Abstract
HIV/AIDS stigma continues to be a challenge for HIV prevention and treatment. When health professionals manifest stigma it can limit access to quality treatment. With an ever-growing epidemic among Latinos, including Puerto Ricans living on the Caribbean Island, the social and structural factors that foster HIV/AIDS stigma need to be understood. In this study, we documented the association of religion with HIV/AIDS stigma in a sample of medical students in Puerto Rico. Findings suggest that importance placed on religion, and participation in religious activities, is associated with HIV/AIDS stigma for this population.
HIV/AIDS continues to impact Latino communities disproportionately and increasingly, with more than 200 000 cases. 1,2 Puerto Ricans share this burden with more than 32 000 (1% of the population) cases infected with HIV. 3
HIV/AIDS stigma among Puerto Ricans with HIV 4 is mirrored among health professionals on the island 5,6 negatively impacting persons living with HIV/AIDS (PLWHA) access to treatment and lowering the quality of physician–patient interactions. 7 –9 The PLWHA in Puerto Rico avoid treatment and self-medicate when faced with stigma in health care settings. 4
Social stigma researchers, including those who address HIV/AIDS stigma, have stressed the need to understand the social and structural factors that foster stigmatization in order to develop informed stigma reduction strategies. 10,11 This recommendation stems from the limitation of exploring stigma as an interpersonal phenomenon, without understanding the cultural underpinnings that shape and foster it. Preliminary findings with health professionals in Puerto Rico have pointed to the role of religion as an important cultural factor that fosters HIV/AIDS stigma. 12 Our study aimed to document the role of religion in HIV/AIDS stigma among medical students in Puerto Rico.
Method
The sample was 507 medical students recruited from the 4 largest medical schools in Puerto Rico (see Table 1). Participants were taken from the baseline measurement of a longitudinal efficacy trial of a stigma reduction intervention. Participants completed a self-administered quantitative questionnaire that included the Spanish HIV/AIDS Stigma Scale (SHASS). 13 The SHASS is a validated, culturally appropriate scale previously developed in Puerto Rico which measures the following dimensions of Puerto Rican HIV/AIDS stigma: (1) restriction of PLWHA’s rights, (2) PLWHA obliged to reveal status, (3) responsibility of PLWHA for their HIV infection, (4) lack of productivity of PLWHA, (5) personal characteristics of PLWHA, (6) fear of infection, (7) emotions associated with HIV/AIDS, (8) closeness to death, (9) need to control PLWHA, (10) PLWHA as vectors of infection, and (11) body signs of HIV/AIDS. Religious importance and participation were assessed using 4-point Likert scale items (see Table 1).
Demographic Data.
Abbreviation: PLWHA, persons living with HIV/AIDS.
Initial multivariate regression analyses tested whether mean levels of HIV/AIDS stigma were equal across the 3 categories of religious importance and participation other than “none.” Unadjusted and adjusted multivariate regressions of the 11 stigma dimensions onto the religion items were then performed. Adjusted analyses added age in years, whether the participant knew someone with HIV/AIDS, and whether the participant had received medical school course work on HIV/AIDS. Our previous work had found important sex differences in HIV/AIDS stigma among Puerto Rico medical students, so all analyses were stratified by sex. The Mplus multivariate analysis program (Muthén and Muthén, Los Angeles, California) was used for all inferential analyses.
Results
Demographic characteristics are shown in Table 1. The sample was predominantly heterosexual, single, and young (mean age, 25 years; median, 25 years, standard deviation, 2.18 years; range 21-39 years). No significant HIV/AIDS stigma differences were found between importance and participation categories (all P values > .05) for participants reporting any degree of religious importance or participation, so subsequent analyses collapsed religious importance into any importance versus none and any participation versus none, respectively. Multivariate regression analyses showed important effects for both the sexes; participation was a less consistent correlate of stigma (Table 2). For religious importance, obligation to reveal serostatus, death associations, PLWHA rights, fear of infection, and PLWHA’s infection responsibility were significant correlates for men; for women significant correlates included PLWHA as vectors of infection, personal characteristics of PLWHA, control over PLWHA, rights of PLWHA, fear of infection, and PLWHA’s infection responsibility (Table 2).
Multivariate Regressions of HIV-Stigma Dimensions on Religion Importance and Participation.a
Abbreviations: CI, confidence interval; PLWHA, persons living with HIV/AIDS; χ 2 , chi-squared test.
a B, unstandardized regression coefficient; 95% CI, asymptotic 95 percent confidence interval for B. P, probability value for null hypothesis test that coefficient is zero, except for the first row for each sex, which reports the global Wald chi-square test that all 11 coefficients are jointly zero. Adjusted analyses controlled for age in years, whether the participant knew anyone infected with HIV/AIDS, and whether the participant had received medical education on HIV/AIDS via medical school coursework. Coefficients, confidence intervals, test statistics, and P values were computed using full information maximum-likelihood in Mplus 6 with robust standard errors and test statistics (Mplus estimator MLR).
Discussion
Religious importance is significantly associated with some overlapping and several unique facets of HIV/AIDS stigma for men and women. Though our conclusions are limited by cross-sectional data, nonprobability sampling, and the inclusion of only 2 broad measures of religious importance and participation, the substantial number of male and female participants and multiple dimensions of culturally relevant stigma dimensions allowed examination of specific religion–stigma dimension relationships by sex. Our findings should be further explored in prospective longitudinal studies to further inform HIV/AIDS stigma reduction interventions with the ultimate goal of improving medical service delivery and doctor–patient communication in Puerto Rico and other high-HIV/AIDS stigma regions.
Footnotes
Authors’ Note
The content is solely the responsibility of the authors and does not necessarily represent the official views of NIMH or the National Institutes of Health.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: the National Institute of Mental Health (NIMH; 1R01MH080694-01).