, related to the instrumental aspect of stigma described above, and anticipated stigma or rejection, related to the symbolic aspect of stigma described above) and stigmas regarding homosexuality and drug addiction, using baseline data from an intervention study that aimed to increase HIV testing and reduce HIV-related stigma among congregants and community members served by predominantly African American churches in Kansas City, MO. First, we examined whether personally knowing someone with HIV was associated with lower discomfort interacting with people with HIV and anticipated stigma or rejection (Herek & Capitanio, 1997; Mall, Middelkoop, Mark, Wood, & Bekker, 2013; Nambiar & Rimal, 2012). We also examined whether stigmas related to drug addiction and homosexuality were associated with greater discomfort interacting with people with HIV and anticipated stigma or rejection (Capitanio & Herek, 1999; Herek & Capitanio, 1999; Price & Hsu, 1992; St. Lawrence, Husfeldt, Kelly, Hood, & Smith, 1990). Finally, since research has found that individuals who have never discussed HIV with anyone have more negative attitudes toward people with HIV (Genberg et al., 2009), we also explore whether taking with others about HIV at church is associated with lower discomfort interacting with people with HIV and anticipated stigma or rejection.

METHODS

Context

This study used baseline data from a two-arm cluster randomized controlled trial that examined efficacy of a religiously tailored HIV testing intervention (Taking it to the Pews, TIPS) against a standard information arm on HIV testing rates among African American church members they serve. The study used community-based participatory research (CBPR) and involved 14 African American churches in Kansas City, MO. A full description of the study protocol is published elsewhere (Berkley-Patton, Bowe Thompson, et al., 2019). One unique aspect of this study compared to other church-based studies is the intentional recruitment of community members (non-congregants) served by church outreach ministries (e.g., food pantries), in addition to church members. Community members are often socio-economically vulnerable, and their inclusion expands the reach of church-based interventions and these interventions’ ability to reduce health disparities in their communities more broadly.

Participants

Church members and community members who participate in church service programs at the 14 churches were screened using self-report to meet the following criteria: 1) aged 18 to 64; 2) willing to participate in three surveys (baseline, 6-month, 12-month) after church services; 3) willing to provide contact information for self and two persons with whom they have ongoing contact; and 4) regularly attend church (at least one a month) or use church outreach services (at least four times per year). The University of Missouri-Kansas City (UMKC) Institutional Review Board approved this study and participants provided written informed consent.

Conceptual Framing

Because our study participants included (potentially) individuals with and without HIV, we drew on the literature regarding instrumental and symbolic HIV stigma among general U.S. populations (as opposed to the literature on measuring HIV stigma among people living with HIV). As noted above, we conceptualized instrumental HIV stigma as discomfort interacting with people with HIV and symbolic stigma as anticipated stigma or rejection (defined below). The most consistent individual-level, independent factors associated with lower instrumental/discomfort and symbolic/anticipated HIV stigma or rejection among general U.S. populations have been lower age, higher education, personal contact with people with HIV, greater HIV knowledge, and more favorable attitudes towards gay persons (Herek, 1999). Among church-affiliated populations (U.S. and Canada), the following factors have been found to be associated with lower HIV stigma: greater HIV knowledge (Berkley-Patton et al., 2013; Kerr et al., 2021; Lindley et al., 2010); female gender (Coleman et al., 2016; Lindley et al., 2010), younger age (Kerr et al., 2021; Lindley et al., 2010), knowing someone with HIV (Coleman et al., 2016; Derose, Kanouse, et al., 2016; Kerr et al., 2021), knowing someone who is gay (Coleman et al., 2016), and less stigmatizing attitudes towards drug addiction (Derose, Kanouse, et al., 2016) and homosexuality (Derose, Kanouse, et al., 2016; Kerr et al., 2021). We therefore use these past findings to guide our multivariable modeling.

Measures

Key dependent variables.

We adapted items from prior studies that measured the following aspects of HIV stigma:

  1. HIV stigma – discomfort (instrumental aspect of stigma), five items that asked about how comfortable respondents would feel being around people with HIV in various community settings (school, church, restaurant, and grocery story) (Berkley-Patton et al., 2013; Herek & Capitanio, 1999), using responses on a 5-point Likert scale from very comfortable to very uncomfortable (α = 0.869 in our sample).

  2. HIV stigma – anticipated stigma or rejection (symbolic aspect of stigma), four items about whether respondents endorse beliefs that if they had HIV, they would be rejected, fired, couldn’t face their families, or might be treated differently or discriminated against (Lauby, Bond, Eroglu, & Batson, 2006; Simbayi et al., 2007), using responses on a 5-point Likert scale from strongly disagree to strongly agree (α = 0.768 in our sample).

Key independent variables.

To explore the role of contact in our church-affiliated sample (knowing someone with HIV), we asked respondents whether they personally know anyone (friends, family, co-workers, others) who “has HIV or AIDS or has died of HIV” (yes/no), similar to how others have measured direct contact (Herek & Capitanio, 1997; Mall et al., 2013; Nambiar & Rimal, 2012). For drug addiction and homosexuality stigmas, we use an adapted 5-item scale on the extent to which respondents endorsed attitudes towards alcoholics (Ronzani, Higgins-Biddle, & Furtado, 2009), changing “alcoholics” and “alcoholism” to “drug addicts” and “drug addiction”(Florez et al., 2015) (α = 0.898 in our sample). For homosexuality stigma, we used 6 items from the 19-item Heterosexual Attitudes Towards Homosexuality (HATH) scale (Larsen, Reed, & Hoffman, 1980) and added one item (“Homosexuals should be barred from the clergy”). For all variables, response categories ranged from “disagree strongly” to “agree strongly” (α = 0.825 in our sample). Both the adapted drug addiction and homosexuality stigma scales were used in a previous church-based study (Derose, Kanouse, et al., 2016).

Other independent variables.

HIV Knowledge was measured with 16 items adapted from the HIV Knowledge Questionnaire (HIV-KQ-18)(Carey & Schroder, 2002). These items included questions such as “A person can get HIV by using a cup or plate that has been used by a person with HIV/AIDS and “HIV can be transmitted through mosquito bites,” with “true, false, or don’t know” as responses; items were scored “1” for correct answers and “0” for incorrect or “don’t know” answers (α = 0.958 in our sample). To explore how previous communication about HIV at church was related to stigma, we asked respondents, “How many people at this church/church center or at an event sponsored by this church did you talk to about any topics related to HIV?” (response categories went from None to 20+, but given distribution of this variable, we used “none,” “1–2 people,” “3–5 people,” and 6+ people”). Because of the two sampling approaches at the study churches – church members vs. community members who participate in the study church’s service programs – we include an identifier for each of these types of study participants (church member vs. community service program participant). Community members are linked to the specific church from which they were recruited.

Socio-demographic variables.

We included the following control variables, given their association with HIV stigma in previous church-based studies (Derose, Kanouse, et al., 2016; Lindley et al., 2010): age (18–29 (reference group), 30–49, and 50–64); gender was defined as male (reference group) and female; and highest level of education completed, with categories of high school or less (reference group), some college/associates degree, or 4-year college degree or more. In addition, we included sexual identity, with categories of heterosexual (reference group), lesbian, gay, or bisexual, other, refused or missing); marital status, with categories of never married (reference group), married/partnered, or divorced/separated/widowed; ever tested for HIV (yes/no) and ever tested for the sexually transmitted infections (chlamydia, gonorrhea, or syphilis; yes/no).

Data Analysis

We computed the internal consistency of each scale with Cronbach’s α. Frequencies and means were computed to describe participant characteristics and stigma scores. Differences between participants who reported knowing someone with HIV vs. those who reported not know someone with HIV were analyzed using chi-square (for categorical variables) and t-tests (for continuous variables). Bivariate (unadjusted) and multivariable (fully adjusted) linear regression models were fit to examine the associations between knowing someone with HIV and the two types of HIV stigma (discomfort and anticipated stigma or rejection). Multivariable models adjusted for individual socio-demographic characteristics, drug addiction and homosexuality stigmas, HIV knowledge, and prior communication about HIV at church. All regression analyses accounted for clustering of individual participants (church members and community members receiving services) within churches. To ensure that our accounting for clustering was sufficient for addressing any lingering differences in stigma across churches, we conducted post-hoc crude and adjusted analyses that controlled for sociodemographic characteristics, testing for HIV, and STI history, and did not identify significant differences in reported stigma across churches. A p-value of less than 0.05 was considered statistically significant. Analyses were completed in Stata, version 17 (Stata Corp, College Station, TX).

RESULTS

Participant Characteristics

A total of 1448 people were enrolled across the 14 churches (985 church members or 68% and 463 community participants in church service programs or 32%). Table 1 provides an overview of participant characteristics, overall and by whether they knew someone with HIV. People who knew someone with HIV were older and more likely to be female, gay or bisexual, married or partnered, ever tested for HIV, and ever tested for other STIs. People who knew someone with HIV had spoken about HIV with more people at church and had lower scores on the HIV discomfort and anticipated stigma or rejection scales, as well as the homosexuality and drug stigma scales, while having higher HIV knowledge.

Table 1:

Characteristics of study participants from 14 African American churches in Kansas City, MO and KS by whether they knew someone with HIV (n=1448)

Know Someone with HIV
Characteristics No (n=844) Yes (n=604) P-value
Subsample 0.432
 Church member 581 (69%) 404 (67%)
 Community service program participant 263 (31%) 200 (33%)
Age group (years) <0.001
 18–29 191 (23%) 66 (11%)
 30–49 327 (39%) 282 (47%)
 50–64 326 (39%) 256 (42%)
Sex <0.05
 Male 288 (34%) 173 (29%)
 Female 552 (66%) 429 (71%)
Sexual identification <0.05
 Heterosexual 800 (96%) 567 (95%)
 Lesbian, gay, bisexual 7 (1%) 17 (3%)
 Other 12 (1%) 6 (1%)
 Refused/Missing 14 (2%) 10 (2%)
Education 0.096
 HS or less 307 (37%) 190 (32%)
 Some college/Associates 332 (40%) 267 (46%)
 4Y Degree+ 191 (23%) 129 (22%)
Marital status <0.001
 Never married 376 (45%) 209 (35%)
 Married/Partnered 283 (34%) 248 (42%)
 Divorced/Separated/Widowed 175 (21%) 141 (24%)
Ever tested for HIV <0.001
 No 212 (27%) 86 (15%)
 Yes 564 (73%) 479 (85%)
Ever STI testing @ Baseline <0.001
 None 251 (33%) 138 (24%)
 Chlamydia, gonorrhea, or syphilis 509 (67%) 426 (76%)
Any sexual risk: last 12M 0.1401
 No 686 (81%) 509 (84%)
 Yes 158 (19%) 95 (16%)
# people talked with about HIV at church (last 12M) <0.001
 None 653 (77%) 363 (60%)
 1–2 135 (16%) 145 (24%)
 3–5 26 (3%) 53 (9%)
 6+ 30 (4%) 43 (7%)
HIV discomfort scale 11.8 (0.2) 10.1 (0.2) <0.001
Anticipated HIV stigma or rejection scale 11.7 (0.1) 11.0 (0.2) 0.0006
HIV knowledge score 10.7 (0.1) 11.5 (0.1) <0.001
Homosexuality stigma 3.0 (0.0) 2.9 (0.0) 0.0093
Drug addiction stigma 2.5 (0.0) 2.4 (0.0) 0.0401
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Multivariable Analyses

Knowing someone with HIV was associated with lower discomfort [adjusted β = −1.057 (CI: −1.72, −0.39)], even after adjusting for sociodemographic characteristics and sexual risk, HIV knowledge, previous communication about HIV at church, and mean drug and homosexuality stigmas (Table 2). Although knowing someone with HIV was associated with lower anticipated stigma or rejection in unadjusted models, it was not statistically significant after adjusting for previously mentioned covariates. Being a member of the study church (vs. a community member participant in church service programs) was associated with lower discomfort and anticipated stigma or rejection, before and after adjustment [discomfort, adjusted β = −1.005 (−1.49, −0.52); anticipated stigma adjusted β = −0.793 (−1.26, −0.33)]. Similarly, having greater HIV knowledge was associated with lower discomfort and anticipated stigma or rejection, before and after adjustment [discomfort, adjusted β = −0.430 (−0.55, −0.31); anticipated stigma adjusted β = −0.139 (−0.23, −0.05)]. Higher stigma towards homosexuality and drug addiction were associated with greater discomfort and anticipated stigma or rejection, before and after adjustment. Specifically, higher stigma towards homosexuality had an adjusted β = 0.475 (0.098, 0.850) for discomfort and adjusted β = 0.673 (0.360, 0.990) for anticipated stigma. Higher stigma towards drug addiction had an adjusted β = 0.572 (0.180, 0.970) for discomfort and adjusted β = 0.410 (0.150, 0.670) for anticipated stigma. The number of people spoken with at church about HIV was not significantly associated with either the discomfort or anticipated stigma or rejection scores.

Table 2.

Correlates of HIV-related discomfort and anticipated stigma or rejection among study participants from 14 African American churches in Kansas City, MO (n=1448)

Discomfort Score Anticipated Stigma
Unadjusted Adjusted* Unadjusted Adjusted*
Knows someone with HIV −1.646 (−2.18, −1.12) −1.057 (−1.72, −0.39) −0.669 (−1.16, −0.18) −0.246 (−0.88, 0.38)
Study church member (vs. community service program participant) −1.221 (−2.07, −0.37) −1.005 (−1.49, −0.52) −0.729 (−1.37, −0.09) −0.793 (−1.26, −0.33)
Age
 18–29 Referent Referent Referent Referent
 30–49 −1.457 (−2.07, −0.84) −0.624 (−1.51, 0.26) −0.530 (−1.15, 0.09) −0.317 (−0.90, 0.27)
 50–64 −0.576 (−1.36, 0.21) −0.372 (−1.13, 0.39) −0.129 (−0.60, 0.34) 0.095 (−0.41, 0.60)
Female gender −1.319 (−2.03, −0.61) −0.574 (−1.35, 0.21) −0.349 (−0.81, 0.11) 0.322 (−0.19, 0.84)
Education
 High school or less Referent Referent Referent Referent
 Some college/Associates −1.995 (−2.52, −1.47) −0.642 (−1.23, −0.05) −0.629 (−1.10, −0.16) −0.106 (−0.52, 0.31)
 4Y degree or more −2.981 (−3.76, −2.20) −1.046 (−2.12, 0.03) −0.648 (−0.95, −0.34) 0.205 (−0.30, 0.71)
Sexual identity
 Heterosexual Referent Referent Referent Referent
 Lesbian, gay, bisexual −0.607 (−2.84, 1.63) 1.375 (−1.65, 4.40) 1.133 (−0.65, 2.92) 1.621 (−0.66, 3.91)
 Other 4.075 (2.31, 5.84) 1.632 (−0.36, 3.63) −0.611 (−2.00, 0.77) −1.317 (−2.84, 0.21)
 Refused/missing 2.583 (0.68, 4.49) −0.032 (−3.17, 3.11) 0.772 (−0.68, 2.23) 0.484 (−2.06, 3.02)
Marital status
 Never married Referent Referent Referent Referent
 Married/partnered −1.120 (−1.61, −0.63) −0.222 (−0.90, 0.45) −0.787 (−1.19, −0.38) −0.410 (−0.83, 0.01)
 Divorced, separated, or widowed −0.695 (−1.53, 0.14) 0.107 (−0.75, 0.97) −0.647 (−1.18, −0.11) −0.499 (−1.14, 0.14)
Ever tested for HIV −1.427 (−2.20, −0.66) −0.469 (−1.22, 0.28) −0.264 (−0.78, 0.25) 0.309 (−0.18, 0.79)
Ever tested for chlamydia, gonorrhea, or syphilis −1.323 (−1.92, −0.73) −0.143 (−0.70, 0.42) −0.194 (−0.76, 0.38) −0.0937 (−0.75, 0.56)
No. people talked to about HIV at church
 None Referent Referent Referent Referent
 1–2 people −0.057 (−0.52, 0.40) 0.0413 (−0.66, 0.74) −0.322 (−1.01, 0.37) −0.288 (−1.06, 0.49)
 3–5 people −1.006 (−2.30, 0.29) −0.705 (−1.88, 0.47) 0.084 (−0.68, 0.84) 0.478 (−0.94, 1.89)
 6+ people 0.0205 (−1.06, 1.10) −0.182 (−0.98, 0.61) −0.405 (−0.87, 0.064) −0.384 (−1.26, 0.49)
HIV knowledge score −0.588 (−0.66, −0.51) −0.430 (−0.55, −0.31) −0.179 (−0.24, −0.11) −0.139 (−0.23, −0.05)
Attitudes towards homosexuality score 0.812 (0.50, 1.12) 0.475 (0.098, 0.85) 0.745 (0.38, 1.12) 0.572 (0.18, 0.97)
Alcohol and drug stigma score 1.225 (0.86, 1.59) 0.673 (0.36, 0.99) 0.719 (0.51, 0.93) 0.410 (0.15, 0.67)
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95% confidence intervals in brackets

*

Adjusted for all co-variates

DISCUSSION

HIV-related stigma has been called a “dynamic and ubiquitous factor that must be considered and addressed in its many forms” if efforts to end the HIV epidemic are to be successful (Greenwood et al., 2022). FBOs have been identified as critical to addressing HIV and stigma (The White House, 2021), however, only a handful of church-based interventions have reported their effects on HIV-related stigma (Berkley-Patton et al., 2013; Derose, Griffin, et al., 2016; Husbands et al., 2021; Payne-Foster et al., 2018). Further, to our knowledge, there is only one previous study (involving 5 churches) that examined in-depth the independent factors associated with HIV-related stigma among church members (Derose, Kanouse, et al., 2016); although this study had a large overall sample of participants and included African American and Latino churches, it did not measure and adjust for HIV knowledge, which is a known correlate of stigma. The present study therefore expands the literature on faith-based HIV stigma reduction efforts by including a larger number of churches (14) and controlling for HIV knowledge as well as other known correlates of HIV stigma, such as related stigmas regarding homosexuality and drug use. In addition, the present study includes not only congregants of the study churches but also community members served through church community service programs, who could also be influenced through faith-based HIV programming.

Our study found that knowing someone with HIV was associated with lower discomfort, even after adjusting for HIV knowledge, homosexuality and drug addiction stigmas, and other correlates. This suggests that HIV education with church-affiliated populations is necessary but not sufficient for HIV stigma reduction. Indeed, previous research has shown that effective HIV stigma-reducing interventions include both an informational component (to increase knowledge) and a contact component (to promote direct or indirect interaction with people with HIV) (Brown, Macintyre, & Trujillo, 2003; Heijnders & Van Der Meij, 2006; Mahajan et al., 2008). Although few church-based HIV interventions have described explicit contact components, two that did had promising results in terms of stigma reduction among certain subsets of participants [e.g., congregants of Latino churches in Derose et al. (Derose, Griffin, et al., 2016) and those exposed to all intervention components in Husbands et al. (2021)]. Certainly, additional research on integrated information-contact interventions in congregational settings is needed to establish efficacy of such approaches as well as factors affecting implementation and results across different churches (Stewart, Salas-Brooks, & Kelly, 2019).

In terms of anticipated stigma or rejection, the association with knowing someone with HIV was not statistically significant after adjustment. This suggests that factors other than contact are influencing perceived attitudes in one’s church community. Anticipated stigma or rejection is related more to perceptions about how one would be received in the community if HIV positive, whereas discomfort is more about the individual’s attitudes towards people with HIV. Factors influencing community attitudes are complex and individuals may perceive them as difficult to change. Like with discomfort, HIV knowledge was negatively associated with anticipated stigma or rejection, suggesting that individual-level information and education are important. However, broader, church-level efforts to create inclusive and compassionate environments within congregations are likely necessary for individuals to feel that they would be well received if they had HIV. To do so, clergy are important partners, given their influence and reach through religious services, group meetings, and one-on-one contact with congregants. Engaging pastors to deliver stigma reducing messages within the context of sermons has been found to be feasible and acceptable, though more theory driven stigma reduction cues (e.g., sharing a story about a person with HIV as a hypothetical contact scenario) may require additional training (Payán et al., 2019).

Across both the discomfort and anticipated stigma or rejection outcomes, there were consistent results with HIV knowledge (negatively associated) and homosexuality and drug additional stigmas (positively associated). Although not surprising given the hypothesized relationships, these findings nonetheless are important since no previous study of church-affiliated populations has included simultaneous examination of all these correlates. The findings suggest the importance of informational or educational components of stigma reduction interventions in congregational settings, as well as consideration of how to address attitudes regarding same sex relations and drug use with cultural and religious sensitivity. Again, recognizing the role of the religious leaders and engaging with them on these issues is important, particularly since one study found that African American faith leaders had higher levels of homosexuality stigma than congregants (Stewart, Hong, & Melton, 2017).

Another consistent result across the two stigma outcomes was that church members had lower discomfort and anticipated stigma or rejection than community members served by these churches, even after controlling for sociodemographics and other correlates. Given the literature that describes stigmatizing attitudes within church settings, particularly homonegativity (Quinn & Dickson-Gomez, 2016), we had expected that church members might have higher stigma than community members. However, in-depth analysis of religious leaders’ messaging suggest variable framing when it comes to HIV (Derose, 2011; Teizazu, Hirsch, Parker, & Wilson, 2022), including those that promote a more inclusive and compassionate response. In addition, analyses of congregational policies and clergy and lay leader attitudes regarding HIV, homosexuality, and drug addiction across 14 congregations in Los Angeles (mostly African American and Latino) found great diversity across and sometimes even within congregations (Bluthenthal et al., 2012). Additional research is needed to fully understand how religious environments (policies, norms, etc.) influence HIV-related stigma attitudes among church members and broader community members who are served by congregational outreach programs. In addition, work is needed to assess whether and how stigma-reducing efforts at the congregational level could affect individuals who are not church members but receive church services. There is some evidence that congregational HIV programming can increase HIV testing among African American congregants and community members served through church service programs (Berkley-Patton, Thompson, et al., 2019), but, to date, no study has examined effects of such programming on non-congregant community members’ HIV-related stigma.

Finally, we did not find any differences in stigma scores based on how many people participants had spoken to at church about HIV. Communication about HIV at the church could create an environment that is more open and accepting and thus less stigmatizing. However, more information is likely needed about the content of these conversations to know whether this is the case.

This study has several limitations. First, the analyses were cross-sectional, and causal relationships cannot be inferred between our key correlates and HIV stigma. Second, all our measures were self-reported and are therefore subject to bias, including recall and social desirability. Third, although our multivariable analyses adjusted for multiple characteristics of congregants, including HIV knowledge, and stigmas toward homosexuality and drug addiction, those who reported knowing someone with HIV may have differed from those who did not report knowing someone in unmeasured ways that could help account for the differences in discomfort that we observed between these two groups. Finally, given that knowing someone with HIV was not significantly associated with anticipated stigma or rejection after adjustment for other co-variates, it could be that mediation analysis is needed to tease out the relationships.

Reducing HIV-related stigma remains an important objective in the quest to end the HIV epidemic. The multidimensional aspects of HIV stigma require consideration of factors that are associated with stigma. As expected, our study found that, among a church-affiliate population (congregants and community members served by church programs), stigmatizing attitudes towards drug addiction and homosexuality were associated with greater HIV discomfort and anticipated stigma, but greater HIV knowledge appeared to help overcome some of these attitudes. Further, knowing someone with HIV seemed to contribute to less discomfort, suggesting that integrating informational and contact components in church-based HIV interventions hold promise for HIV stigma reduction.

ACKNOWLEDGEMENTS

This study was supported by Grant Number R01MH099981 from the National Institute of Mental Health (NIMH). Analyses and writing were also supported by 3R01DK124664-01S1 from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Its contents are solely the responsibility of the authors and do not represent the official views of NIMH or NIDDK. The authors thank Pastor Cassandra Wainright and the Kansas City FAITH Community Action Board. We also thank the 14 churches and church and community members who participated in the study. Finally, we acknowledge University of Missouri – Kansas City colleagues who assisted with data collection and/or processing of our congregation-based surveys: Erin Moore, Alex Bauer, Kelsey Christensen, and Nia Johnson.

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