Challenging Dogma - Fall 2009

Thursday, May 20, 2010

Social Marketing and HIV Stigma: The Need of Community Help with Marginalized Populations – Nicolas Karr

In 2008, 33.4 million people had a positive HIV status (1). Through out the year, 2.7 million new infections joined the tally and 2 million left because of AIDS-related deaths (1). The infection devastates low-resource populations. Prevention programs intervene to help these populations and provide the resources that could change the tide of infection. Unfortunately, while HIV/AIDS prevention programs provide the tools to fight infection, the populations do not necessarily change their behaviors. Content-rich interventions fall short when the target community does not use the resources.
In a summary analysis and critique of 21 interventions to reduce HIV/AIDS stigma, Brown, Trujillo, and Macintyre stated that HIV/AIDS stigma “undermines public health efforts to combat the epidemic” (2). They found that stigma affects the magnitude of reactions to epidemics and causes violence against infected people (2). Populations affected by stigma might fear societal attitudes and could deny their risk of infection. This denial could lead to inaction and ignoring risk factors; inaction could manifest as not using condoms, not testing for HIV, and not disclosing HIV status (2). Stigma can trigger actions to avoid a loss of a job, health benefits, or social ostracism (2). These actions on the part of the stigmatized could cause harm to themselves and the surrounding population. Acting in fear, marginalized populations experiencing HIV/AIDS stigma could endanger their relationship networks.
Stigma has prevailed throughout generations as an impediment to public health. When confronting disease, stigma causes negative views and reduces access to care. Stigma embeds itself within a population and breeds a culture of fear. In order to reduce infections in high-risk populations, interventions need to address stigma. In a meta-analysis of twenty-four studies, occurring between 2000 and 2007, of people living with HIV/AIDS in North America, Logie and Gadalla found that marginalized populations experienced higher stigma levels (3). Specifically, the researchers found stigma highly associated with low social support, poor physical health, poor mental health, lower income, and younger age (3). Consequently, according to Herek and Capitanio, who looked at behaviors towards people living with HIV/AIDS, stigma causes reduced access to care due to discrimination through violence and exclusion (4).
Marginalized populations endure the most stigma and these misunderstandings lead to low resources, poor funding, and inconsistent interventions and treatments. In order to help these populations the current interventions need to make changes. This paper focuses on three specific sub-populations at high-risk for HIV/AIDS and stigma: young black men, female substance abusers, and young men who have sex with men (MSM). The first section presents critiques on interventions targeted at each group and the second section provides ideas for improvements upon the current interventions. To stop the spread of HIV/AIDS, health interventions need to reach the high-risk, marginalized populations; interventions need to mitigate stigma to facilitate proper care.
Young Black Men: Bearing the Brunt of New Infections
According to the Centers for Disease Control and Prevention (CDC), African-Americans make-up 13% of the U.S. population, but account for 50% of all new HIV/AIDS cases, demonstrating a highly prevalent, yet underserved population (5). Along with high prevalence among the entire population, African-American men continue to acquire more infections than their female counterparts (5). HIV/AIDS prevention programs tend to show effectiveness in controlled settings, but the transfer to the real world has less than promising results.
When developing improvements for a current intervention to target young black men, O’Donnell et al. found that interventions have too many requirements and attrition sets in(6). This issue arises specifically with stigmatized populations who choose to avoid over exposure in HIV/AIDS programs. Dworkin, Pinto, Hunter, Rapkin, & Remien found that research tested the efficacy of prevention programs, but failed to design programs acceptable, affordable, sustainable, and adaptable to the population (7). HIV/AIDS has greatly affected young black men, but interventions have failed to address this issue. In order to reach the population O’Donnell et al. stressed the importance of tailoring the intervention for population penetration (6). The prevention programs fail to address barriers to care; HIVS/AIDS stigma limits accessibility to care and the interventions fail to reach the high-risk population.
O’Donnell et al. noted that a significant level of HIV/AIDS stigma develops from internalized and externalized homophobia (6). This stigma leads young black men to test late or avoid testing at all (6). O’Donnell et al. found that African-American females would seek medical care while young black males, more commonly, self-treat (6). This could explain why interventions fail to reach young black males, due to the medical services involved with HIV/AIDS testing. In addition, issues of stigma related to medical services inhibit access to care. Stigma of medical services among the population interacts with HIV/AIDS stigma and makes seeking care significantly less likely.
In order to overcome these obstacles, interventions need to address these issues of avoiding care. If evaluations of these prevention programs only focus on the efficacy in controlled settings, they fail to deal with issues of adaptability. The population at risk avoids medical services and HIV/AIDS care because of stigma. Until the interventions acknowledge this stigma surrounding the access to care, the programs cannot effectively reach those at high risk for infection.
HIV/AIDS interventions have many flaws, but simple changes in approach can lead to greater success. Evaluations of prevention programs need to address the dynamics within each high-risk population. Without adjustments to target different contexts, interventions cannot reach the populations. As stipulated, population penetration remains an important factor in all HIV/AIDS interventions (6); interventions must change to understand their population or fail in trying to reach them.
Female Substance Abusers: Inequality and Instability
HIV infection might come directly from sharing needles, but injecting and non-injecting drug use has developed as a risk factor for risky sexual behavior, a risk factor for HIV/AIDS. Among female substance abusers, risks for violence and HIV increase. Due to gender-specific inequality and violence, female substance abusers need interventions tailored to their issues.
Interventions of the past failed to address the gender-based issues of substance abusers. Wechsberg found, through a survey of past and present HIV/AIDS interventions for women, that past interventions did not account for low status in the culture and community, low education levels, and high rates of unemployment among female substance abusers (8). These factors significantly stigmatized the population. The interventions never reached the people because they could not access medical services. Beyond low access to health care caused by these factors, the high unemployment rates led the women to sell sex (8). The factors that increased stigma also increased the likelihood of acquiring HIV/AIDS.
With the increased stigma surrounding female substance abusers, the difficulty in reaching them increases. Wechsberg noted that failed interventions did not provide knowledge and personal enhancement training specifically targeted to changing behaviors (8). These behavior specific interventions could change behaviors when issues such as substance abuse, violence, and sexual risk arise (8). Culturally specific interventions targeted at females could improve the success of the programs. Unfortunately, the failed interventions did not acknowledge cultural specificity. The women find themselves without any power to act. The interventions fail to reach women who cannot make the decisions themselves or fear losing social support.
Interventions have low compliance to condom use because the programs ignored community context. In the case of sex worker interventions, Evans and Lambert, through an ethnographical study of HIV/AIDS community interventions, found that their noncompliance stemmed from lack of control over their work and social conditions (9). If prevention programs cannot change the dynamics within high-risk populations, distributing condoms makes no difference.
Evans and Lambert also observed that government policy and bureaucrats often disrupt interventions (9). Interventions unable to adapt to changing political tides must confront possible failure; police raids due to changing political temperaments could easily ruin months or years of community-building (9). Prevention programs must adjust to the changing political, cultural atmosphere in order to succeed.
The dependence the women have on the men controlling their lives continues to impede interventions. Failure to address gender inequality means more unsuccessful prevention programs. In order to aid female substance abusers, interventions need to provide ways to increase access to care. The women need to have feelings of safety and support if they choose to seek medical services. Without stability, predominant stigma and fear prevents access to care.
Young MSM: New Generations Facing Decade Old Problem
Stigma has been an impediment to care for all people living with HIV/AIDS. Among men though, internalized and externalized homophobia has led to fear of negative social consequences (10, 11). Valdiserri noted in his review of HIV/AIDS stigma literature that internalized homophobia led to lower self-esteem and consequently, a reduced sense of self-protection (10). This lack of self-protection leads to higher risk sexual behaviors and increased susceptibility to infection (10). These factors impede public health interventions that provide tools for safer sex, but ignore the inaction by participants.
The stigma surrounding young MSM and HIV/AIDS interact and result in negative self-feelings. According to Valdiserri, young MSM experiencing self-doubt seek validation through multiple partners (10). The environments where these encounters occur also facilitate alcohol and drug use and reduced inhibitions to practicing unsafe sex (9). Interventions fail to address young MSM dealing with negative self-feelings. Prevention programs do not work if the participants assimilate information, but make different choices in the heat of the moment.
Dowshen, Binns, and Garofalo studied the effects of HIV/AIDS stigma on four psychosocial measures among MSM. The measurements included depression, self-esteem, loneliness, and social support (11). They found some correlations between perceived stigma level and psychosocial measures, but due to a small sample size, could not declare significance (11). Among their study participants though, they found a correlation between perceived levels of stigma and discovery of a positive HIV status; both of these measures highest at the beginning and reducing with time (11).
Current interventions targeted at young MSM fail to change behaviors because they do not acknowledge how MSM incorporate stigma into their decisions (10). From sexuality to gender identity to HIV/AIDS, these young men deal with multiple levels of stigma (10). Until current interventions address how MSM deal with all levels of stigma, the ability to change behaviors significantly drops.
Prevention programs fail when they ignore the needs of the population. Many programs plan interventions based on best practice protocol. In the case of people living with HIV/AIDS, the programs focus on distributing prevention tools and education. The ethnographical research of Evans and Lambert found that different dynamics influence the decisions individuals make (9). These dynamics include context, practice, agency, and power (9). The researchers found that intervention evaluations review content and the relationship to the results (9). This traditional critique leads evaluations to base success on effectiveness of distributing project resources; grading the efficacy of interventions based on the number of condoms distributed or the prevention classes taught does not demonstrate the true intervention results.
Many problems dealing with population dynamics develop from transferring intervention models from one context to another. Evans and Lambert found that evaluations of efficacy for HIV/AIDS interventions lead to best practice protocols that ignore the context and dynamics of populations (9). Best practice guidelines fail to account for distinct circumstances of marginalized populations (9).

A New Design: Ideas for Change in HIV/AIDS Interventions
Stigma involves many different issues and they affect all facets of an intervention. However, interventions that deal with stigma can change the behaviors of high-risk populations. Valdiserri states that HIV/AIDS interventions need to empower people about health issues, mobilize communities to solve the health problem, develop policies and plans in support of individual and community health, and conduct research to find innovative solutions to health problems (10). By accomplishing these health services public health can mitigate the effects of stigma and effectively reach populations (10).
Behavioral theory remains an important part of affecting change among HIV/AIDS populations. Interventions that focused only on distributing resources to combat infection need to adjust for population-level behavioral dynamics. In a review of the AIDS Community Demonstration Projects, Yzer, Fishbein, and Hennessy found that behavioral theory plays an important role in designing HIV interventions; theory identifies thoughts and feelings that can determine behaviors (12). The researchers also determined that evaluations of interventions need to measure effects of behavior change associated with the variables the intervention modified (12); evaluations should look at how the intervention changes behaviors based on the targeted variables. This way the evaluation determines how the methods of intervention truly affected the population (12).
In their ethnographic study of community HIV/AIDS interventions, Evans and Lambert found that success developed from peer education, community mobilization, and structural interventions (9). These key points emphasize the importance of involving the target community in the intervention. Community involvement ensures individual empowerment and this leads to behavior changes. Brown, Trujillo, and Macintyre note that many of the successful interventions in developing countries utilized community-based approaches opposed to the individual level approaches employed in the U.S. (2). They speculated that the use of community-based approaches reflects an understanding that confronting stigma involves both collective and individual level action (2).
With these factors in mind, new HIV/AIDS interventions should utilize social marketing campaigns within high-risk communities to find opinion leaders and start programs for peer education, community involvement in promoting prevention techniques, and individual enhancement to mitigate HIV/AIDS stigma. An important focal point involves finding respected community leaders to lessen the fear of stigma. With proper influential leaders among the intervention, the programs can more effectively reach the target population. In the following sections, this paper focuses on specific techniques for intervening with young black men, female substance abusers, and young MSM.
Lessening the Burden of Young Black Men
In developing a new HIV intervention for young black men, O’Donnell et al. found that successful interventions must overcome barriers to disseminating information (6). The researchers also stated that the failure of medical services remains the inability to link young black men with needed medical services (6). Available resources do not translate to effective interventions.
O’Donnell et al. stresses the importance of a community review of program components before implementation of the intervention (6). This step makes sure the community understands the intervention approach and, more importantly, the design fits with community dynamics. The next step in a successful intervention includes social marketing. O’Donnell et al. used the community meetings to identify potential spokespersons that have influence (6). Along with recognizing leaders in the community, the discussions identified people young black men would listen too. The discussions determined peers had the greatest impact (6). Utilizing opinion leaders helped get young black men to seek medical services, but the next step involves reducing the requirements of the screening test. If the men find the screening test invasive, time-consuming, or overly demanding they might avoid testing (6). O’Donnell et al. noted the value of using context-pertinent learning models. The intervention utilized computer-based modules that the men found interesting and engaging. The learning module incorporated videos, games, and an overarching storyline that kept the interest of participants (6). Lastly, O’Donnell et al. stressed the importance of developing individual risk reduction plans. This allotted for population dynamics and allowed the men to voice their concerns (6).
Overall, the intervention proposed by O’Donnell et al. focuses on the effects of social marketing. Without the social marketing element, the men would never reach the screening test, learning module, or individual risk reduction plan. Most importantly, the social marketing approach involved the community. The community discussed each approach and component and aided in the successful implementation of the program.
Providing Stability and Equal Footing for Female Substance Abusers
In situations where a person living with HIV/AIDS has dependency issues, interventions fail to change behaviors. This problem stems from a persons’ inability to give up control, but interventions focus on their unwillingness to change. Resources do not aid those who need stability to utilize prevention methods. HIV/AIDS interventions focusing on female substance abusers need to incorporate personal enhancement programs into their prevention methods.
Commercial sex work, violence, and substance abuse usually intersect and complicate the issue of HIV/AIDS infections. Wechsberg found that interventions incorporating knowledge enhancement and hands-on skills training strategies could change behaviors in this population (8). The intervention needs to focus on empowering the woman to make assertive decisions.
Sex facilitates a main conduit for infection and improved condom use could come from enhanced negotiation skills (8). The women of this marginalized population tend to deal with inequality issues. This inequality leads to contexts with high risk of infection. Wechsberg notes that the ability to empower and enhance negotiation skills increases the likelihood of assertiveness with sex partners (8). The disparate contexts these women live in causes dependency and lack of power. In order for prevention resources to find use, the women need a feeling of stability. Effective enhancement and empowerment interventions could overcome the treatment barriers.
Utilizing community support in these situations could prove difficult. If the women do not have a network connecting them, peer influence might have little effect. With the right approach, communities could develop for these women. Sometimes, the health workers need to think creatively to piece together a network or community. If possible, this social support could improve the chances of behavior change after empowerment and enhancement training strategies.
A New Solution for Young MSM
The stigma surrounding MSM develops from both HIV/AIDS and sexuality. The issues intertwine and result in added fear of negative social consequences. In order to address MSM, interventions need to mitigate the stigma surrounding both HIV/AIDS and sexuality. Valdiserri noted that young MSM might avoid clinicians because of fear of judgment (9). If public health officials expect at-risk men to screen for HIV, they must account for worries of social ostracism. Brown, Trujillo, and Macintyre state that information, counseling, coping skills acquisition, and contact demonstrated effectiveness in interventions (2). The researchers also found that different approaches to coping skills acquisition occurred in several interventions and each showed effectiveness in the specific population (2). This point demonstrates the importance of tailoring the intervention to the community. The prevention program must work with the community to reach the target population.
Brown, Trujillo, and Macintyre present a different concept for interventions: contact. This method involves combating stigma through inducing empathy for people living with HIV/AIDS (2). They saw positive results associated with the contact method, but overall the method failed to provide lasting reductions in stigma overall (2). However, a community-based approach provides a means of utilizing contact (2). The influence of opinion leaders in a community and the use of community discussions on interventions could lead to changing attitudes towards infected people.
As with the other high-risk populations, interventions need to employ the power of the community and social networks. The community can help develop effective programs that target the at-risk populations. In order to affect a difficult to reach group the intervention needs to utilize the community to adapt to the group dynamics. No individual health official understands the community as well as the members.

Conclusion and Discussion
While many factors affect the behaviors of at-risk populations, perceived levels of stigma can predict possible behavior change. The presence of stigma has negative effects on public health interventions and leads people living with HIV/AIDS to avoid health services. Sivaram et al., when looking at social capital and HIV stigma in consideration for HIV/AIDS prevention intervention design, stated that stigma manifests from “social norms that render an attribute or condition inferior or inappropriate” (13). These social norms lead to reactions of fear and perceived threat (13). Under this perceived threat, people living with HIV/AIDS find difficulty in seeking health and medical services.
Beyond perceived threat, Sivaram et al. found situations where clinicians refused care to infected people (13). When an example such as this happens, stigma finds a new hold among the population. Trepidation can cause victims of stigma to avoid health and medical services. This not only makes intervention efforts ineffectual, but also creates a high risk dynamic. Stigma leads people to develop negative self-feelings and these feelings lead people to seek validation. Engaging in high-risk behaviors because of feelings of low self-worth not only puts the individual in danger, but the rest of the population. Sivaram et al. speculates that individuals hesitate to engage in prevention and care-seeking behaviors because they anticipate discrimination and possible violence (13).
HIV/AIDS interventions need to focus on community-level approaches. Most importantly, interventions should involve the community in the development of prevention programs. In this way, the program can identify key community members and opinion leaders. These influential leaders can help adapt the intervention to the group dynamics. Outside of opinion leaders, the community can help develop proper implementation methods for the intervention. Community members understand how the population digests information and ideas; their ideas can help the intervention penetrate the population (6). Key to intervention success, social marketing helps open the door for prevention programs. Without social marketing, the key components of a successful intervention cannot find their audience.
In summary, interventions need to utilize opinion leaders, peer education, enhancement training, and prevention techniques to change behaviors in people living with HIV/AIDS. These techniques help to mitigate stigma among the population and surrounding community. The interventions must involve the community every step of the way to reduce fear of exposure. Stigma exemplifies a real fear of people living with HIV/AIDS and a true deterrent to successful interventions. Prevention programs can reach marginalized populations if confronting stigma becomes a focal point of HIV/AIDS intervention.
1. UNAIDS. (2009). AIDS Epidemic Update 2009. UNAIDS.
2. Brown, L., Trujillo, L., & Macintyre, K. (2008). Interventions to Reduce HIV/AIDS Stigma: What Have We Learned? Horizons Program Tulane University.
3. Logie, C., & Gadalla, T. (2009). Meta-analysis of health and demographic correlates of stigma towards people living with HIV. AIDS Care, 21(6), 742-753.
4. Herek, G.M., & Capitanio, J.P. (1999). AIDS stigma and sexual prejudice. American Behavioral Scientist, 42(7), 1130 – 1147.
5. Centers for Disease Control and Prevention. (2008). HIV/AIDS Surveillance Report, 2006. Atlanta, GA: U.S. Department of Health and Human Services.
6. O'Donnell, L., Bonaparte, B., Joseph, H., Agronick, G., Leow, D., Myint-U, A., et al. (2009). Keep It Up: Development Of A Community-Based Health Screening And HIV Prevention Strategy For Reaching Young African American Men. AIDS Education & Prevention, 21(4), 299-313.
7. Dworkin, S., Pinto, R., Hunter, J., Rapkin, B., & Remien, R. (2008). Keeping the Spirit of Community Partnerships Alive in the Scale Up of HIV/AIDS Prevention: Critical Reflections on the Roll Out of DEBI (Diffusion of Effective Behavioral Interventions). American Journal of Community Psychology, 42(1/2), 51-59.
8. Wechsberg, W. (2009). Adapting HIV Interventions For Women Substance Abusers In Internationalsettings: Lessons For The Future. Journal of Drug Issues, 39(1), 237-243.
9. Evans, C., & Lambert, H. (2008). Implementing community interventions for HIV prevention: Insights from project ethnography. Social Science & Medicine, 66(2), 467-478.
10. Valdiserri, R.O. (2002). HIV/AIDS Stigma: An Impediment to Public Health. American Journal of Public Health, 92(3), 341-342.
11. Dowshen, N., Binns, H., & Garofalo, R. (2009). Experiences of HIV-Related Stigma Among Young Men Who Have Sex with Men. AIDS Patient Care & STDs, 23(5), 371-376.
12. Yzer, M., Fishbein, M., & Hennessy, M. (2008). HIV interventions affect behavior indirectly: results from the AIDS Community Demonstration Projects. AIDS Care, 20(4), 456-461.
13. Sivaram, S., Zelaya, C., Srikrishnan, A., Latkin, C., Go, V., Solomon, S., et al. (2009). Associations Between Social Capital And HIV Stigma In Chennai, India: Considerations For Prevention Intervention Design. Aids Education & Prevention, 21(3), 233-250.

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