Discrimination against people with HIV/AIDS

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Discrimination against people with HIV/AIDS or serophobia is the prejudice, fear, rejection, and stigmatization of people afflicted with HIV/AIDS (PLHIV; people living with HIV/AIDS). Marginalized, at-risk groups such as members of the LGBTQ+ community, intravenous drug users, and sex workers are most vulnerable to facing HIV/AIDS discrimination. The consequences of societal stigma against PLHIV are quite severe, as HIV/AIDS discrimination actively hinders access to HIV/AIDS screening and care around the world.[1] Moreover, these negative stigmas become used against members of the LGBTQ+ community in the form of stereotypes held by physicians.[2]

HIV/AIDS discrimination takes many forms such as blood donation restrictions on at-risk populations, compulsory HIV testing without prior consent, violations of confidentiality within healthcare settings, and targeted violence against persons living with HIV. Although disability laws within many countries prohibit HIV/AIDS discrimination in housing, employment, and access to health/social services, HIV-positive individuals around the world still experience instances of stigma and abuse.[3] Overall, pervasive HIV/AIDS discrimination leads to low turn-out for HIV counseling and testing, identity crises, isolation, loneliness, low self-esteem, and a lack of interest in containing the disease.[4] Additionally, violent acts against HIV infected individuals or people who are perceived to be infected with HIV can severely shut down the advancement of treatment in response to the progression of the disease.[5]

HIV-related stigma[edit]

Stigma is often enforced by discrimination, callous actions, and bigotry. HIV/AIDS stigma is divided into the following three categories:

  • Instrumental AIDS stigma—a reflection of the fear and apprehension that are likely to be associated with any deadly and transmissible illness.[6]
  • Symbolic AIDS stigma—the use of HIV/AIDS to express attitudes toward the social groups or lifestyles perceived to be associated with the disease.[6]
  • Courtesy AIDS stigma—stigmatization of people connected to the issue of HIV/AIDS or HIV- positive people.[4]

HIV-related stigma is very common worldwide.[7][8] People who are infected with HIV often experience systemic discrimination and ostracism within their communities.[9] In both high-income and low-income nations, persons living with HIV are routinely discriminated against at work, school, and healthcare facilities.[10] In conjunction with internal distress, these construed beliefs make it more difficult for PLHIV to feel comfortable in obtaining the medical services they need.[11]

Misconceptions about HIV in the United States[edit]

Today, there continues to be significant misconceptions about HIV within the United States. Furthermore, misconceptions about the transmission of HIV promotes fear amongst many members of society, and this often translates into biased and discriminatory actions against PLHIV.[12]

A 2009 study conducted by the Kaiser Family Foundation found that many Americans still lack basic knowledge about HIV.[13] According to the survey, a third of Americans erroneously believe that HIV could be transmitted through sharing a drink or touching a toilet used by an HIV-positive individual.[13] Furthermore, the study reported that 42 percent of Americans would be uncomfortable with having an HIV-positive roommate, 23 percent would be uncomfortable with an HIV-positive coworker, 50 percent would be uncomfortable with an HIV-positive person preparing their food, and 35 percent would be uncomfortable with their child having an HIV-positive teacher.[13] Many of the respondents who were able to correctly answer questions about HIV transmission still reported similar biased views against HIV-positive individuals; in fact, 85 percent of these respondents reported that they would feel uncomfortable working with an HIV-positive coworker.[13]

Misconceptions about transmission of HIV[edit]

The only way that HIV can be transmitted from one individual to the next is by sharing of certain bodily fluids such as semen, blood, and vaginal discharge which the virus uses as a medium to enter the bloodstream of the recipient; HIV is not transmissible via fluids such as saliva, sweat, tears, or urine as it is not in high enough concentrations to spread in these matters.[14] In order for HIV to enter another person, either the semen, blood, or vaginal discharge must find an entry point by way of injection, unprotected sex, or during pregnancy as the mother can pass it along; one would only contract the virus when coming in direct contact with these fluids, for example, with an open cut on the skin that exposes blood.[14]

PLHIV do not always pass on the virus to someone else when engaging in sexual activities or sharing bodily fluids; PLHIV can have no transmission risk by taking medication which lowers the amount of HIV present in the bloodstream, rendering the individual as having an undetectable viral load.[15][16] PrEP (Pre-exposure prophylaxis), on the other hand, is a drug that is used as a preventative measure against HIV for those who are at a higher risk of contracting the virus but does not cure someone who has HIV; furthermore, the medication should be taken regularly in order to have a higher protective chance against HIV and is not a one-time medication nor does it treat PLHIV.[17]

People cannot contract AIDS, rather they are infected with HIV which progresses into AIDS over time when left unchecked; if someone has HIV, it does not guarantee that they will develop AIDS. By frequently taking medication such as antiretroviral therapy (ART), the abundance of HIV in the bloodstream is reduced and prevents it from developing into AIDS.[18]

Misconceptions about at-risk populations[edit]

Many people incorrectly believe that HIV is exclusive to gay men who have sex, but, although the risks are higher for gay and bisexual males, anyone is susceptible to contracting the virus regardless of their sexual orientation, race, age, and so forth.[19] Some forms of violence such as childhood trauma, rape, and sexual assault can lead people to engage in unsafe sexual practices which would increase their chances of contracting HIV.[20] In some cases, young girls and women who experience these traumatic events become sex workers or engage in prostitution which further increases these risks as well as contributes to the development of AIDS with lack of treatment.[20]

These discriminatory views of HIV-positive patients also persist within the medical field. A 2006 study of health professionals in Los Angeles County found that 56 percent of nursing facilities, 47 percent of obstetricians, and 26 percent of plastic surgeons had unlawfully refused to treat an HIV-positive patient, citing concerns of HIV transmission.[21] Overall, this societal stigma and discrimination has exacerbated distrust towards healthcare workers within the HIV-positive population.[21] The health care community therefore has an ethical duty to dispel stereotypes and misconceptions about HIV.[22]

Blood donation restrictions on at-risk populations[edit]

Between 1970 and 1980, more than 20,000 HIV infections were attributed to contaminated blood transfusions.[23] The lack of sensitive blood screening methods for HIV detection prompted the enactment of lifetime bans on blood donations from men who have sex with men (MSM), sex workers, and intravenous drug users, as these population groups were viewed to be at high risk of contracting HIV.[23] At the time, this policy was viewed by health professionals as an emergency measure to prevent the contamination of the general blood supply. Multilateral institutions such as the World Health Organization actively promoted the enactment of lifetime bans in efforts to mitigate transfusion-related HIV infections.[23] This ban was adopted by the United States, as well as several European countries in the 1980s.[23]

The blood donation ban on MSM and transgender women, in particular, has provoked substantial criticism. Members of the LGBTQ+ community view these laws as discriminatory and homophobic.[24] A significant criticism of the blood donation restrictions is that healthcare workers treat the LGBTQ+ community as a homogenous population that engages in similar sexual practices and behaviors.[24] However, like any other population, MSM vary greatly in the number of sexual partners they have and in their engagement in high-risk sexual behaviors.[24] Overall, the donation ban on MSM and transgender women has further exacerbated growing distrust of the medical system within the LGBTQ+ community, especially given the history of homophobia within the medical profession.[23] As a result of these policies, LGBTQ+ individuals have felt substantial pressure to conceal their sexual orientation from medical providers and healthcare personnel.[23]

Blood banks today utilize advanced serological testing technologies with close to 100% sensitivity and specificity.[23] Currently, the risk of HIV-contaminated blood infection is 1 per 8-to-12 million donations, thus demonstrating the effectiveness of modern HIV screening technologies.[23] Despite these significant laboratory advances, the lifetime blood donation ban on MSM remains in several Western countries.[23] Today, medical organizations such as the American Red Cross and World Health Organization are highly critical of these lifetime bans on men who have sex with men, as the epidemiology of HIV has changed drastically in the last 40 years.[25] In 2015, a mere 27% of novel HIV infections originated from the MSM population.[23] In response to this epidemiological data, public health experts, medical personnel, and blood-banking organizations have called upon country governments to reform these outdated MSM blood donation policies.[25]

Mounting public pressure has prompted countries such as the United States and United Kingdom to reform their MSM blood donation restrictions.[25] In 2015, the United States substituted its lifetime ban for a 12-month deferral since last MSM sexual contact, although indefinite lifetime bans remain in place for sex workers and IV drug users.[26] Despite these small steps in the right direction, the American Red Cross has recommended that the Food and Drug Administration (FDA) further revise its policy by adopting a 3-month deferral period for MSM, as this is the current standard in countries such as Canada and the United Kingdom.[27] Overall, it is estimated that completely lifting the MSM blood donation ban could increase the total blood supply in the United States by 2-4%, which could help save millions of lives.[28] Given the blood supply shortage during the COVID-19 pandemic, blood donation restrictions have recently become the subject of further criticism.[29]

Discriminatory practices in health-care settings[edit]

Discriminatory practices within the medical field have greatly impacted the health outcomes of HIV-positive individuals.[30] In both low-income and high-income nations, there have been several reported cases of medical providers administering low-quality care or denying care altogether to patients with HIV.[30] In a 2013 study conducted in Thailand, 40.9 percent of health workers reported worrying about touching the clothing and personal belongings of patients with HIV, despite possessing the knowledge that HIV does not spread through such items.[30] In a 2008 study of 90 countries, one in four persons living with HIV reported experiencing some form of discrimination in health-care settings.[30] Furthermore, one in five individuals with HIV reported having been denied medical care.[30] Even more concerning is the impact HIV-related discrimination has had on HIV-positive women. According to the 2008 study, one in three women living with HIV have reported instances of discrimination related to their sexual and reproductive health within a health-care setting.[30]

Another common form of discrimination within healthcare settings is the disclosure of a patient's HIV status without the patient's explicit permission.[30] Within many countries, an HIV-positive status can result in social exclusion, loss of social support, and decreased chances of getting married.[31] Therefore, concerns about potential breaches of confidentiality by health workers pose significant barriers to care for HIV-positive individuals. In a comprehensive study of 31 countries, one in five persons living with HIV reported instances of a health provider disclosing their HIV-positive status without consent.[30]

These discriminatory practices within the medical field have resulted in the delayed initiation of HIV treatment among HIV-positive individuals.[31] In New York City, men who have sex with men, transgender women, and persons of color living with HIV have all reported that stigma among medical providers was a major deterrent from entering or staying in HIV care.[30] A 2011 community-based study found that the most widely reported barrier to care amongst HIV-positive individuals is fear of stigma within healthcare settings.[31] HIV-positive individuals who have experienced significant HIV-related stigma are 2.4 times less likely to present for HIV care.[30] Currently, as many as 20–40 percent of Americans who are HIV-positive do not begin a care regimen within the first six months of diagnosis.[32] Overall, this perpetuation of HIV stigma has been detrimental to the health outcomes of HIV-positive individuals, as patients who begin treatment late in the progression of HIV have a 1.94 times greater risk of mortality in comparison to those who start treatment at the onset of diagnosis.[33] Therefore, delayed HIV treatment due to fears of discrimination can have fatal consequences.[33]

Violence against persons living with HIV[edit]

Discrimination that is violent or threatening violence stops a lot of individuals from getting tested for HIV, which does not aid in curing the virus. Violence is an important factor against the treatment of people afflicted with AIDS. When PLHIV, particularly women, develop an intimate relationship, they tend not to be able to disclose to their partners of the presence of HIV in their system for fear of violence against them; this fear prevents them from receiving financial support to seek out testing, treatment, and general support from medical professionals & family members.[5] A study done on PLHIV in South Africa shows that out of a study population of 500, 16.1% of participants reported being physically assaulted, with 57.7% of those resulting from one's intimate partners such as husbands and wives. The available data show high rates of participants socially isolating themselves from both friends and family, in addition to avoiding the seeking of treatment at hospitals or clinics due to increasing internalized fears.[34]

Psychological impact of HIV discrimination[edit]

Persons living with HIV have developed self-depreciating mindsets and coping skills to deal with the social repercussions of an HIV-positive diagnosis. A common concern of PLHIV is the belief that they will automatically develop AIDS and not be able to live a long, productive life as others around them. While there is no cure for HIV/AIDS, ART and other medication prevent the virus from worsening and spreading which allows for PLHIV to live longer and still establish a life or family with people.[35] Albeit, not every PLHIV is knowledgeable about these resources which can lead them to adopt a depressive state of mind by associating their condition with early death.[36] In some cases, ART can reduce feelings of anxiety in individuals while induce other symptoms that worsen the mental health of some PLHIV and should be taken as directed by a physician; likewise, taking ART with other prescriptions might exacerbate these mental health conditions.[36]

Negative social consequences such as stigmatization and discrimination have severe psychological implications on PLHIV: when a person chooses to disclose their status, it can lead to restricted options for marriage and even employment. This tends to worsen the mental health of these individuals and often results in a fear of disclosure.[37]

Research done in South Africa has found that the high levels of stigma experienced by HIV-positive individuals has a severe psychological impact. Internalized stigma and discrimination run rampant throughout the PLHIV community, as many PLHIV in South Africa blamed themselves for their current situation.[38] The psychological support for PLHIV in certain countries around the world is quite scarce.

A study examining the impact of stigma on PLHIV concluded that experiencing higher levels of HIV discrimination is correlated with a depressive state and even receiving psychiatric care the previous year. Depressive symptoms have also been correlated with elevated rates of suicidal ideation, anxiety and disease progression.[39] Another recent study that predominantly focused on HIV-positive African American men concluded that stigma has a profound impact on reducing the quality of life of these individuals.[40]

Studies have also shown that individuals living in non-metropolitan areas of the United States also experience large amounts of emotional distress. 60% of participants enrolled in a randomized clinical trial reported moderate or severe levels of depressive symptomatology on the Beck Depression Inventory. This is due to these participants receiving much less social support, and also due to great levels of HIV-related stigma and rejection within families.[39] Furthermore, relative to their urban counterparts, PLHIV in non-metropolitan areas experience more loneliness, a lack of sufficient healthcare and social services, and higher levels of discrimination which contribute to much greater levels of emotional distress.[39]

HIV/AIDS health disparities in marginalized groups[edit]

The U.S. HIV epidemic has drastically evolved over the course of the last 30 years and has been rampantly widespread in socially marginalized and underrepresented communities. Statistics show that most HIV infections afflict sexual minorities and communities of color. For example, in 2009, African Americans accounted for 44% of all new HIV infections while making up only 14% of the U.S. population.[41] Similarly, 78% of HIV infections in Georgia occur among African Americans, while African Americans comprise only 30% of the overall population.[41] Hall et al. (2008) found distinct incidence rates of HIV infection among African Americans (83/100,000 population) and Latinos (29/100,000), specifically when compared to whites (11/100,000).[41]

The single group that is consistently at the greatest risk for HIV infection happens to form the intersection of sexual orientation and racial background; MSM (men who have sex with men) are the most HIV affected Americans, and African American MSM are at an HIV risk that is six times greater than that of white MSM.[41] Aside from race and sexual orientation, socioeconomic status, education and employment are all equally important factors that studies link to HIV infection. The CDC reports that HIV rates are highest among groups who are at or below the poverty level; they also found that individuals who are unemployed and/or have less than a high school education are more prone to HIV infection.[41]

In order to help HIV infected persons receive care, the first vital step revolves around HIV testing and early diagnosis. Delayed testing is highly detrimental and leads to an increased risk of HIV transmission. Currently, there are many issues associated with HIV diagnosis and lack of available testing for minorities. A study of 16 US cities found that African Americans are more likely to be tested much later for HIV infection, which places this group at a stark disadvantage for gaining access to proper treatment.[42] This is problematic because HIV is only half of the story: a prolonged HIV infection can quickly become an AIDS diagnosis, and this can be prevented with early and frequent testing. Approximately 35%-45% of those diagnosed with HIV are believed to also have AIDS at the time of testing.[42] About half of the people diagnosed with HIV do not receive care in any given year, which poses a risk that they are endangering others while they are not given treatment.[42] Various studies suggest that groups with lower socioeconomic status and lower education level are associated with poorer medication adherence.[43] However, those with HIV who are more privileged and more educated have easy access to quality health insurance and the best medical care.

See also[edit]

References[edit]

  1. ^ Mahajan, Anish P.; Sayles, Jennifer N.; Patel, Vishal A.; Remien, Robert H.; Ortiz, Daniel; Szekeres, Greg; Coates, Thomas J. (August 2008). "Stigma in the HIV/AIDS epidemic: A review of the literature and recommendations for the way forward". AIDS (London, England). 22 (Suppl 2): S67–S79. doi:10.1097/01.aids.0000327438.13291.62. ISSN 0269-9370. PMC 2835402. PMID 18641472.
  2. ^ Morris, Matthew; Cooper, Robert Lyle; Ramesh, Aramandla; Tabatabai, Mohammad; Arcury, Thomas A.; Shinn, Marybeth; Im, Wansoo; Juarez, Paul; Matthews-Juarez, Patricia (2019-08-30). "Training to reduce LGBTQ-related bias among medical, nursing, and dental students and providers: a systematic review". BMC Medical Education. 19 (1): 325. doi:10.1186/s12909-019-1727-3. ISSN 1472-6920. PMC 6716913. PMID 31470837.
  3. ^ "Civil Rights". HIV.gov. 2017-11-10. Retrieved 2018-04-10.
  4. ^ Parker, Richard; Aggleton, Peter (2003-07-01). "HIV and AIDS-related stigma and discrimination: a conceptual framework and implications for action". Social Science & Medicine. 57 (1): 13–24. doi:10.1016/S0277-9536(02)00304-0. ISSN 0277-9536. PMID 12753813.
  5. ^ a b "Violence Against Women and HIV/AIDS: Critical Intersections. Intimate Partner Violence and HIV/AIDS" (PDF). World Health Organization. 2004.
  6. ^ a b Herek, G.M. (1999). "AIDS and stigma in the United States. [Special issue]". American Behavioral Scientist. 42 (7).
  7. ^ Yokota, Fumihiko; VanLandingham, Mark J. (2013), "Gender Differences in Stigma and Community Support Among People Living with HIV/AIDS in Thailand", Stigma, Discrimination and Living with HIV/AIDS, Springer Netherlands, pp. 399–415, doi:10.1007/978-94-007-6324-1_23, ISBN 978-94-007-6323-4
  8. ^ Mohseni Tabrizi, Alireza; Hekmatpour, Peyman (2016-06-01). "HIV/AIDS Related Stigma in Iran: A Qualitative Study". IAU International Journal of Social Sciences. 6 (2): 13–19. ISSN 2228-7221.
  9. ^ Wyrod, Robert (2013), "Gender and AIDS Stigma", Stigma, Discrimination and Living with HIV/AIDS, Springer Netherlands, pp. 39–51, doi:10.1007/978-94-007-6324-1_3, ISBN 978-94-007-6323-4
  10. ^ Cameron, Sally; Jane Wilson, Julian Hows, Rodrigo Pascal, Jaime Todd-Gher, Liz Tremlett, Ann Stevens, and John Godwin. "People Living with HIV Stigma Index; Asia Pacific Regional Analysis 2011."(1–99). Joint United Nations Program, 2011.
  11. ^ Mirza, Shabab Ahmed; Rooney, Caitlin (2018-01-18). "Discrimination Prevents LGBTQ People From Accessing Health Care". Center for American Progress. Retrieved 2020-06-21.
  12. ^ Waite, Katherine R.; Paasche-Orlow, Michael; Rintamaki, Lance S.; Davis, Terry C.; Wolf, Michael S. (2008-06-19). "Literacy, Social Stigma, and HIV Medication Adherence". Journal of General Internal Medicine. 23 (9): 1367–72. doi:10.1007/s11606-008-0662-5. ISSN 1525-1497. PMC 2518013. PMID 18563494.
  13. ^ a b c d Apr 01, Published; 2009 (2009-04-02). "2009 Survey of Americans on HIV/AIDS: Summary of Findings on the Domestic Epidemic". The Henry J. Kaiser Family Foundation. Retrieved 2020-04-27.CS1 maint: numeric names: authors list (link)
  14. ^ a b "HIV Transmission | HIV Basics | HIV/AIDS | CDC". www.cdc.gov. 2019-09-25. Retrieved 2020-06-30.
  15. ^ "Undetectable Viral Load and HIV Transmission Risk". Healthline. Retrieved 2020-06-23.
  16. ^ "HIV Treatment as Prevention | HIV Risk and Prevention | HIV/AIDS | CDC". www.cdc.gov. 2020-04-06. Retrieved 2020-06-30.
  17. ^ "PrEP | HIV Basics | HIV/AIDS | CDC". www.cdc.gov. 2020-06-04. Retrieved 2020-06-23.
  18. ^ June 05, Content Source: HIV govDate last updated; 2020 (2020-06-05). "Symptoms of HIV". HIV.gov. Retrieved 2020-06-23.CS1 maint: numeric names: authors list (link)
  19. ^ May 15, Content Source: HIV govDate last updated; 2017 (2017-05-15). "Who Is at Risk for HIV?". HIV.gov. Retrieved 2020-06-30.CS1 maint: numeric names: authors list (link)
  20. ^ a b "WHO | Violence against women and HIV". WHO. Retrieved 2020-06-26.
  21. ^ a b Sears, Brad; Ho, Deborah (2006-12-01). "HIV Discrimination in Health Care Services in Los Angeles County: The Results of Three Testing Studies". UCLA: The Williams Institute: Other Recent Work.
  22. ^ Anderson, Bebe J. (2009-12-01). "HIV Stigma and Discrimination Persist, Even in Health Care". AMA Journal of Ethics. 11 (12): 998–1001. doi:10.1001/virtualmentor.2009.11.12.oped1-0912. ISSN 2376-6980. PMID 23207098.
  23. ^ a b c d e f g h i j Karamitros, Georgios; Kitsos, Nikolaos; Karamitrou, Ioanna (2017-06-08). "The ban on blood donation on men who have sex with men: time to rethink and reassess an outdated policy". The Pan African Medical Journal. 27: 99. doi:10.11604/pamj.2017.27.99.12891. ISSN 1937-8688. PMC 5554671. PMID 28819520.
  24. ^ a b c "Ban the Ban: An argument against the 12 month blood donation deferral for men who have sex with men". GLAAD. 2018-11-28. Retrieved 2020-04-06.
  25. ^ a b c Miyashita, Ayako (September 2014). "Effects of Lifting Blood Donation Bans on Men Who Have Sex with Men" (PDF).
  26. ^ Research, Center for Biologics Evaluation and (2019-04-11). "Revised Recommendations for Reducing the Risk of Human Immunodeficiency Virus Transmission by Blood and Blood Products - Questions and Answers". FDA.
  27. ^ "American Red Cross Statement on FDA MSM Deferral Policy". www.redcross.org. Retrieved 2020-04-06.
  28. ^ Miyashita, Ayako (2014). "Effects of Lifting Blood Donation Bans on Men who Have Sex with Men" (PDF). The Williams Institute.
  29. ^ "PAHO warns of potential blood shortages during the COVID-19 pandemic - PAHO/WHO | Pan American Health Organization". www.paho.org (in Spanish). Retrieved 2020-04-27.
  30. ^ a b c d e f g h i j "UNAIDS warns that HIV-related stigma and discrimination is preventing people from accessing HIV services". www.unaids.org. Retrieved 2020-05-13.
  31. ^ a b c Pollini, Robin A.; Estela Blanco; Carol Crump; Maria Zuniga (2011). "A community-based study of barriers to HIV care initiation". AIDS Patient Care and STDs. 601-09. 25 (10): 601–609. doi:10.1089/apc.2010.0390. PMC 3183651. PMID 21955175.
  32. ^ Mugavero, MJ (2008). "Improving engagement in HIV care: What can we do?". Top HIV Med. 16 (5): 156–161. PMID 19106431.
  33. ^ a b Panel on Antiretroviral Guidelines for Adults and Adolescents (October 14, 2011). "Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents". Department of Health and Human Services.
  34. ^ dos Santos, Monika ML; Kruger, Pieter; Mellors, Shaun E; Wolvaardt, Gustaaf; van der Ryst, Elna (2014-01-27). "An exploratory survey measuring stigma and discrimination experienced by people living with HIV/AIDS in South Africa: the People Living with HIV Stigma Index". BMC Public Health. 14 (1): 80. doi:10.1186/1471-2458-14-80. ISSN 1471-2458. PMC 3909177. PMID 24461042.
  35. ^ "HIV/AIDS". www.who.int. Retrieved 2020-06-23.
  36. ^ a b March 19, Content Source: HIV govDate last updated; 2020 (2020-03-19). "Mental Health". HIV.gov. Retrieved 2020-06-23.CS1 maint: numeric names: authors list (link)
  37. ^ "The Psychological Impact of HIV – AIDS 2020". Retrieved 2020-06-26.
  38. ^ Visser, Maretha J.; Makin, Jennifer D.; Vandormael, Alain; Sikkema, Kathleen J.; Forsyth, Brian W. C. (February 2009). "HIV/AIDS stigma in a South African community". AIDS Care. 21 (2): 197–206. doi:10.1080/09540120801932157. ISSN 0954-0121. PMC 4238924. PMID 19229689.
  39. ^ a b c Heckman, T. G.; Anderson, E. S.; Sikkema, K. J.; Kochman, A.; Kalichman, S. C.; Anderson, T. (2004). "APA PsycNet". Health Psychology. 23 (1): 94–100. doi:10.1037/0278-6133.23.1.94. PMID 14756608.
  40. ^ Buseh, Aaron G.; Kelber, Sheryl T.; Stevens, Patricia E.; Park, Chang Gi (2008). "Relationship of Symptoms, Perceived Health, and Stigma With Quality of Life Among Urban HIV-Infected African American Men". Public Health Nursing. 25 (5): 409–419. doi:10.1111/j.1525-1446.2008.00725.x. ISSN 1525-1446. PMID 18816358.
  41. ^ a b c d e Pellowski, Jennifer A.; Kalichman, Seth C.; Matthews, Karen A.; Adler, Nancy (2013). "A pandemic of the poor: social disadvantage and the U.S. HIV epidemic". The American Psychologist. 68 (4): 197–209. doi:10.1037/a0032694. ISSN 0003-066X. PMC 3700367. PMID 23688088.
  42. ^ a b c Gardner, Edward M.; McLees, Margaret P.; Steiner, John F.; del Rio, Carlos; Burman, William J. (2011-03-15). "The Spectrum of Engagement in HIV Care and its Relevance to Test-and-Treat Strategies for Prevention of HIV Infection". Clinical Infectious Diseases. 52 (6): 793–800. doi:10.1093/cid/ciq243. ISSN 1058-4838. PMC 3106261. PMID 21367734.
  43. ^ Kleeberger, C. A.; Phair, J. P.; Strathdee, S. A.; Detels, R.; Kingsley, L.; Jacobson, L. P. (2001-01-01). "Determinants of heterogeneous adherence to HIV-antiretroviral therapies in the Multicenter AIDS Cohort Study". Journal of Acquired Immune Deficiency Syndromes (1999). 26 (1): 82–92. doi:10.1097/00126334-200101010-00012. ISSN 1525-4135. PMID 11176272.