Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA.
Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA.
BMC Health Serv Res. 2022 Sep 20;22(1):1179. doi: 10.1186/s12913-022-08572-4.
Complex manifestation of stigma across personal, community, and structural levels and their effect on HIV outcomes are less understood than effects in isolation. Yet, multilevel approaches that jointly assesses HIV criminalization and personal sexual behavior stigma in relation to HIV testing have not been widely employed or have only focused on specific subpopulations. The current study assesses the association of three types of MSM-related sexual behavior-related stigma (family, healthcare, general social stigma) measured at both individual and site levels and the presence/absence of laws criminalizing HIV transmission with HIV testing behaviors to inform HIV surveillance and prevention efforts among HIV-negative MSM in a holistic and integrated way.
We included nine National HIV Behavioral Surveillance (NHBS) 2017 sites: Baltimore, MD; Denver, CO; Detroit, MI; Houston, TX; Long Island/Nassau-Suffolk, NY; Los Angeles, CA; Portland, OR; San Diego, CA; and Virginia Beach and Norfolk, VA. Multivariable generalized hierarchical linear modeling was used to examine how sexual behavior stigmas (stigma from family, anticipated healthcare stigma, general social stigma) measured at the individual and site levels and state HIV criminalization legislation (no, HIV-specific, or sentence-enhancement laws) were associated with past-year HIV testing behaviors across sites (n = 3,278).
The majority of MSM across sites were tested for HIV in the past two years (n = 2,909, 95.4%) with the average number of times tested ranging from 1.79 (SD = 3.11) in Portland, OR to 4.95 (SD = 4.35) in Los Angeles, CA. In unadjusted models, there was a significant positive relationship between stigma from family and being tested for HIV in the past two years. Site-level HIV-specific criminalization laws were associated with an approximate 5% reduction in the prevalence of receiving any HIV test in the past two years after individual level stigma and sociodemographic covariate adjustments (PR = 0.94, 95% CI, 0.90-0.99).
Structural barriers faced by MSM persist and ending the HIV epidemic in the US requires a supportive legal environment to ensure effective engagement in HIV services among MSM. Home-based solutions, such as self-testing, used to deliver HIV testing may be particularly important in punitive settings while legal change is advocated for on the community and state levels.
个人、社区和结构层面上复杂的污名表现及其对 HIV 结果的影响，不如单独的影响那么容易理解。然而，综合评估 HIV 刑事定罪和个人性传播感染相关污名的多层次方法，尚未得到广泛应用，或者仅关注特定的亚人群。本研究评估了在个人和地点层面上测量的三种与男男性行为相关的性行为相关污名（家庭、医疗保健、一般社会污名），以及存在/不存在将 HIV 传播定罪为犯罪的法律与 HIV 阴性男男性行为者的 HIV 检测行为之间的关联，以便以整体和综合的方式为 HIV 监测和预防工作提供信息。
我们纳入了 9 个 2017 年全国 HIV 行为监测（NHBS）地点：马里兰州巴尔的摩、科罗拉多州丹佛、密歇根州底特律、德克萨斯州休斯顿、纽约长岛/拿骚-萨福克、加利福尼亚州洛杉矶、俄勒冈州波特兰、加利福尼亚州圣地亚哥以及弗吉尼亚海滩和诺福克。使用多变量广义分层线性模型，研究了个体和地点层面上的性传播感染相关污名（来自家庭的污名、预期的医疗保健污名、一般社会污名）以及州 HIV 刑事定罪立法（无、HIV 特异性、或加重刑罚的法律）与过去两年的 HIV 检测行为之间的关系，共纳入 3278 名参与者。
大多数参与者在过去两年中接受了 HIV 检测（n=2909，95.4%），其中在俄勒冈州波特兰接受的检测次数最多（n=2909，平均次数为 1.79[SD=3.11]），而在加利福尼亚州洛杉矶接受的检测次数最多（n=2909，平均次数为 4.95[SD=4.35]）。在未调整的模型中，来自家庭的污名与过去两年接受 HIV 检测之间存在显著的正相关关系。在个体层面上的污名和社会人口统计学协变量调整后，地点层面上的 HIV 特异性刑事定罪法律与过去两年中接受任何 HIV 检测的比例降低了约 5%（PR=0.94，95%CI，0.90-0.99）。
男男性行为者面临的结构性障碍仍然存在，要想在美国终结 HIV 流行，就需要一个支持性的法律环境，以确保男男性行为者有效参与 HIV 服务。家庭为基础的解决方案，如自我检测，可能在惩罚性环境中特别重要，而在社区和州层面上则应倡导法律变革。
