The Harms of Internalized AIDS Stigma: a Comment on Tsai et al.

The long-term negative impacts of AIDS stigma cannot be overstated. Broadly defined as the social discrediting and devaluation of individuals due to their living with HIV infection [1], AIDS stigma impedes prevention efforts, deters HIV antibody testing, fuels discrimination, and creates barriers to treatment services. Population-based surveys across countries consistently show AIDS stigmatizing beliefs are prevalent [2–4]. Even in countries that lack empirical research, the evidence for discrimination and violence against people living with HIV from personal testimonies, news reports, and anecdotes is overwhelming. Despite these harsh realities, there is surprisingly little research aimed at understanding the mechanisms and ramifications of AIDS stigma. To date, AIDS stigma research has been mostly cross-sectional and descriptive. The stagnated state of AIDS stigma research is at least in part the result of leading stigma researchers not entering into the AIDS arena and an overreliance on theories that date back more than 50 years. [5] Fortunately, a new generation of investigators is advancing fresh conceptual models to explain AIDS stigma and therefore stimulating progress in the field. For example, Earnshaw et al. [6, 7] have proposed the HIV Stigma Framework in which they identify three mechanisms that have direct implications for the health, behavior, and emotional adjustment of people living with HIV. Two stigma mechanisms, anticipated stigma and enacted stigma, evolve from the social interactions of individuals living with HIV. Enacted stigma results from the experience of discrimination and prejudice attributable to HIV infection, and anticipated stigma is the expectancy for such adverse reactions. The third mechanism in the HIV Stigma Framework is internalized stigma. Unlike enacted and anticipated stigma, internalized stigma does not necessarily stem from the actions of the others [7]. Internalized stigma occurs when people living with HIV themselves adopt the AIDS stigmatizing beliefs. There is considerable evidence that internalized stigma is related to poorer health and mental health [8, 9]. The longitudinal study in this issue of Annals of Behavioral Medicine by Alexander Tsai and his colleagues [10] reports that internalized stigma inhibits disclosure of HIV status among people living with HIV in Uganda. HIV status disclosure is essential to accessing support and services as well as informing persons at potential risk for exposure, particularly sexual and drug using partners. However, disclosure carries risks of adverse social reactions. Although previous studies have found a relationship between internalized stigma and HIV status disclosure [11, 12], Tsai et al. for the first time show that the magnitude of the association between internalized stigma and disclosure is a function of social distance in relationships. Internalized stigma exerts greater inhibition on disclosure in more distal relationships, such as disclosing to neighbors and religious leaders, and in public disclosures to strangers. In contrast, the association between internalized stigma and disclosure in close relationships such as friends is much less robust. Of particular importance is the limited impact of internalized stigma on disclosure to sexual partners, where disclosure decisions have significant implications for the spread of HIV infection. HIV status disclosure to sexual partners is the source of considerable stress for people living with HIV [13] and non-disclosure of HIV status to sex partners is frequently criminalized [14, 15]. Until now, we have assumed that internalized stigma should be a primary target of interventions that assist people living with HIV in their disclosure decisions and strategies. The findings of Tsai et al. push the field forward by illustrating that the multidimensional structure of AIDS stigma intersects with multiple dimensions of social relationships. Anticipated and enacted stigma, the other two mechanisms specified in the HIV Stigma Framework [7], for example, may also vary as a function of the social distance. Interventions aimed at resolving internalized stigma and supporting HIV status disclosure will require careful attention to social distances when examining the interpersonal context of relationships among people living with HIV.