The impact of stigma on health outcomes has been well documented, with negative effects identified in relation to quality of life, mental and physical health, interpersonal relationships and healthcare access [1,2]. Stigma in relation to HIV has been recognized as a barrier to accessing HIV prevention and care services since the start of the epidemic [3–6].
As well as having negative impacts on people living with HIV (PLHIV), stigma can affect people who share connections with PLHIV through stigma by association – originally termed ‘courtesy stigma’ .
Stigma by association refers to discrimination or prejudice experienced by individuals who are associated with people who are stigmatized, even though they do not possess the stigmatized attribute themselves [7,8]. This stigma can affect those who share similar social identities, close personal relationships or who are affiliated with a stigmatized person or community in some way [7,9]. In line with Goffman's conceptualization of ‘courtesy stigma’, HIV stigma by association has been investigated among family members, informal caregivers and social networks of PLHIV, as well as healthcare professionals who work with PLHIV [10–14].
HIV stigma by association can have similar outcomes to the stigma experienced by PLHIV, such as social isolation, shame and fear, and can also lead to breakdowns in social and familial support . Due to fears of experiencing discrimination, family members may go to great lengths to ensure that their relative's HIV status is not widely known [15–17].
HIV stigma by association should be considered in the context of existing stigma towards other related issues, such as sexual identity or history of drug use [12,18,19]. Since the start of the epidemic, gay and bisexual men (GBM) and people who inject drugs have been portrayed as sources of HIV because of their behaviours (or identities), compounding historical forms of stigma (such as the pathologization of same-sex attraction or illicit drug use). This compounding or layering of HIV and other forms of stigma has contributed to GBM being inappropriately characterized as a threat to general population health .
In Australia, male-to-male sex is the most common route of HIV transmission, accounting for 84% of transmissions among all diagnosed PLHIV  and 70% of new HIV transmissions in 2016 . As a population widely affected by HIV, GBM could potentially experience HIV stigma by association, regardless of their HIV status, sexual behaviour, or risk of HIV acquisition.
Previous research has documented the effects of anticipating HIV stigma among non-HIV-positive GBM. For example, expecting HIV stigma has been associated with GBM avoiding HIV testing [19,23–27]. Although they may not hold stigmatizing beliefs towards HIV themselves, concerns about potential negative attitudes from health workers in a testing environment or possible future rejection if they were to receive an HIV diagnosis may act as a barrier to GBM seeking HIV testing .
In light of the negative effects of stigma (including anticipated stigma and stigma by association), it is important to consider factors that can mitigate these outcomes. Earnshaw et al. found that community support and HIV identity centrality buffered the association between HIV symptoms and anticipated stigma, whereas a study involving various stigmatized groups found that those reporting the least identity centrality also reported the most anticipated stigma . Identifying closely with one's sexual identity and connections with GBM communities can increase the resources available to support GBM, increase resilience, and mitigate the negative effects of stigma [30,31]. Acceptance within a community can also reduce engagement in practices that place GBM at risk of HIV acquisition and increase HIV testing [32–34]. The history of HIV responses in GBM communities has seen active attempts to counter HIV stigma, and support notions of shared responsibility and solidarity , however, HIV stigma within GBM communities continues to be a recognized problem . HIV stigma within GBM communities may result in non-HIV-positive men socially excluding HIV-positive men or rejecting them as sexual partners .
The present study sought to investigate experiences of HIV stigma by association among non-HIV-positive Australian GBM. Specifically, this study aimed to identify characteristics that were associated with experiencing stigma by association, the relationships between stigma by association and GBM community connections, and the potential effects of experiencing HIV stigma by association, including personal wellbeing outcomes and the rejection of HIV-positive partners.
This study formed part of a larger research project monitoring experiences of stigma among Australian priority groups impacted by blood-borne viruses (BBVs) and sexually transmissible infections (STIs) . The current survey targeted gay, bisexual, and other MSM, and investigated stigma related to their sexual identity, with an additional focus on HIV stigma. Ethics approval for the study was granted by the University of New South Wales Human Research Ethics Committee.
Participants were asked a series of questions about their sexual behaviour, HIV testing and prevention practices, HIV status and STI testing and diagnosis. These questions were modelled on those used in Australian HIV behavioural surveillance .
Attachment to the GBM community was measured using a four-item scale based on the scale used by Brener et al. (e.g. ‘How much do you feel part of a gay/bisexual community?’, see supplementary material for the full scale, http://links.lww.com/QAD/B735). Participants responded on a five-point Likert scale and were summed to provide an overall measure of GBM community attachment (α = 0.72 in this study).
The centrality of participants’ sexual identity was measured using a four-item subscale of the Lesbian, Gay and Bisexual Identity Scale  (e.g. ‘My sexual orientation is a central part of my identity’). Responses were measured on a five-point Likert scale (1= ‘strongly disagree’ to 5 ‘strongly agree’). One item was reverse scored and all item responses were summed to provide an overall measure of centrality (α = 0.75 in this study).
HIV stigma by association and sexual identity stigma were measured using two single items – ‘Do you ever feel stigmatised by other people assuming you are at risk of HIV?’ and ‘In the last 12 months, have you experienced any stigma or discrimination in relation to your sexual orientation?’ . Participants responded to each of these items on a five-point scale ranging from ‘never’ to ‘always’. Responses were also coded into dichotomous variables to represent ever experiencing HIV stigma by association (0 = never; 1 = ever) and ever experiencing sexual identity stigma within the past 12 months (0 = never; 1 = ever).
Participants were asked how often they had rejected male sex partners in the past 12 months for being HIV-positive, HIV-negative or untested for HIV. For each of these, responses were measured on a five-point scale (1 = ‘never’ to 5 = ‘always’).
Psychological distress was measured using the Kessler Psychological Distress Scale (K10) . This widely used 10-item scale measures symptoms of psychological distress experienced within the past 4 weeks, scored on a five-point scale (1 = ’none of the time’ to 5 ‘all of the time’). Items were summed to calculate an overall measure of psychological distress (α = 0.94 in this study).
Participants were also asked to provide demographic information, including age, gender, sexual identity, country of birth, state of residence, identification as Aboriginal or Torres Strait Islander, education level and employment status.
Participants were recruited via paid Facebook advertising. Consistent with Australian HIV behavioural surveillance recruitment methods [41,42], advertisements were targeted to men over the age of 18 years who lived in Australia and whose Facebook profiles included any LGBTI-related interests, such as ‘same sex relationship’, ‘gay friendly’, ‘LGBT social movements’, or ‘LGBT culture’. Participants were directed to the survey website, which contained detailed information about the study and obtained participants’ consent before commencing the survey. Having completed the online survey, participants were invited to enter a draw to win one of five $100 gift vouchers by providing their e-mail address (but no other personal details).
Analyses focused on being stigmatized because of a perceived risk of having HIV, despite not being HIV-positive. Therefore, only non-HIV-positive participants (i.e. HIV-negative and untested/unknown status) were included, and HIV-positive participants were excluded from these analyses. Chi-square and independent samples t-tests were conducted to compare non-HIV-positive participants who had ever experienced HIV stigma by association with those who had not.
Variables for which there was a bivariate statistical difference between the two groups (P < 0.05) were then block entered into a multivariable logistic regression model to identify statistically independent differences between the groups. Those who had not experienced HIV stigma by association were the reference group. Adjusted odds ratios and 95% confidence intervals are reported.
To further investigate the relationships between statistically significant variables in the multivariable analysis (GBM community attachment, sexual identity stigma, HIV testing frequency, HIV stigma by association and psychological distress), z-scores were calculated for each variable, and a serial mediation model was tested. It was hypothesized that psychological distress and rejection of sex partners might be outcomes of experiencing HIV stigma by association, so serial mediation models were developed to investigate these relationships. In the first model, GBM community attachment was the independent variable, psychological distress was the dependent variable, and HIV-testing frequency and frequency of HIV stigma by association (using responses to the five-point scale) were included as mediators. Sexual identity stigma was included as a covariate in the model. This model was repeated with different dependent variables using rejection of partners for being HIV-positive, and rejection of partners for not testing for HIV.
Analyses were conducted using SPSS version 22. Serial mediation analysis was conducted using Hayes’ PROCESS SPSS macro Version 3 (model 6) .
In total, 1760 participants commenced the survey, 72.7% of whom provided a completed response (n = 1,280). A summary of demographic characteristics is shown in Table 1.
Among non-HIV-positive participants, 71.9% (n = 874) reported ever feeling stigmatized by others assuming they were at risk of HIV, including 17.3% who reported that it ‘often’ or ‘always’ occurred (note that 12 participants did not answer this question).
Table 2 compares non-HIV-positive participants who reported ever experiencing HIV stigma by association with those who had never experienced such stigma in terms of their demographic characteristics, sexual behaviour, HIV and STI-testing practices, GBM community attachment, sexual identity centrality, psychological distress, sexual identity stigma and rejection of potential sex partners.
At the bivariate level, there were no demographic differences between the two groups. GBM who had ever experienced HIV stigma by association were more likely to report having sex with casual partners and reported more sexual partners in the last 12 months. They also reported more frequent and recent HIV testing, and were also less likely to have an unknown HIV status. Use of preexposure prophylaxis (PrEP) was not significantly different between groups. Those who had ever experienced HIV stigma were more likely to have tested for STIs in the last 12 months, but of those tested, there were no differences in STI diagnoses between groups. Men who had ever experienced HIV stigma reported higher levels of GBM community attachment, sexual identity centrality, psychological distress and were more likely to have experienced sexual identity stigma. They were also more likely to report rejecting sex partners for being HIV-positive or not testing for HIV.
A multivariable logistic regression analysis was conducted with those who had not experienced HIV stigma by association as the reference group. Due to multicollinearity with the number of HIV tests in the last 12 months, time since last HIV test and HIV status (i.e. HIV-negative vs. unknown status) were excluded from this analysis. Variables related to the rejection of sex partners were also excluded from this analysis as they were hypothesized to be potential behavioural outcomes of HIV stigma rather than potential causes (see below). Adjusted odds ratios and 95% confidence intervals are shown in Table 3.
More frequent HIV testing was independently associated with experiencing HIV stigma by association (specifically in relation to participants who had tested once or three or more times in the past 12 months), as was greater attachment to the GBM community, experiencing sexual identity stigma, and higher levels of psychological distress.
To further investigate the relationships between GBM community attachment, sexual identity stigma, HIV testing frequency, HIV stigma by association and psychological distress, a serial mediation model was tested. The results of this model are shown in Fig. 1.
Greater attachment to the GBM community was not directly associated with psychological distress (total effect = −0.05, 95% CI [−0.10 to 0.01]; direct effect = −0.05, 95% CI [−0.10 to 0.003]). Greater GBM community attachment was associated with increased HIV testing (direct effect = 0.17, 95% CI [0.12--0.23]) and more experiences of HIV stigma by association (direct effect = 0.08, 95% CI [0.03--0.13]), both of which were associated with psychological distress (direct effects = −0.09, 95% CI [−0.15 to −0.04] and 0.18, 95% CI [0.12--0.24], respectively). Greater GBM community attachment was indirectly associated with reduced psychological distress through increased HIV testing frequency (indirect effect = −0.02, 95% CI [−0.03 to −0.01]). Greater GBM community attachment was indirectly associated with increased psychological distress through more frequent experiences of HIV stigma by association (indirect effect = 0.01, 95% CI [0.004-- 0.03]) and both HIV-testing frequency and HIV stigma by association (indirect effect = 0.005, 95% CI [0.002--0.01].
To investigate potential behavioural outcomes of experiencing HIV stigma by association, a second serial mediation model was tested. The results of this model are shown in Fig. 2.
Greater attachment to the GBM community was directly associated with being less likely to reject sex partners for being HIV-positive (total effect = −0.08, 95% CI [−0.14 to −0.02]; direct effect=−0.11, 95% CI [−0.17 to −0.05]). However, greater GBM community attachment was also associated with increased HIV testing (direct effect = 0.17, 95% CI [0.11--0.22]) and more experiences of HIV stigma by association (direct effect = 0.08, 95% CI [0.03--0.13]), both of which were associated with being more likely to reject sex partners for being HIV-positive (direct effects = 0.12, 95% CI [0.06--0.17] and 0.11, 95% CI [0.05--0.18], respectively). Greater GBM community attachment was associated with an increased likelihood of rejecting HIV-positive partners through increased HIV testing frequency (indirect effect = 0.03, 95% CI [0.02--0.05]), through increased HIV stigma by association (indirect effect = 0.01, 95% CI [0.002--0.02]), and through both testing frequency and HIV stigma by association (indirect effect = 0.002, 95% CI [0.001--0.01]).
The same analysis was repeated with rejecting others for not testing for HIV as the dependent variable. In this model, the relationships between variables and coefficients were similar to those shown in Fig. 2, though the total effect was not statistically significant (total effect = −0.02, 95% CI [−0.08 to 0.04]; direct effect = −0.07, 95% CI [−0.13 to −0.02]; total indirect effect = 0.05, 95% CI [0.04--0.07]) (see Figure 3 in supplementary material, http://links.lww.com/QAD/B735).
This study sought to investigate experiences of HIV stigma by association among HIV-negative and untested GBM. The concept of stigma by association is an understudied area in relation to GBM and HIV, but remains important given that previous research has suggested that stigma by association can have the same negative consequences as experienced by those with a stigmatized attribute . A majority of non-HIV-positive participants (71.9%) reported experiencing HIV stigma by association, suggesting that this is likely to be a common experience among GBM. In terms of demographic characteristics, there were no differences between men who had experienced HIV stigma by association and those who had not.
Those who had experienced HIV stigma by association were more likely to have tested for HIV within the last 12 months. They also felt more connected to the GBM community and were more likely to have experienced stigma in relation to their sexual identity. These results suggest that the enduring effects of HIV stigma and the layering of stigma associated with homosexuality persist in society , with many GBM continuing to feel as though others perceive them to be at risk of HIV acquisition. Those who reported HIV stigma by association also reported higher levels of psychological distress compared with those who had not experienced stigma, which aligns with previous research regarding negative personal outcomes associated with stigma [44,45].
The association between experiencing stigma related to sexual identity and HIV stigma by association highlights the significance of multiple stigmas. The complexity of stigma suggests that it can be difficult to disentangle stigma in relation to various attributes. For example, participants may have felt stigmatized because of their sexual identity, or perceived risk of HIV acquisition or a combination of both. Further research is warranted to investigate interactions such as these, as well as potential layering of other stigmas (e.g. drug use, STIs, mental health, ethnicity). Results of this study suggest that experiencing one form of stigma (i.e. HIV stigma by association) is associated with elevated psychological distress and rejection of others even when controlling for one other stigma (i.e. sexual identity stigma). Additional research is warranted to further explore manifestations associated with multiple layers of stigma and discrimination.
Previous literature has investigated stigma by association experienced by healthcare workers, family members and close social networks [10–14], however, HIV-affected communities and populations have not previously been studied in this way. The present study addressed this gap and highlights some important issues for engaging GBM in HIV prevention and testing, and ensuring quality of care. As a community affected by HIV, these results underscore that all GBM can be affected by HIV stigma regardless of the HIV status . Furthermore, results suggest that the presence of this stigma is more notable among men who regularly engage in HIV testing, feel more connected to the GBM community, and who experience more sexual identity stigma. Regular HIV testing is an important step in promoting the treatment and prevention of HIV, while both engagement with the GBM community and identity centrality have previously been demonstrated to have social benefits [30,31]. Although positive outcomes, such as increased HIV testing should be encouraged, results suggest that encouraging engagement with HIV services does not lessen (and may in fact intensify) the effects of HIV stigma. In this way, stigma continues to be a major barrier to health promotion efforts among affected populations.
Alternatively, it may be the case that other factors influence experiences of HIV stigma by association among GBM. While HIV testing was found to be associated with HIV stigma by association, other factors may contribute to this (e.g. behaviour that increases the risk of HIV transmission). Variables, such as number of sex partners and relationship status were not significantly associated with HIV stigma by association in this study; however, the measures utilized are not necessarily comprehensive. Further research is warranted to further investigate the association between HIV testing and stigma to identify other factors associated with these experiences.
There are also important flow-on effects of HIV stigma by association. Specifically, GBM who experienced more HIV stigma were more likely to reject potential sex partners for being HIV-positive or for not testing for HIV. This supports a heightened vigilance about proximity to PLHIV and GBM who have not tested for HIV, suggesting not only a strong investment in being HIV-negative but also the use of exclusionary practices to maintain this status. The effects of stigma are, therefore, broader than for the individual experiencing stigma, and extend throughout the GBM community . This highlights the importance of reducing HIV stigma in order to enhance accessibility to HIV testing and prevention as collective, community-based practices [35,46].
Although greater attachment to the GBM community was associated with less rejection of others, HIV stigma by association partially mediated this relationship. The indirect effects of GBM community attachment (through HIV testing frequency and HIV stigma by association) increased the likelihood of rejecting others, suggesting that there are both positive and negative effects of GBM community attachment. Similarly, increased GBM community attachment was associated with reduced psychological distress (though this relationship was not statistically significant in the serial mediation model). The indirect pathways through HIV stigma by association; however, were associated with increased levels of psychological distress. Although the social support available through increased community connections may have positive effects on mental health and wellbeing, the increased HIV stigma by association that was associated with GBM community attachment appeared to have negative effects. To maximize the social benefits of being highly engaged with the GBM community (e.g. resilience, social support, engagement with healthcare, increased HIV testing), interventions are needed to reduce stigmatizing attitudes about HIV from outside (and within) the GBM community. Stigma by association was also exacerbated when non-HIV-positive GBM regularly tested for HIV. Despite efforts to create welcoming environments in health services, it should not be assumed that engagement with HIV-related services prevents experiences of HIV stigma and discrimination.
This study is limited by the use of single-item measures of stigma, which cannot capture the complexity of stigmatizing experiences. However, our earlier research has demonstrated the validity of single item measures of stigma when used alongside more detailed measures [37,47]. Future research should explore other aspects of stigma by association, including relationships with PLHIV, as well as more fully addressing the existence of multiple, layered stigmas. As a cross-sectional study, causality could not be inferred from the findings. Longitudinal research would be needed to identify prospective effects of stigma by association. It should be noted that the sample may be biased because of the self-selection method of recruitment. People who experience stigma may be more likely to respond to advertisements for a study about stigma than those who have never experienced stigma, thereby overrepresenting these experiences within the sample. There are also specific benefits and limitations to the use of social media to recruit participants for health-related research. While this recruitment method will not capture potential participants who are disengaged from social media, Facebook advertising is an effective and cost-effective way to recruit participants compared with traditional methods [48,49].
HIV stigma is a major social and health issue facing the GBM community. Not only do HIV-positive men experience stigma because of their HIV status, but HIV-negative and untested GBM experience HIV stigma by virtue of their membership of a community that is affected by HIV. The effects of this stigma by association include psychological distress and the rejection of others based on their HIV status or testing behaviour. In order to encourage HIV testing and prevention among GBM, and to facilitate the benefits that extend from community connections, there is an ongoing need to address HIV stigma within GBM communities and across society, both towards PLHIV and those who are stigmatized by association.
Study concept: T.B., L.B., M.Hop., E.C., C.T., M.Hol. Survey design: T.B., L.B., E.C., M.Hop., C.T. Data analysis: T.B., L.B., M.Hol. Interpretation of results: T.B., L.B., M.Hol. Article development: T.B., L.B., M.Hol. Critical revision of the article: all authors.
Conflicts of interest
There are no conflicts of interest.
Funding support: The Stigma Indicators Monitoring Project was supported by a grant from the Australian Government Department of Health
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