key: cord-0016786-vjf39jc2
authors: Babel, Riddhi A.; Wang, Peng; Alessi, Edward J.; Raymond, Henry F.; Wei, Chongyi
title: Stigma, HIV Risk, and Access to HIV Prevention and Treatment Services Among Men Who have Sex with Men (MSM) in the United States: A Scoping Review
date: 2021-04-18
journal: AIDS Behav
DOI: 10.1007/s10461-021-03262-4
sha: 65b69596bc12fe08becc032eeb63c7487e063eab
doc_id: 16786
cord_uid: vjf39jc2

In light of recent advances in HIV prevention and treatment, we reviewed the literature to understand how different types of stigma impact HIV risk; access to HIV prevention, care, and treatment services; and related health outcomes among men who have sex with men (MSM) in the US. We conducted a scoping literature review of observational and qualitative studies that examined stigma and HIV-related outcomes among MSM. Our search identified 5794 studies, of which 47 met the eligibility criteria and were included in the final analysis. The review suggests that stigma remains a formidable barrier to engaging in HIV prevention and treatment among both HIV-negative and HIV-positive MSM. Among the studies of HIV-positive MSM, internalized stigma was related to lower levels of treatment engagement. HIV-positive MSM in the Southern part of the US were also more likely to engage in risky sexual behavior. Perceived health care discrimination was negatively associated with PrEP awareness, particularly among HIV-negative Black MSM. Among young MSM of color, intersectional stigma compounded the social structural barriers to PrEP adherence. Findings indicate that stigma reduction interventions should be implemented in diverse MSM communities to address the disproportionate burden of HIV along with critical gap in the care continuum. Further research should examine how individual types of stigma, including intersectional stigma, affect viral suppression and PrEP uptake and adherence, especially among MSM of color. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s10461-021-03262-4.

Stigma is a social-psychological construct that manifests in a process by which individuals relegated to a particular social category are subjected to prejudice, discrimination, and unfair treatment because of this category [1, 2] . Stigma has been shown to relate to host of negative health outcomes [1, 2] . Thus, different domains of stigma have been studied to enhance health-related research and develop interventions that specifically target these domains. Enacted stigma refers to the actual experience of prejudice and discrimination that occurs due to one's social category (e.g., being the victim of a hate crime because one is gay) [3] . Anticipated stigma is the fear or expectation of being rejected due to, for example, one's social category (e.g., sexual identity, gender identity, race/ethnicity, or HIV serostatus) [4] . Perceived stigma refers to one's perception about how others might feel about them because they are part of stigmatized group [5] . Internalized stigma is the internalization of negative societal attitudes related to one's stigmatized identity, typically resulting in diminished self-worth [6] . Marginalized groups such as men who have sex with men (MSM) often contend with these various forms of stigma. Further, because they may also possess more than one minority status (e.g., Black, gay man), they may also experience intersectional stigma [7, 8] , which studies have begun to demonstrate negatively impact HIV-related outcomes among MSM [9] .

Understanding the impacts of stigma on HIV risk, prevention, and care among MSM warrants immediate attention, as empirical studies continue to show that MSM are disproportionately affected by HIV, despite advances in prevention and treatment [10] [11] [12] . In fact, in 2018, 1.1 million people in the US were living with HIV, with MSM accounting for approximately 69% of all the diagnosed HIV infections [13] . The burden that is concentrated among this population has been attributed to a combination of psychosocial factors contributing to syndemics among MSM [14] [15] [16] [17] [18] . For example, syndemic factors such as child abuse, substance use, depression, traumatic stress, as well as various forms of stigma interact to increase the vulnerability of these individuals and confer excess risk to HIV infection [15, 16, 19] . One of the suggested mechanisms is through minority stress pathway [20, 21] . In addition to concurrently acting as factors that amplifies the risks for HIV, stigma or marginalization associated with sexual identity, exploration, and race has also been known to act in an additive way through this path [17, 22] .

In the absence of a cure for HIV infection, HIV prevention methods and programs that use antiretroviral treatment (ART), also referred to as Treatment as Prevention (TasP) can control and prevent further spread of the virus to uninfected individuals [23] . However, efficacy and effectiveness of TasP can be greatly reduced in MSM who are often stigmatized due to concurrent discriminations acting in unison. Different types of stigma such as internalized stigma, HIV related stigma, stigma experienced in healthcare settings impacts prevention strategies and results in reduced accessibility and decreased quality of care [24, 25] . Thus, stigma may play a significant role in hampering HIV prevention efforts among the MSM population. It can discourage them from seeking information, prevent them from getting tested, seeking care or support, and hinder access to biomedical interventions such as TasP and PrEP [26] . This has resulted in significant challenges when conducing biobehavioral HIV surveillance studies as well as understanding of the social structural factors contributing to HIV risk. In order to strengthen efforts to characterize and to reduce stigma and discrimination and further improve health outcomes, an improved understanding of how stigma impacts HIV risk and access to prevention and care among MSM is needed. Studies have assessed stigma in different ways, some examine it by using a scale while others adopted a more qualitative or a mixed method approach [20, 27, 28] . This paper presents a critical scoping review by summarizing the largely fragmented literature on stigma among MSM in the United States as it pertains to risk of HIV infection, access to prevention, care and treatment services, and other health outcomes. The review is guided by the following research questions:

(1) How did the studies conceptualize and measure individual types of stigma as well as intersectional stigma? (2) How did different types of stigma affect HIV risks, in particular syndemic conditions? (3) What types of stigma negatively impact prevention (e.g., PrEP) and care continuum outcomes?

Our objectives were to summarize research on the associations between stigma and these different measures of HIV cascade by systematically reviewing peer-reviewed literature. In line with the broad coverage of our topic, a scoping review was chosen as the most appropriate methodology to inform the way research has been conducted [29] .

Original peer-reviewed articles published in English language journals from early 1980's to October 2019 were obtained from systematic searches of five electronic bibliographic databases: PubMed, CINAHL, Psych Info, Scopus, and Web Science. The search was implemented in November 2019. The search query consisted of terms such as stigma, discrimination, stereotype, gay, HIV, AIDS, MSM or other associated terms (supplementary file), and this was tailored to the specific requirements of each database. Grey literature, commentaries, or other document types such as reports, and essays were excluded since they were not peer reviewed. All identified articles from the searches were transferred to a bibliographic management system software program (EndNote, Rayyan). Duplicates were excluded by automatic duplication removal process in EndNote's default one step auto-deduplication process. The articles were further checked and then removed manually if they had not already been identified by the reference manager software. This was carried out independently by two reviewers (RAB, PW).

In order to be included in this scoping review, original peerreviewed articles had to meet three inclusion criteria. First, the study had to be conducted in the United States among the adult MSM population. This criterion was not limited to behavior only; we have included gay and bisexual men in this review. Second, the study had to examine at least one type of stigma and discrimination and have at least one HIV-related outcomes as the dependent variable (e.g., risk of HIV acquisition, HIV medication or treatment adherence, suppression of viral load, linkage to care, and HIV prevention measures such as HIV testing and PrEP use). Third, only peer-reviewed articles written in English that presented original quantitative, qualitative, or mixed methods research were considered. Studies were excluded if any of the above criteria were missing.

Applying the eligibility criteria, the two independent reviewers screened and assessed the articles using a twostep process. In the first step, the reviewers selected the articles based on title and abstract and in the second step they screened the full text of the articles that had been included in the first step. In circumstances where the title/abstract was deemed to not provide sufficient information, the full article was retrieved and examined before a final decision was made. All conflicts and disagreements generated through the screening stages between the two reviewers were discussed until consensus was reached. Furthermore, when needed, a third opinion from the senior author (CY) was consulted to reach unanimity. After the articles were selected, the following data was recorded in a spreadsheet for data extraction and charting: author(s), year, city/region, study purpose, study design (e.g., quantitative, qualitative, or mixed methods), exposure, outcomes measured, and key findings. To ensure accuracy, the same reviewers abstracted the data. We did not perform an assessment of the quality of included studies in align with the methodology of scoping reviews.

The initial literature search resulted in a total of 5,794 citations from the five electronic databases (PubMed: 1356, CINAHL: 921, Psych Info: 1346, Scopus: 392, and Web Science: 1779). After removing the duplicates, a total of 2,482 records were potentially eligible and were hence screened for title and abstract. Subsequent to this, a full text assessment of 217 articles were performed. The full-text screening led to 47 eligible articles relevant to our scoping review that were included in the final data extraction and further analysis. Figure 1 shows the flow chart of articles examined for this scoping review.

The results begin with an overall summary of the studies included in the scoping review and then describe the findings related to different types of stigma and its measurements, as well as its association with syndemic conditions, PrEP use, and the HIV care continuum.

The majority of studies were quantitative (n = 30) [20, 24, 28, with the remaining being qualitative studies (n = 16) [25, [57] [58] [59] [60] [61] [62] [63] [64] [65] [66] [67] [68] [69] [70] [71] . There was only one study that applied a mixed method study design [27] . Five studies spanned the larger geographical area of the United States, thereby including the 50 states [31, 36, 38, 39, 52] . Most frequently, the studies were conducted in New York City (n = 15) [27, 32, 33, 37, 40, 43, 47, 49, 51, 54, 59, 63, 66, 68, 70] , followed by Chicago (n = 6) [35, 37, 48, 57, 58, 69] , Los Angeles (n = 6) [25, 30, 34, 37, 51, 61] , Boston (n = 5) [20, 37, 46, 51, 56] , and San Francisco (n = 4) [27, 28, 37, 51] . Twenty-seven of the quantitative investigations were cross-sectional surveys [24, 28, 30, 31, [33] [34] [35] [36] [37] [38] [39] [40] [41] [43] [44] [45] [46] [47] [48] [49] [50] [51] [52] [53] [54] [55] [56] , and the remaining three were longitudinal studies [20, 32, 42] . Of the seventeen qualitative and mixed method studies [25, 27, [57] [58] [59] [60] [61] [62] [63] [64] [65] [66] [67] [68] [69] [70] [71] , seven were conducted using focus group discussions [25, 61-64, 67, 68] and the remaining were either in-depth or semi-structured interviews [27, 57-60, 65, 66, 69-71] . Approximately, 85% (n = 40) of all included studies were published in 2010 or later [20, 24, 25, 28, 30-43, 45-54, 56-62, 64, 65, 67, 70, 71] .

Fewer studies (n = 14) [20, 27, 30-35, 57-60, 70, 71] were conducted among HIV-positive MSM as compared to HIV-negative MSM (n = 33) [24, 25, 28, [61] [62] [63] [64] [65] [66] [67] [68] [69] . Only one quantitative [35] and three qualitative studies [58] [59] [60] focused exclusively on the effects of stigma among HIV-positive African American MSM. In contrast, one qualitative study [71] focused on HIV-negative Hispanic MSM, while three other studies were conducted on both Hispanic and Black MSM populations [30, 34, 70] . Furthermore, among HIV-negative Black MSM, five quantitative [43, 45, 48, 49, 51] and six qualitative [25, 61, 63, [67] [68] [69] studies were conducted, whereas one qualitative study [62] was among Hispanic MSM. Lastly, there was only one quantitative study [41] that included both Black and Hispanic MSM.

Both quantitative and qualitative studies of MSM living with HIV showed that internalized, perceived and experienced HIV stigma was associated with increased prevalence of HIV-transmission risk behaviors and poorer self-reported health [20, 27, 30-35, 57-60, 70, 71] (Table 1) . Among HIV-negative MSM, the most frequently measured stigma was experienced stigma due to sexual or racial prejudice [37, 38, 40, 41, 43, 48, 53, 55, 56] . Internalized and perceived stigma were less frequently assessed [24, 36, 39, 51] , as were structural and healthcare discrimination [42, 44, 45, 47] . These various forms of stigma and discrimination have been shown to be negatively associated with willingness and awareness to use PrEP and engage in HIV testing but positively associated with engagement in high-risk sexual behavior [24, 25, 28, [61] [62] [63] [64] [65] [66] [67] [68] [69] (Table 2) .

Of all the studies reviewed, the theory of intersectionality was explicitly investigated in just one qualitative study [71] . Individual, community and structural determinants among MSM was informed by intersectional stigma in this particular study, which included Hispanic MSM living with HIV. This qualitative study assessed the salient intersections of identities among participants and how their multiple identities shaped HIV testing and treatment experiences. Findings from this study demonstrated that Hispanic MSM who are HIV-positive may find it easier to disclose their sexual orientation to family, friends, and sexual partners than their HIV status, due to both internalized and perceived HIV stigma [71] . Intersecting identities are even discriminated against within gay communities, leading to more social isolation and lesser support. Even though not explicitly investigating intersectional stigma, one of the significant findings of this particular study among HIV negative MSM is worth mentioning. It reported the interaction between enacted stigma and healthcare discrimination resulting in increased substance use and thus resulting in more risky behaviors such as condom less sex [56] .

Of the literature available on the interaction of syndemic conditions, six studies examined the relationships between stigma and syndemic conditions [20, 32, 35, 40, 46, 62] . The greater likelihood of sexual risk behavior among MSM can be explained by higher co-occurrence of psychosocial health problems, resulting in increased HIV infection. In a study of HIV negative Hispanic MSM, it was reported that various sexual behaviors and health and social conditions (sexual risk, substance abuse, and violence), which were compounded by heath disparities and social inequalities, increased their risk of HIV exposure [62] . This phenomenon is further intensified among African Americans, where co-occurring conditions like racism, HIV stigma, and substance use increase their risk of infection by acting as a barrier for PrEP adherence [46] . This was supplemented by another study, that reported substance abuse and mental health distress as consequences of sexual orientation-based discrimination, resulting in higher observed sexual risk [40] . Among HIV positive MSM, the stress associated with HIV stigma was one of the fundamental hypothesized and examined syndemic relationships that was considered to drive the HIV epidemic [20, 35] . This was strengthened by findings from a longitudinal study that reported that, internalized HIV stigma along with sexual minority stressor was significantly related with adverse mental health, which ultimately led to an increased risk of transmission [32] .

Among HIV negative MSM, there were a total of 11 studies that assessed the association between stigma and PrEP awareness and use [24, 25, 45, 48, 50, 52, 61, [63] [64] [65] [66] . In particular among Black and Hispanic MSM, perceived intolerance against someone with HIV resulted in the knowledge, awareness, and intention to take PrEP among them as being low. This was due to the cultural norms of belonging to a particular race, resulting in reduced visibility and availability of services [24, 50, 65] . In addition, among Black MSM, perceived health-care discrimination as result of race and sexual orientation led to negative awareness about PrEP, thereby, restricting information. However, disclosure of same-sex behavior to healthcare providers (HCP) was positively related to PrEP awareness [45] . Among trans-MSM, although knowledge about PrEP was high, its use was nevertheless low, due to internalized stigma as a result of sexual orientation [52] . Moreover, merely being cognizant about PrEP is not sufficient, its usage is increased if you know other PrEP users or individuals with recent infections in your network, thereby, bridging the gap between them [48] . Besides, major barriers have been noted pertaining to this high-risk population. As compared to young MSM (YMSM, ages [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] [28] [29] , the awareness about PrEP was lower in older MSM [45] . In YMSM, the perception of HIV related stigma was identified as a formidable barrier to HIV testing [64] .

In addition to this, among YMSM of color, other factors that contributed to not getting tested was unfriendly environment at the testing centers attributable to one's race and lack of support within community [25, 63] . Moreover, lack of knowledge among both MSM and some HCP as they are not comfortable in prescribing PrEP, low awareness about testing, and the psychological impact that the fear of a positive test result might also act as a barrier to HIV prevention measures [61, 66] . Among MSM with HIV, a total of eight studies addressed relationship between stigma and care continuum. Specifically, among older Black MSM in the South or elsewhere, medical care settings that are considered to be a safety net, were themselves a source of stigmatization [58] [59] [60] . The ability to manage their illness was impeded if individuals were structurally marginalized by the healthcare organizations. This was predominantly due to lower linkage to care, retention in care, adherence to antiretroviral therapy (ART), and inability to achieve viral suppression. Consequently, individuals usually weaken the care continuum by either missing the stages completely or by exiting the continuum altogether for a period of time. As a result, they revert back to an earlier stage in the HIV treatment cascade due to the fear of stigma and discrimination associated with HIV diagnosis. Since YMSM of color are disproportionately affected by HIV [35, 70] , various domains of HIV stigma act differently in relation to care continuum outcomes, for example, internalized HIV stigma was negatively associated with viral load suppression [35] whereas perceived HIV stigma was a deterrent to engagement in care [70] . However, another form of HIV related stigma, disclosure of HIV status, was not found to be associated with either viral load suppression or medication adherence [35] . Depression was found to mediate the association between enacted and anticipated HIV related stigma and adherence to medications, but not between perceived HIV stigma and sexual risk behaviors [20, 31] . As compared to Hispanics, the persistence of discrimination due to race was higher specifically among Blacks, leading to an exacerbation of AIDS-related symptoms [30] .

The purpose of this review was to examine different types of stigma and how they affect HIV prevention, care, and treatment services among MSM in the United States. As evidenced by this review, HIV vulnerability generated through structural inequalities among MSM is fueled by social stigma and discrimination that influences their behaviors and health outcomes. Thus, the interplay between multiple stigmatized identities can severely intensify the negative detrimental health effects among MSM. Several important factors stood out during this review. First, since the advent of HAART is considered one of the historic achievements, we chose to examine this larger time frame within the context of stigma. While the treatment has definitely improved the prognosis for HIV positive individuals, we wanted to understand whether there were any studies concerning stigma and HIV risks or syndemic conditions in the pre-treatment era. However, we did not find any studies that had been conducted in this regard. Second, the other significant gap that were reported in the literature was the lack of research among YMSM of color. These individuals experience disparities across the HIV care continuum and it has further been demonstrated that stigma impacts the willingness to use PrEP among YMSM regardless of where they live in the US [72] . Perceptions about PrEP use were challenged and determined by societal stigmas such as racism, homophobia, healthcare access along with individual factors such as age and employment. Thus, the disparities in HIV incidence among men of color are further increased due to their inability to discuss PrEP with a healthcare provider and lack of health coverage [73, 74] . As already established in the literature, knowledge about PrEP is directly related to its use and therefore the campaign by CDC about PrEP is very crucial, especially, within the non-White communities. However, while education raises awareness and improve knowledge, it is often not the primary factor in changing behavior. Structural interventions such as increasing access to PrEP and decreasing stigma associated with PrEP uptake/use is far more crucial by decreasing provider-patient stigma, increasing access to easy and free PrEP, and ensuring that those on PrEP are able to stay on PrEP. Therefore, to increase the PrEP care continuum among MSM, multilevel interventions, increased dialogue concerning sexuality and visibility with social groups and community groups are needed. Third, Southern states have reported disproportionate number of new infections among MSM, however, few studies conducted in this region were focused on stigma. This is surprising, since it has already been established that transmission of HIV is mainly dependent on individual sexual networks and social conditions such as poverty, prejudice, and inequality. Studies have shown that within African American MSM communities, sexual networks are mostly closed and interconnected due to racism such that, if HIV is introduced, it is more likely to be transmitted to a large proportion of other African Americans than to outside groups [75] [76] [77] . Our review also revealed that none of these studies included MSM in rural areas, where stigma may be higher than urban areas [78] . In addition, the scant number of studies that have been carried out specifically among Hispanics may not be generalizable because many were conducted using qualitative research methodology. Furthermore, due to a lack of longitudinal studies, our ability to account for temporal ordering; that is, that stigma led to the inability to access components of HIV prevention or treatment services is limited. As most of these quantitative studies were cross-sectional in nature, any associations that have been observed, cannot be considered causal. A mixed-method approach should be employed among this population where participant's experiences would be grounded in quantitative findings.

Fourth, empirical findings from this study emphasize the need for future research and intervention studies to better understand and address intersectional stigma. Intersectional stigma continues to be a barrier to the uptake of HIV testing and evidence-based prevention interventions. The need to address intersectional stigma has been corroborated by the fact that these already marginalized groups due to one stigma are yet further stigmatized by membership in another stigmatized group based on their serostatus thus further exacerbating negative health outcomes. There is very limited research that has been conducted to understand and analyze intersectional stigma that may drive HIV vulnerability among MSM. Furthermore, interventions designed to address intersectional stigma in order to improve HIV prevention outcomes are notably absent from the literature. There is an urgent need to integrate an intersectionality lens by addressing the multi-level factors that frequently play a role in the experiences of marginalized populations. Science-based dissemination of measurement of intersectional stigma, along with HIV prevention and treatment strategies, would be crucial in mitigating this type of stigma. Future studies should focus more on the intricate co-existence and interactions between different types of stigma and concurrent health conditions. Finally, the impact of syndemics among MSM on the increased risk for HIV infection have been clearly established as seen in the studies above. While prior work has established the deleterious impact on mental health, stigma not only increases their risk of infection but also has an additive impact on poor antiretroviral uptake, lower medication adherence and viral suppression [19, 79] . Thus, these synergistically acting syndemic factors should not be treated in isolation and instead they should be regularly screened for and treated as an essential step in HIV care continuum. Hence, applying a holistically integrated approach to HIV care among MSM is suggested.

There are several limitations to our scoping review. The scope of the review was restricted to only English peer reviewed based articles, thereby introducing a potential bias by not accounting for relevant studies that would have been published in other languages. We noted the individual study designs as described in the literature, however, as is typical for scoping reviews, we did not intend to assess the quality of the information analyzed. Thus, the conclusions of this review are based on the existence of studies rather than their quality. Due to the limited number of studies, our study was not able to measure the strength of association between one particular type of stigma and one type of HIV outcome. By conducting a scoping review, we intended to answer broader research questions. Our hope is that findings from our review will provide a blueprint for future research on this important topic such as conducing meta-analyses to answer more nuanced and specific research questions while the literature continues to grow. Furthermore, this review provides a comprehensive overview of the existing research on stigma and its associated health outcomes suggesting that research attention to stigma is a field with more attention among MSM in the United States.

Therefore, to address the health disparities among this highly stigmatized populations, an ideal combination of stigma reduction interventions along with TasP would be required. Moreover, interventions will have to be tailored to be culturally specific, suitable, and appropriate to address the critical gap in the care continuum in this population. Finally, existing laws, programs and policies should be evaluated, and evidence-based intervention and policy changes should be made.

Although significant progress has been made in the field of HIV/AIDS, the greatest public health challenge in the fight against the HIV epidemic may still be stigma and discrimination. It is essential to disentangle the stigma associated with risk of acquisition of HIV and prevention efforts. MSM often hold multiple intersecting identities, and the stigma and discrimination they face related to these identities, can impact their health outcomes. Stigmatizing beliefs can severely influence an individual's decision to seek care and act as a barrier to testing, numerous intervention programs, healthcare access, and treatment adherence. This can lead to severe public health ramifications. There is an urgent need to bridge the gap in programmatic knowledge regarding stigma and the vulnerable risk categories. The integration of different measures of stigma approaches along with psychological and social supports should be incorporated into the national HIV response.

The online version contains supplementary material available at https:// doi. org/ 10. 1007/ s10461-021-03262-4.

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The authors acknowledge the helpful guidance of Yingting Zhang, a research services librarian at the Robert Wood Johnson Library of the Health Sciences for her guidance during the implementation of the search.Author contributions CY and RAB conceived the paper and developed the search strategy. RAB drafted the manuscript. RAB implemented the search strategy, led the title, abstract, full-text review and data abstraction processes of this article. PW contributed to the title, abstract, and full-text reviews and the data abstraction. All authors (RAB, PW, EJA, HR, CY) critically revised and approved the final version of manuscript.

The authors declare that they have no conflict of interest.