Poor HIV-related Knowledge, Perceived Risks and Attitudes Among Urban-dwelling Malaysian Older Adults: Key Barriers to Zero HIV Transmission by 2030.

Globally and in Malaysia, there are increasing rates of HIV infection among older adults but a corresponding decline in other younger age groups. We aimed to investigate the HIV-related knowledge, perceived risks, attitudes, and risk behaviours among multi-ethnic urban-dwelling older adults in Malaysia. A cross-sectional, questionnaire-based study was conducted among 320 adults aged 50 years and above residing in urban Klang Valley, Malaysia. Participants were recruited via convenience sampling in the community and in the outpatient clinics and pharmacy of University Malaya Medical Centre, Malaysia, from April 2021 to January 2022. The median (IQR) age of participants was 58 (55-64) and 42.5% were males. The median (IQR) knowledge score was 10 (8-12) out of 14. Significant knowledge gaps were noted and ethnic Chinese, higher education levels and better HIV-related attitudes were associated with better scores. The median (IQR) attitude score was 49 (41-55) out of 65. Ethnic Chinese and Indian, knowing people living with HIV (PLHIV), and better HIV-related knowledge were associated with better attitude scores. Many (43.8%) older adults were sexually active however rates of consistent condom use was low (19%) and the majority (89.9%) of participants had low self-perceived risk of HIV. These findings highlight underlying drivers for HIV transmission and delayed treatment among older adults in Malaysia and indicate a need for targeted HIV prevention programs for this population.

HIV Activist Identity, Commitment, and Orientation Scale (HAICOS): Psychometric Evaluation to Assess Clinician's Propensity Towards HIV Activism in Malaysia.

HIV activism has a long history of advancing HIV treatment and is critical in dismantling HIV-related stigma. This study evaluated the psychometric quality of the HIV Activist Identity, Commitment, and Orientation Scale (HAICOS) to assess clinicians' propensity towards HIV activism in Malaysia. From November 2022 to March 2023, 74 general practitioners and primary care physicians in Malaysia participated in the study. The exploratory factor analysis (EFA) extracted an internally consistent three-factor solution with 13 items: (1) HIV activist identity and commitment, orientation towards (2) day-to-day, and (3) structural activism. The Cronbach's alpha value was 0.91, and intra-class correlation coefficient for test-retest reliability was 0.86. Stigma-related (prejudice and discrimination intent) and clinical practice (comfort in performing clinical tasks with key populations and knowledge about HIV pre-exposure prophylaxis) measures supported the construct validity of the scale. The study provided concise, structurally valid, and reliable measures to evaluate HIV activism among clinicians.

RESUMEN: El activismo del VIH tiene una larga historia de avanzar el tratamiento del VIH y es crítico para desmantelar el estigma relacionado al VIH. Este estudio evaluó la calidad psicométrica de la Escala de Identidad, Compromiso y Orientación de Activistas del VIH (HAICOS) para evaluar la propensión de los médicos hacia el activismo del VIH en Malasia. Desde noviembre del 2022 hasta marzo del 2023, 74 médicos generales y de atención primaria en Malasia participaron en este estudio. El análisis factorial exploratorio (AFE) extrajo una solución de tres factores internamente consistente con 13 ítems: (1) identidad y compromiso del activismo del VIH; orientación hacia (2) el activismo cotidiano y (3) el activismo estructural. El valor alfa de Cronbach fue de 0.91 y el coeficiente de correlación intraclase para la confiabilidad prueba-reprueba fue de 0.86. Las medidas relacionadas con el estigma (prejuicio e intención de discriminación) y la práctica clínica (comodidad realizando tareas clínicas con poblaciones claves y conocimiento sobre la profilaxis pre-exposición del VIH) respaldaron la validez de constructo de la escala. El estudio proporcionó medidas concisas, estructuralmente válidas y confiables para evaluar el activismo de VIH entre los médicos.

"I want the doctors to know that I am as bright as a candle": : Experiences with and Hopes for Doctor Interactions Among Malaysian Key Populations and People Living with HIV.

Stigma in healthcare settings is a pernicious barrier to HIV prevention and treatment in contexts with strong HIV-related structural stigma. Previous work has documented substantial stigma towards key populations and people living with HIV (PLWH) among Malaysian doctors. The perspectives of Malaysian key populations and PLWH, however, remain understudied. In 2021, 34 Malaysian participants representing key populations and PLWH engaged in a photovoice study designed to qualitatively explore their experiences with and hopes for doctor interactions. Many participants reported stigma from their doctors, perceiving that doctors view them as not normal, sinful, misguided, and incapable. Several emphasized that they wear figurative masks to conceal aspects of themselves from doctors. Yet, many also remain hopeful for constructive relationships with doctors. They want their doctors to know that they are bright, capable, kind, and valuable. Interventions are needed to address stigma among doctors working in contexts with strong structural stigma.

RESUMEN: El estigma en los ambientes de atención médica es una barrera perniciosa en la prevención y el tratamiento del VIH. Investigaciones anteriores han documentado un estigma sustancial hacia los grupos de población clave y las personas que viven con el VIH (PLWH por sus siglas en inglés) entre los médicos de Malasia. Sin embargo, las perspectivas de los grupos de población clave y las PLWH en Malasia siguen sin estudiarse. En 2021, 34 participantes que representaban los grupos de población clave y PLWH en Malasia participaron en un estudio de fotovoz diseñado para explorar cualitativamente sus experiencias y esperanzas en las interacciones con los médicos. Muchos participantes describieron el estigma de sus médicos, percibiendo que los médicos los ven como no normales, pecaminosos, equivocados e incapaces. Varios enfatizaron que usan máscaras figurativas para ocultar aspectos de ellos mismos a los médicos. Sin embargo, muchos también mantienen la esperanza de tener relaciones constructivas con los médicos. Quieren que sus médicos sepan que son inteligentes, capaces, amables y valiosos. Se necesitan intervenciones para abordar el estigma estructural entre los médicos que trabajan en la prevención y el tratamiento del VIH.

Acceptability and Feasibility of Online, Asynchronous Photovoice with Key Populations and People Living with HIV.

Photovoice is an action-oriented qualitative method involving photography and story-telling. Although photovoice yields a powerful form of data that can be leveraged for research, intervention, and advocacy, it has arguably been underutilized within HIV research. Online, asynchronous photovoice methods represent a promising alternative to traditional in-person methods, yet their acceptability and feasibility with key populations and people living with HIV (PLWH) have yet to be explored. The current study describes the methods and evaluation of an online, asynchronous photovoice project conducted with 34 members of key populations and PLWH in Malaysia in 2021. A HIPAA-compliant website incorporating a series of instructional videos was created to facilitate participant engagement and data collection. Quantitative and qualitative indicators suggest that participants found the project to be highly acceptable and feasible. Online, asynchronous photovoice methods hold potential for increasing the scale of this powerful and versatile qualitative research method with key populations and PLWH.

RESUMEN: La fotovoz es un método cualitativo orientado a la acción que usa fotografía y narración de historias. Aunque la fotovoz produce una poderosa forma de datos que se puede utilizar para la investigación, la intervención y la promoción, podría decirse que ha sido poca aplicada en la investigación del VIH. Los métodos de fotovoz asincrónicos en línea representan una alternativa prometedora a los métodos en persona tradicionales, pero aún no se ha explorado su aceptabilidad y viabilidad con los grupos de población clave y las personas que viven con el VIH (PLWH por sus siglas en inglés). El estudio actual describe los métodos y la evaluación de un proyecto de fotovoz asincrónico en línea realizado con 34 miembros de grupos de población clave y PLWH en Malasia en 2021. Se creó un sitio web compatible con HIPAA que incorpora una serie de videos instructivos para facilitar la participación y la recopilación de datos. Los indicadores cuantitativos y cualitativos sugieren que los participantes encontraron el proyecto altamente aceptable y realizable. La fotovoz asincrónica en línea es un poderoso y versátil método cualitativo de investigación la cual tiene potencial para usarse más con los grupos de población clave y PLWH.

Religiosity and Stigmatization Related to Mental Illness Among African Americans and Black Immigrants: Cross-Sectional Observational Study and Moderation Analysis.

ABSTRACT: Stigma about mental illness is a known barrier to engagement in mental health services. We conducted an online cross-sectional study, aiming to estimate the associations between religiosity and mental illness stigma among Black adults ( n = 269, ages 18-65 years) in the United States. After adjusting for demographic factors (age, education, and ethnicity), respondents with higher attendance at religious services or greater engagement in religious activities ( e.g. , prayer, meditation, or Bible study) reported greater proximity to people living with mental health problems (rate ratio [RR], 1.72; 95% confidence interval [CI], 1.14-2.59 and RR, 1.82; 95% CI, 1.18-2.79, respectively). Despite reporting greater past or current social proximity, respondents with higher religiosity indices also reported greater future intended stigmatizing behavior (or lower future intended social proximity) (RR, 0.92-0.98). Focusing specifically on future intended stigmatizing behavior and the respondent's level of religiosity, age, and ethnicity may be critical for designing effective stigma-reducing interventions for Black adults.

A qualitative study of healthcare providers' attitudes toward assisted partner notification for people with HIV in Indonesia.

BACKGROUND: Assisted partner notification (APN) is recommended as a public health strategy to increase HIV testing in people exposed to HIV. Yet its adoption in many countries remains at an early stage. This qualitative study sought the opinions of HIV health service providers regarding the appropriateness and feasibility of implementing APN in Indonesia where such services are on the cusp of adoption. METHODS: Four focus group discussions totaling 40 health service providers were held in Jakarta, Indonesia to consider APN as an innovative concept and to share their reactions regarding its potential implementation in Indonesia. Voice-recorded discussions were conducted in Bahasa, transcribed verbatim, and analyzed. RESULTS: Participants recognized APN's potential in contacting and informing the partners of HIV-positive clients of possible viral exposure. They also perceived APN's value as a client-driven service permitting clients to select which of three partner notification methods would work best for them across differing partner relationships and settings. Nonetheless, participants also identified personal and health system challenges that could impede successful APN adoption including medical and human resource limitations, the need for specialized APN training, ethical and equity considerations, and lack of sufficient clarity concerning laws and government policies regulating 3rd party disclosures. They also pointed to the job-overload, stress, personal discomfort, and the ethical uncertainty that providers might experience in delivering APN. CONCLUSION: Overall, providers of HIV services embraced the concept of APN but forecast practical difficulties in key service areas where investments in resources and system change appeared necessary to ensure effective and equitable implementation.

Randomized Clinical Trial of Stigma Counseling and HIV Testing Access Interventions to Increase HIV Testing Among Black Sexual Minority Men and Transwomen.

Advances in HIV prevention tools have outpaced our ability to ensure equitable access to these tools. Novel approaches to reducing known barriers to accessing HIV prevention, such as stigma and logistical-related factors, are urgently needed. To evaluate the efficacy of a randomized controlled trial with four intervention arms to address barriers to HIV/STI testing uptake (primary outcome) and PrEP use, depression, and HIV test results (secondary outcomes). We tested a 2 × 2 research design: main effect 1-stigma-focused vs. health information evaluation-focused counseling, main effect 2-offering HIV/STI testing appointments in person vs. at home with a counselor via video chat, and the interaction of the main effects. Participants (N = 474) residing in the southeastern USA were screened and enrolled in a longitudinal trial. Intervention efficacy was established using generalized linear modeling with binomial or Poisson distributions. Intervention efficacy demonstrated an increase in HIV/STI testing uptake when testing was made available at home with a counselor via video chat vs. in person (83% vs. 75% uptake, p < .05), and participants were also more likely to test positive for HIV over the course of the study in the at-home condition (14.5% vs. 9.4%, p < .05). Stigma-focused counseling resulted in lower depression scores and greater uptake of PrEP among participants < 30 years of age when compared with health information counseling (15.4% vs. 9.6%, p < .05). In order to prevent further disparities between HIV prevention advances and access to HIV prevention tools, we must prioritize improvements in linking people to care. Novel interventions, such as those proposed here, offer a practical, evidence-based path to addressing long-standing barriers to HIV prevention strategies. Trial registration: NCT03107910.

High levels of undiagnosed rectal STIs suggest that screening remains inadequate among Black gay, bisexual and other men who have sex with men.

OBJECTIVE: To better understand rectal STI screening practices for Black gay, bisexual and other men who have sex with men (BGBMSM). FINDINGS: Although 15% of BGBMSM lab tested positive for a rectal STI, the majority of these (94%) were asymptomatic. Though all participants reported their status as HIV negative/unknown, 31 of 331 (9.4%) tested positive on HIV rapid tests. Neither condomless anal intercourse nor the number of male sex partners was associated with rectal STI or HIV diagnosis, although rectal STI diagnosis was positively related to testing HIV positive. CONCLUSIONS: Findings suggest that substantial numbers of BGBMSM have asymptomatic STIs but are not tested-an outcome that is likely a strong driver of onward HIV acquisition. Therefore, we must address the asymptomatic STI epidemic among GBMSM in order to reduce HIV transmission, as well as temper STI transmission, among this key population.

Methods in HIV-Related Intersectional Stigma Research: Core Elements and Opportunities.

Researchers are increasingly recognizing the importance of studying and addressing intersectional stigma within the field of HIV. Yet, researchers have, arguably, struggled to operationalize intersectional stigma. To ensure that future research and methodological innovation is guided by frameworks from which this area of inquiry has arisen, we propose a series of core elements for future HIV-related intersectional stigma research. These core elements include multidimensional, multilevel, multidirectional, and action-oriented methods that sharpen focus on, and aim to transform, interlocking and reinforcing systems of oppression. We further identify opportunities for advancing HIV-related intersectional stigma research, including reducing barriers to and strengthening investments in resources, building capacity to engage in research and implementation of interventions, and creating meaningful pathways for HIV-related intersectional stigma research to produce structural change. Ultimately, the expected payoff for incorporating these core elements is a body of HIV-related intersectional stigma research that is both better aligned with the transformative potential of intersectionality and better positioned to achieve the goals of Ending the HIV Epidemic in the United States and globally. (Am J Public Health. 2022;112(S4):S413-S419. https://doi.org/10.2105/AJPH.2021.306710).

Understanding Repeat Positive HIV Testing in South Africa Under Changing Treatment Guidelines.

Some people with HIV (PWH) test positive multiple times without initiating antiretroviral therapy (ART). We surveyed 496 ART-eligible PWH following routine HIV testing at three clinics in Soweto and Gugulethu, South Africa in 2014-2015. Among repeat positive testers (RPTs) in this cohort, we compared rates of treatment initiation by prior treatment eligibility and assessed psychosocial predictors of treatment initiation in logistic regression models. RPTs represented 33.8% of PWH in this cohort. Less than half of those who reported eligibility for ART on prior testing started treatment upon retesting, in contrast to two thirds of RPTs who were previously ineligible for treatment who started treatment once they learned of their eligibility. Those who reported coping through substance use were more likely to decline treatment versus those not using substances. PWH who test repeatedly represent a vulnerable population at risk for ART non-initiation who may benefit from interventions addressing individualized coping strategies.

Development of Long and Short Forms of the Multilevel Resilience Resource Measure for African American/Black Adults Living with HIV.

Understanding resilience in relation to HIV-related outcomes may help address racial/ethnic disparities, however, significant gaps in its measurement preclude in-depth study. Thus, this research aims to develop and evaluate the psychometric properties of long and short forms of the Multilevel Resilience Resource Measure for African American/Black Adults Living with HIV. To develop the items, we conducted a mixed methods study (N = 48) and reviewed published resilience measures. We completed content validity index analyses to ensure the items reflected the resilience construct. Next, we conducted 20 cognitive interviews and a field survey (N = 400). The long and short forms demonstrated acceptable to excellent psychometric properties based on factorial validity, internal consistency and convergent validity and on measurement invariance (conducted for the short form only). These measures provide a comprehensive framework to examine resilience and HIV-related outcomes and can inform resilience-building interventions to reduce racial and ethnic health disparities.

Optimizing Provider Preexposure Prophylaxis (PrEP) Training: A Cross-Sectional Analysis of Recommendations from Providers Across the PrEP Implementation Cascade.

Expanding PrEP access necessitates training that supports healthcare providers' progression along the PrEP implementation cascade, moving from PrEP awareness to prescription. We surveyed 359 USA providers about PrEP training content and format recommendations. We examined the association between cascade location and training recommendations. Most providers were aware of PrEP (100%), willing to prescribe PrEP (97.2%), had discussed PrEP with patients (92.2%), and had prescribed PrEP (79.9%). Latent class regression analysis revealed that cascade location was associated with training recommendations. Although all providers recommended PrEP-specific content (e.g., patient eligibility), providers who were located further along the cascade also recommended more comprehensive content, including sexual history-taking and sexual and gender minority competence training. Providers further along the cascade were also more likely to recommend interactive training formats (e.g., role-playing). These insights from providers furthest along the cascade indicate the importance of including comprehensive content and interactive formats in future PrEP training initiatives.

An Experimental Study of the Effects of Patient Race, Sexual Orientation, and Injection Drug Use on Providers' PrEP-Related Clinical Judgments.

Social biases may influence providers' judgments related to pre-exposure prophylaxis (PrEP) and patients' consequent PrEP access. US primary and HIV care providers (n = 370) completed an experimental survey. Each provider reviewed one fictitious medical record of a patient seeking PrEP. Records varied by patient race (Black or White) and risk behavior (man who has sex with men [MSM], has sex with women [MSW], or injects drugs [MID]). Providers reported clinical judgments and completed measures of prejudice. Minimal evidence of racially biased judgments emerged. Providers expressing low-to-moderate sexual prejudice judged the MSM as more likely than the MSW to adhere to PrEP, which was associated with greater PrEP prescribing intention; sexual prejudice was negatively associated with anticipated MSM adherence. Providers judged the MID to be at higher risk, less likely to adhere, less safety-conscious, and less responsible than both the MSM and MSW; adverse adherence and responsibility judgments were associated with lower prescribing intention.

RESUMEN: Los sesgos sociales pueden influir sobre los juicios de proveedores de salud con respecto a la profilaxis pre-exposición (PrEP) y el consecuente acceso de los pacientes a PrEP. Proveedores de cuidados primarios y de VIH en los Estados Unidos (n = 370) respondieron una encuesta experimental. Cada proveedor leyó una historia médica de un paciente ficticio interesado en obtener PrEP. Las historias médicas variaron la raza (Negro o Blanco) y conducta de riesgo (hombre que tiene sexo con hombres [HSH], hombre que tiene sexo con mujeres [HSM], u hombre  usuario de drogas inyectables [HDI]) del paciente. Los proveedores reportaron juicios clínicos y completaron medidas sobre prejuicio. La evidencia sobre sesgos raciales en los juicios clínicos fue mínima. Los proveedores que expresaron prejuicio sexual bajo a moderado, juzgaron que el paciente HSH tendría mayor adherencia a PrEP que el paciente HSM, lo cual se asoció con mayor intención de prescribir PrEP; el prejuicio sexual se asoció negativamente con la adherencia anticipada en HSH. El paciente HDI fue percibido como en mayor riesgo, con menor adherencia, menos preocupado por la seguridad, y menos responsable que los HSH y HSM; los juicios sobre baja adherencia y responsabilidad estuvieron asociados con menor intención de prescribir PrEP.

Exploring HIV stigma among future healthcare providers in Indonesia.

Future healthcare professionals are an important group for interventions to eliminate HIV stigma in the health workforce. Researchers examined HIV stigma and its relationship with healthcare discipline, HIV knowledge, and religiosity among nursing, medical, and midwifery students (N = 505) in three regions of Indonesia. In a multivariable linear model, higher HIV stigma was associated with male sex, lower levels of income and HIV knowledge, and higher levels of religiosity. An interaction of healthcare discipline and province was also significant. Medical students in Jakarta had higher predicted stigma scores compared to nursing students in Jakarta and compared to medical students in other provinces. Nursing students in Papua had lower predicted stigma scores compared to medical and midwifery students in Papua and compared to nursing students elsewhere. Strategies to reduce HIV stigma in the Indonesian health workforce should include a strong focus on pre-clinical educational settings and consider public nursing institutions as providing possible best practice models.

The Stigma of Criminal Legal Involvement and Health: a Conceptual Framework.

The USA incarcerates more people than any other nation in the world. Exposure to the criminal legal system has been associated with a myriad of health outcomes but less is understood about what drives these associations. We argue that stigma due to criminal legal involvement, what we call criminal legal stigma, likely has a larger role in the association between incarceration and negative health outcomes than has been previously appreciated. There is limited research on the impact on health of criminal legal stigma despite abundant research on its negative social consequences. In this paper, we describe a conceptual framework of the health effects of criminal legal stigma drawing on previous research of criminal legal stigma and advances in other areas of stigma research. We outline key concepts related to stigma mechanisms, how they function at structural and individual levels, and how they might cause health outcomes. Finally, we identify potential areas for future research and opportunities for clinical interventions to remediate negative effects of stigma.

Sex-Positivity, Medical Mistrust, and PrEP Conspiracy Beliefs Among HIV-Negative Cisgender Black Sexual Minority Men in Atlanta, Georgia.

Because the public health response to the disproportionate HIV burden faced by Black sexual minority men (BSMMM) has focused on sexual risk reduction and disease prevention, other vital components of sexual health (e.g., intimacy, pleasure, benefits of sex) have been often overlooked. Sex-positive describes a more open, holistic approach toward sex and sexuality that prioritizes these other components, though such an approach is rarely applied to BSMM's sexual health. For sex-positive BSMM, risk/preventive discourse may foster or exacerbate medical mistrust as a reaction to the dissonance between how these men view sexual health and how the medical establishment views it, which may discourage sexual healthcare-seeking. We assessed sex-positivity and its association with medical mistrust and PrEP conspiracy beliefs among 206 HIV-negative cisgender BSMM in Atlanta, Georgia. We performed exploratory factor analytic procedures on responses to a sex-positivity scale, followed by multivariable linear regressions to determine sex-positivity's associations with medical mistrust and PrEP conspiracy beliefs. We extracted two sex-positivity factors: sexual freedom (α = 0.90), reflecting openness toward casual sex and rejection of sexual mores, and essence of sex (α = 0.77), reflecting the intimate, relational, and pleasurable qualities of sex. Sexual freedom was independently associated with perceived provider deception (ß = 0.19, CI = 0.04, 0.34). Essence of sex was independently associated with PrEP conspiracy beliefs (ß = 0.16, CI = 0.02, 0.31) and marginally associated with perceived provider deception (ß = 0.14, CI = - 0.00, 0.29). Healthcare providers and public health practitioners may cultivate greater trust with BSMM by incorporating a sex-positive approach into patient/participant interactions, clinical decision-making, and interventions. Improving access to sexual pleasure acknowledges BSMM's right to optimal, holistic sexual health.

Faster than warp speed: early attention to COVD-19 by anti-vaccine groups on Facebook.

BACKGROUND: The unprecedented rapid development of COVID-19 vaccines has faced SARS-CoV- (COVID-19) vaccine hesitancy, which is partially fueled by the misinformation and conspiracy theories propagated by anti-vaccine groups on social media. Research is needed to better understand the early COVID-19 anti-vaccine activities on social media. METHODS: This study chronicles the social media posts concerning COVID-19 and COVID-19 vaccines by leading anti-vaccine groups (Dr Tenpenny on Vaccines, the National Vaccine Information Center [NVIC] the Vaccination Information Network [VINE]) and Vaccine Machine in the early months of the COVID-19 pandemic (February-May 2020). RESULTS: Analysis of 2060 Facebook posts showed that anti-vaccine groups were discussing COVID-19 in the first week of February 2020 and were specifically discussing COVID-19 vaccines by mid-February 2020. COVID-19 posts by NVIC were more widely disseminated and showed greater influence than non-COVID-19 posts. Early COVID-19 posts concerned mistrust of vaccine safety and conspiracy theories. CONCLUSION: Major anti-vaccine groups were sowing seeds of doubt on Facebook weeks before the US government launched its vaccine development program 'Operation Warp Speed'. Early anti-vaccine misinformation campaigns outpaced public health messaging and hampered the rollout of COVID-19 vaccines.

Incarcerated People Living with HIV: A Qualitative Exploration of Stigma.

Thousands of people living with HIV are incarcerated in the United States. Research about this vulnerable community has focused on access and adherence to medical care, including the impact of stigma on these treatment outcomes. This study presents qualitative data collected from 18 incarcerated and formerly incarcerated men and women living with HIV to expand knowledge about how HIV stigma shapes the lived experience of incarceration. The HIV Stigma Framework, including theory about enacted, anticipated, and internalized stigma, was used to analyze participants' narratives. Findings demonstrate an ongoing struggle with all three of these stigma mechanisms. Most participants deliberately concealed their HIV status and, therefore, experienced little enacted stigma. However, their narratives do describe anticipated stigma and, to a lesser extent, internalized stigma. There were gender differences in HIV disclosure and symbolic stigma and intersectionality are used to understand this variation. These findings illustrate the persistence of HIV stigma in correctional institutions and underscore the importance of fighting HIV stigma and homophobia within social work practice.

The stigma system: How sociopolitical domination, scapegoating, and stigma shape public health.

Stigma is a fundamental driver of adverse health outcomes. Although stigma is often studied at the individual level to focus on how stigma influences the mental and physical health of the stigmatized, considerable research has shown that stigma is multilevel and structural. This paper proposes a theoretical approach that synthesizes the literature on stigma with the literature on scapegoating and divide-and-rule as strategies that the wealthy and powerful use to maintain their power and wealth; the literatures on racial, gender, and other subordination; the literature on ideology and organization in sociopolitical systems; and the literature on resistance and rebellion against stigma, oppression and other forms of subordination. we develop a model of the "stigma system" as a dialectic of interacting and conflicting structures and processes. Understanding this system can help public health reorient stigma interventions to address the sources of stigma as well as the individual problems that stigma creates. On a broader level, this model can help those opposing stigma and its effects to develop alliances and strategies with which to oppose stigma and the processes that create it.

A Concept Mapping Study to Understand Multilevel Resilience Resources Among African American/Black Adults Living with HIV in the Southern United States.

Resilience may help people living with HIV (PLWH) overcome adversities to disease management. This study identifies multilevel resilience resources among African American/Black (AA/B) PLWH and examines whether resilience resources differ by demographics and neighborhood risk environments. We recruited participants and conducted concept mapping at two clinics in the southeastern United States. Concept Mapping incorporates qualitative and quantitative methods to represent participant-generated concepts via two-dimensional maps. Eligible participants had to attend ≥ 75% of their scheduled clinic appointments and did not have ≥ 2 consecutive detectable HIV-1 viral load measurements in the past 2 years. Of the 85 AA/B PLWH who were invited, forty-eight participated. Twelve resilience resource clusters emerged-five individual, two interpersonal, two organizational/policy and three neighborhood level clusters. There were strong correlations in cluster ratings for demographic and neighborhood risk environment comparison groups (r ≥ 0.89). These findings could inform development of theories, measures and interventions for AA/B PLWH.