AIDS PATIENT CARE and STDs BEHAVIORAL AND PSYCHOSOCIAL RESEARCH

Volume 30, Number 2, 2016

ª Mary Ann Liebert, Inc.
DOI: 10.1089/apc.2015.0197

HIV-Related Stigma and HIV Prevention Uptake

Among Young Men Who Have Sex with Men
and Transgender Women in Thailand

Carmen H. Logie, PhD,1 Peter A. Newman, PhD,1 James Weaver, MPH,1

Surachet Roungkraphon, MEd,2 and Suchon Tepjan, BA1

Abstract

HIV-related stigma is a pervasive structural driver of HIV. With an HIV epidemic among young men who have
sex with men (MSM) and transgender women (TG) in Thailand characterized as explosive, we conducted a cross-
sectional survey among MSM and TG aged 18–30 years. From April–August 2013, participants recruited using
venue-based sampling from gay entertainment sites and community-based organizations completed a tablet-
assisted survey interview in Thai language. We conducted multiple logistic regression to assess correlations
between HIV-related stigma (felt-normative, vicarious domains) and socio-demographic variables, HIV vul-
nerabilities (gay entertainment employment, sex work, forced sex history), and HIV prevention uptake (condom
use, HIV testing, rectal microbicide acceptability). Among participants (n = 408), 54% identified as gay, 25%
transgender, and 21% heterosexual. Two-thirds (65.7%) were employed at gay entertainment venues, 67.0% had
more than three male partners (past month), 55.6% had been paid for sex, and 4.5% were HIV-positive. One-fifth
(21.3%) reported forced sex. Most participants reported experiencing felt-normative and vicarious HIV-related
stigma. Adjusting for socio-demographics, participants with higher total HIV-related stigma scores had signifi-
cantly lower odds of HIV testing and rectal microbicide acceptability, and higher odds of having experienced
forced sex. Both vicarious and felt-normative dimensions of HIV-related stigma were inversely associated with
HIV testing and rectal microbicide acceptability. Our findings suggest that HIV-related stigma harms the health of
HIV-negative MSM and TG at high risk for HIV infection. HIV-related interventions and research among young
MSM and TG in Thailand should address multiple dimensions of HIV-related stigma as a correlate of risk and a
barrier to accessing prevention.

Introduction HIV-related stigma refers to multi-level processes of de-

valuation that involve labeling, status loss, and discrimination
targeting people living or associated with HIV.14 Cultural
M en who have sex with men (MSM) and transgender
women (TG) in Thailand are disproportionately im-
pacted by HIV. In comparison with an HIV prevalence of 1.1%
variations in conceptualizations of sexuality and stigma un-
derscore the need to examine HIV-related stigma across
in the general Thai population, national prevalence is esti- different contexts.15,16 Widespread HIV-related stigma has
mated at 7% among MSM1 and 12% among TG,2,3 with 30% been documented in Thailand, resulting in job loss, health
HIV prevalence documented among MSM in Bangkok.4 care discrimination, and mental health issues among people
Disproportionate HIV infection risks among MSM and TG living with (PLHIV).17–20 HIV-related stigma is multidi-
globally are best understood in the context of structural drivers mensional and includes awareness of negative societal norms
of HIV.2,5–7 HIV-related stigma is a pervasive structural driver and judgments (felt-normative or perceived stigma)15 and
of HIV that functions distally to reduce access to HIV pre- hearing stories of discriminatory treatment (vicarious stigma)
vention resources, HIV testing, and treatment.6,8–13 Despite towards PLHIV.21,22
elevated HIV infection risks among MSM and TG in Thailand, Stigma surrounding HIV has been intrinsically linked with
scant research has assessed the associations between HIV- marginalized groups, such as MSM and sex workers, since
related stigma, HIV risk, and prevention in this context. the beginning of the epidemic.23 This symbolic nature of

1
Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada.
2
Faculty of Science and Technology, Rajamangala University of Technology Phra Nakhon, Bangkok, Thailand.

92
HIV-RELATED STIGMA FOR MSM AND TG 93

HIV-related stigma reproduces shame and blame for HIV ple would think they were HIV-positive and ‘‘dirty’’ if they
among these already marginalized populations and contrib- used a rectal microbicide.48 This underscores the potential
utes to the conceptualization of disease as punishment.24,25 negative impact HIV-related stigma could have on rectal
Investigations in India22 and the US26 indicate HIV-related microbicide uptake, and the need for socio-behavioral re-
stigma has negative psychological impacts on HIV-negative search to facilitate rectal microbicide implementation sci-
MSM, in addition to MSM living with HIV, highlighting the ence.48 The association between HIV-related stigma and
importance of examining health impacts of HIV-related rectal microbicide acceptability among MSM and TG war-
stigma on MSM across HIV serostatus. Even less is known rants further investigation.
about health impacts of HIV-related stigma among TG. We aim to address three gaps in the literature in this study.
Discrimination towards MSM and TG in Thailand has been First, several investigations have yielded mixed results re-
described as pervasive and grounded in negative stereotypes garding associations between HIV-related stigma and HIV
reinforced by media, cinema, and TV.27,28 Employment preventive behaviors, such as condom use.30–32 This has not
discrimination among gender non-conforming MSM and been explored in Thailand among MSM and TG, groups at
among TG result in many engaging in survival sex work.28,29 highest risk of HIV infection. Second, while investigations
Although HIV-related stigma has been described as a barrier have identified HIV-related stigma as a predictor of lower
to accessing HIV prevention resources and testing in various HIV testing rates among MSM,8,12 this association has not
global contexts,6,8,11,12 less is known about the impacts of been explored among TG or in the Thai context. Finally,
HIV-related stigma on HIV risk, HIV testing, and uptake of scant research has explored associations between HIV-
HIV prevention strategies among MSM and TG in Thailand. related stigma and acceptability of new prevention technol-
Findings regarding the influence of HIV-related stigma on ogies, such as rectal microbicides, among TG and MSM.46–48
condom use are mixed and largely derived from US-based The objective of our study was to explore associations
investigations. One US study with PLHIV found no relation between HIV-related stigma and (1) socio-demographic var-
between HIV-related stigma and condom use,30 while other iables; (2) HIV vulnerabilities (gay entertainment employ-
US studies with rural MSM reported associations between ment, sex work, forced sex history); and (3) HIV prevention
HIV-related stigma and sexual risk behavior.31,32 Studies uptake (condom use, HIV testing, rectal microbicide accept-
among MSM and TG in Thailand33–35 have identified corre- ability). Specifically, we examined if experiences of HIV-
lates of inconsistent condom use, including socio-demographic related stigma among MSM and TG in Thailand would be
(e.g., gay identity versus heterosexual/bisexual,34,36 lower ed- associated with: sex work; gay entertainment employment;
ucation37) and health indicators (substance use,28 recent HIV increased likelihood of having experienced forced sex; lower
diagnosis35), low HIV knowledge,34 and forced sex.37 No stud- rates of consistent condom use; decreased likelihood of having
ies were found that examined associations between HIV-related received an HIV test; and lower levels of rectal microbicide
stigma and condom use among MSM or TG in Thailand. acceptability.
HIV testing is central to HIV prevention and has signifi-
cant epidemiological consequences, particularly for newly
infected persons who have higher viral loads and therefore Methods
higher infectiousness in sexual encounters.38,39 Research in Study background
China with MSM,40 and in the US with MSM and TG,8 found
anticipated HIV-related stigma was associated with lower We worked in conjunction with community-based orga-
likelihood of HIV testing. Studies with general populations in nizations (CBOs) in Chiang Mai and Pattaya that serve MSM
South Africa also highlight correlations between HIV-related or TG, including male and TG service (sex) workers, to re-
stigma and lower HIV testing levels among general popula- cruit a community sample of young MSM and TG. Venue-
tions of adults.12,41,42 Among TG sex workers in Bangkok, based sampling was conducted in go-go bars, host bars,
only half had tested for HIV, and being tested was associated massage parlors/spas, gay recreational sites, and CBO of-
with receiving HIV prevention information and resources fices. Study inclusion criteria were being MSM or TG, from
(e.g., condoms).28 We were unable to locate Thai studies that 18–30 years-old, and able to understand Thai language.
explored HIV-related stigma and HIV testing among MSM Participants were invited individually by trained Thai com-
and TG. munity research staff. The study received approval from the
Scant research has addressed associations between HIV University of Toronto Research Ethics Board, and MPlus+
stigma and acceptability of new prevention technologies. (Chiang Mai) and Take Care!! (Pattaya).
Studies with MSM in Thailand have revealed moderate ac-
ceptability of new biomedical prevention options such as
Data collection
PrEP, and technologies in development, such as HIV vac-
cines.33,43–45 Ongoing development of topical rectal micro- The survey questionnaire was constructed in English,
bicides that include antiretroviral medications,46 with a Phase translated into Thai, back-translated into English and revised.
II trial in progress,47 may yield much needed new prevention The questionnaire was then programmed in Thai language on
options to reduce HIV infection risk associated with con- Android tablet devices, debugged, and pilot tested with the
domless anal sex. study populations. Trained Thai interviewers familiar with
However, a qualitative study of rectal microbicide accept- the local communities provided instructions to participants
ability with MSM and TG in Pattaya and Chiang Mai revealed on use of the tablets, observed self-administration of practice
that discrimination targeting MSM/TG and HIV-related questions, and remained on hand to respond to questions or
stigma may pose significant challenges to rectal microbicide difficulties. The average time to survey completion was
acceptability.48 For instance, participants reported that peo- 33 min (range: 25–45 min).
94 LOGIE ET AL.

Measures PLHIV. Vicarious stigma questions include, ‘‘How often have

you heard stories about people being mistreated by hospital
Socio-demographic characteristics included region born, workers because of their HIV-positive status?’’ and ‘‘How
age, sexual orientation/gender identity, education, income, often have you heard stories about people being forced by
living situation, and recruitment city. We dichotomized age family members to leave their home because they were HIV-
at 25 years or older versus under 25 years. We assessed positive?’’ These items are measured on a Likert scale ranging
gender identity (transgender, male) and sexual orientation from 0 (‘‘Never’’) to 3 (‘‘Often’’). We created felt-normative
(gay, heterosexual, bisexual). Thailand’s dominant concep- and vicarious stigma sub-scale scores by first rescaling the
tualizations of ‘phet’ include a spectrum of both sexuality and responses to a 0–100 scale and summing the mean of items in
gender expression; accordingly, we addressed sexual and the two sub-scales; to create a total stigma score we calculated
gender identity in one question. We grouped bisexual- and the mean of all items. Scale reliability was high for the overall
heterosexual-identified MSM in the same analytic category HIV-related stigma scale [Cronbach’s alpha (a) = 0.91], the
due to the low percentage (4.4%) of bisexual participants. We felt-normative HIV-related stigma sub-scale (a = 0.93), and
categorized education as no formal education to 6th grade, vicarious HIV-related stigma sub-scale (a = 0.85).
7th grade to some high school, and high school diploma or
higher. Monthly income was dichotomized at 7500 Thai baht Statistical analysis
(approximately $233 USD), below Thailand’s minimum
wage. Participant living situation was categorized as living All analyses were performed using Stata version 11.2
with family, a partner/boyfriend, alone or with a roommate. (StataCorp 2009, College Station, TX). We characterized the
HIV vulnerabilities included a history of forced sex (ever, sample in terms of socio-demographics, HIV vulnerabilities,
never), working in the gay entertainment industry, and in- and HIV prevention uptake using descriptive statistics.
volvement in sex work. HIV prevention uptake included: (1) Where table cell sizes were five or less, we used Fisher’s
condom use (always consistent vs. inconsistent); (2) (self- exact non-parametric test. To compare stigma score across
reported HIV tested status (tested, untested); and (3) rectal categorical variables, we used t-tests for comparisons across
microbicide acceptability. Trained interviewers described variables with two groups and ANOVA for comparisons
rectal microbicides as a new HIV prevention product in de- across variables with two or more groups. Stigma scale
velopment that would possibly be in the form of a gel (‘‘gel’’ item data were complete so applying methods to account for
or ‘‘lube’’ in Thai) or suppository (‘‘insert drug’’ in Thai)— missing data were unnecessary.
both of which were familiar to participants—and would be Logistic regression was used to determine the unadjusted
applied to the anus and used every day or before sex to help association between HIV-related stigma and selected HIV
prevent HIV infection. Acceptability of a hypothetical rectal vulnerabilities and HIV prevention uptake. Further, we used
microbicide was assessed by the question: ‘‘If a rectal mi- multiple logistic regression to quantify the association be-
crobicide became available, do you think you would use it?’’ tween stigma and HIV vulnerabilities, and between stigma
The response was measured as definitely/probably willing to and HIV prevention uptake, adjusted by age, education, sex-
use versus definitely/probably not willing to use/unsure. ual orientation/gender identity, and recruitment city. Lastly,
We measured and assessed HIV-related stigma using a 21- we tested the associations after stratifying the sample on
item scale adapted for the Indian context. This scale was sexual orientation. We standardized the stigma scale scores
validated with general populations of PLHIV in India,21 and for use in the logistic regression models in order for the model
with HIV-negative MSM in India.22 The only measure we coefficients to represent a meaningful change in reported
found of HIV-related stigma used in Thailand was among TB stigma. The model coefficients represent the increased or
patients and PLHIV (sexuality not defined) that examined decreased odds of the risk factor for a one standard deviation
community and patient perspectives towards HIV.20 As this increase in reported stigma. We assessed model goodness-of-
scale did not include sub-scales to measure felt-normative or fit using Hosmer and Lemeshow’s test and applied standard
vicarious dimensions of HIV-related stigma that may be model diagnostic tests to identify and assess overly influential
experienced by groups associated with, but not necessarily observations and covariate multicollinearity.
living with HIV, such as HIV-negative MSM,20 we adapted
the scale developed by Steward et al.21 We worked with Thai Results
key informants (including SR and ST) to adapt items for the
Participant socio-demographic characteristics
Thai context.
The first 11 items address felt-normative stigma21,22 by Table 1 describes socio-demographic characteristics, HIV
asking about how members of the participants’ community vulnerabilities, and HIV prevention uptake of the sample
treat or think about PLHIV. Felt-normative stigma questions (n = 408). Approximately half of the participants were born in
include, ‘‘In your community, how many people avoid visiting the Northern region (50.5%), slightly over a quarter were born
the homes of people with HIV?’’ and ‘‘In your community, in the Northeast (27.7%), and the remainder were born in other
how many people think that a person with HIV is disgust- regions. Among participants, 51.2% were under 25 years old,
ing?’’, and are measured on a Likert scale ranging from 0 41.4% had not completed high school, 38.7% earned 7500
(‘‘No one’’) to 3 (‘‘Most people’’). The 11th item is an ad- Thai Baht or less per month, and most lived with a roommate
dition that was specific to the Indian context: ‘‘In your (35.3%) rather than alone (27.0%), with a partner/boyfriend
community, how many people think that men who have sex (20.6%), or with their family (17.2%). Most participants self-
with men deserve to get HIV?’’22 identified as gay (53.2%), followed by transgender (25.4%).
The second 10 items address vicarious stigma21,22 by ask- The remaining 21.0% self-identified as heterosexual or
ing about stories that the participant may have heard about bisexual.
 Table 1. Socio-Demographic, HIV Vulnerability, and HIV Prevention Uptake Variables
by City and HIV-Related Stigma Score
Total Chiang Mai Pattaya HIV-related stigma
Total score
N = 408 100% N = 204 50% N = 204 50%
n col. % n col. % n col. % p Mean SE p
Socio-demographics
Region born <0.001 0.274
North 206 50.49 180 88.24 26 12.75 35.65 1.61
Northeast 113 27.70 8 3.92 105 51.47 39.91 1.98
Central/west 50 12.25 9 4.41 41 20.10 42.54 3.40
East 28 6.86 4 1.96 24 11.76 37.36 4.24
South 11 2.70 3 1.47 8 3.92 36.08 5.99
Age 0.023 0.700
<25 years 209 51.23 116 56.86 93 45.59 38.22 1.50
‡ 25 year 199 48.77 88 43.14 111 54.41 37.36 1.67
Education 0.001 0.125
No formal education up to 6th grade 55 13.48 28 13.73 27 13.24 32.27 3.09
7th grade-some high school 114 27.94 41 20.1 73 35.78 39.65 2.04
‡ High school 239 58.58 135 66.18 104 50.98 38.19 1.47
Monthly income [Thai baht (THB)]a 1.000 0.909
0–7500 THB 158 38.73 79 38.73 79 38.73 37.96 1.76
>7500 THB 250 61.27 125 61.27 125 61.27 37.70 1.44
Living situation <0.001 0.381
With family 70 17.16 55 26.96 15 7.35 33.74 2.90
With partner/boyfriend 84 20.59 38 18.63 46 22.55 38.87 2.52
Alone 110 26.96 65 31.86 45 22.06 37.65 2.25
With roommate 144 35.29 46 22.55 98 48.04 39.27 1.71
Sexual orientation/gender identity 0.020 0.168
Heterosexual, straight/bisexual 86 21.08 54 26.47 32 15.69 33.87 2.42
Gay 218 53.43 98 48.04 120 58.82 39.29 1.54
Transgender 104 25.49 52 25.49 52 25.49 37.94 2.16
Recruitment city 0.027
Chiang Mai 204 50.00 35.33 1.63
Pattaya 204 50.00 40.27 1.51
HIV vulnerabilities
Gay entertainment industry <0.001 0.436
employment
No 140 34.31 89 43.63 51 25.00 36.60 1.79
Yes 268 65.69 115 56.37 153 75.00 38.43 1.42
Ever forced into sex 0.546 0.013
No 321 78.68 163 79.90 158 77.45 36.37 1.25
Yes 87 21.32 41 20.10 46 22.55 43.09 2.38
Received payment for sex (missing = 3) 0.002 0.957
Not at all 180 44.44 105 51.98 75 36.95 37.72 1.66
Yes, with any frequency 225 55.56 97 48.02 128 63.05 37.59 1.52
Paid partner for sex (missing = 23) <0.001 0.473
Not at all 255 66.23 161 80.50 94 50.81 38.35 1.43
Yes, with any frequency 130 33.77 39 19.50 91 49.19 36.59 1.98
HIV prevention uptake
Rectal microbicide acceptability 0.204 0.005
Not willing to use/not sure 33 8.09 13 6.37 20 9.80 48.44 3.95
Definitely/probably willing to use 375 91.91 191 93.63 184 90.20 36.87 1.15
HIV testing 0.552 0.009
Not tested 202 49.51 104 50.98 98 48.04 40.73 1.60
Tested 206 50.49 100 49.02 106 51.96 34.94 1.53
Condom use consistency (missing = 12) 0.776 0.168
Inconsistent 142 35.86 70 35.18 72 36.55 39.88 1.83
Always consistent 254 64.14 129 64.82 125 63.45 36.61 1.44
Condom use last time anal sex 0.350 0.515
No 67 16.42 37 18.14 30 14.71 39.45 2.72
Yes/not applicable 341 83.58 167 81.86 174 85.29 37.48 1.22
a
7500 Thai baht = *$211 USD.

95
96 LOGIE ET AL.

Participants were recruited evenly from Chiang Mai and associations, total HIV-related stigma was higher for those
Pattaya from April to August 2013. Participants recruited in who were recruited in Pattaya (Pattaya: 40.3 vs. Chiang Mai:
Chiang Mai were more likely to be from the north (Fisher’s 35.3, t = -2.22, p = 0.03), who were untested for HIV (not
exact p < 0.01), younger (v2[1] = 5.2, p = 0.02), more educated tested: 40.7 vs. tested: 34.9, t = 2.61, p < 0.01), who have a
(v2[2] = 13.0, p = 0.01), live alone (v2[3] = 46.0, p < 0.01), and history of forced sex (forced sex: 43.1 vs. none: 36.4, t = -2.48,
self-identify as heterosexual/straight or bisexual (v2[2] = 7.8, p = 0.01) and are unwilling to use or unsure about using a
p = 0.02). Pattaya participants were more likely to be em- rectal microbicide (not willing/unsure: 48.4 vs. willing: 36.9,
ployed at gay entertainment venues (v2[1] = 15.7, p < 0.01), to t = 2.85, p < 0.01) (see Table 1).
have been paid for sex (v2[1] = 9.3, p = 0.02), and to have paid Table 2 shows the raw and adjusted odds ratios for the
for sex (v2[1] = 37.9, p < 0.01). Nineteen participants (4.5%) associations between HIV-related stigma and consistent
self-reported testing HIV-positive. HIV-positive participants condom use, being tested for HIV, forced sex, and rectal
were more likely to be from eastern Thailand (including microbicide acceptability. Adjusted for age, education, sexual
Pattaya) (Fisher’s exact p = 0.02), with less education (Fish- orientation/gender identity, and recruitment city, participants
er’s exact p = 0.01) and lower income (v2[1] = 5.0, p = 0.03) who reported higher total HIV-related stigma scores were less
than HIV-negative or untested participants. likely to have been tested for HIV (AOR 0.75, 95% CI 0.61,
0.92) and were less willing to use a rectal microbicide (AOR
HIV vulnerabilities 0.57, 95% CI 0.39, 0.83). Participants reporting higher HIV-
related stigma scores had greater odds of reporting a history of
Two-thirds of participants (65.7%) were employed at gay
forced sex (AOR 1.39, 95% CI 1.09, 1.79).
entertainment venues. Over half (55.6%) reported having
Results stratified by sexual orientation (not shown) indi-
been paid for sex, while a third (33.8%) reported having paid
cate that self-identified gay men who reported higher total
other partners for sex during the past 3 months. One-fifth
HIV-related stigma had lower odds of having been tested for
(21.3%) reported being forced to have sex against their will.
HIV (AOR 0.72, 95% CI 0.54, 0.96), lower odds of rectal
There were no significant differences in HIV vulnerabilities
microbicide acceptability (AOR 0.55, 95% CI 0.31, 0.98),
(gay entertainment industry employment, history of forced
and higher odds of a past forced sexual experience (AOR
sex, received payment for sex, paid for sex) between HIV-
1.52, 95% CI 1.08, 2.14). Self-identified transgender women
positive and HIV-negative or untested participants.
who reported higher total HIV-related stigma had lower odds
of being tested for HIV (AOR 0.14, 95% CI 0.41, 0.99) (see
HIV prevention uptake
Table 2).
Over the past month, 64.1% of participants reported condom Table 3 presents the raw and adjusted odds ratios for as-
use all of the time, and 83.6% reported condom use the last time sociations between felt-normative and vicarious domains of
they had anal sex. Just under half of participants (48.1%) re- HIV-related stigma, and consistent condom use, being tested
ported ever being tested for HIV. The vast majority of partic- for HIV, forced sex, and rectal microbicide acceptability.
ipants (92.0%) indicated willingness to using use a rectal Felt-normative (AOR 0.74, 95% CI 0.60, 0.95) and vicarious
microbicide if it became available. There were no significant (AOR 0.72, 95% CI 0.53, 0.99) stigma domains were asso-
differences in HIV prevention uptake variables between HIV- ciated with lower odds of having received an HIV test. Par-
positive and HIV-negative or untested participants. ticipants reporting vicarious stigma were more likely to have
experienced forced sex (AOR 1.69, 95% CI 1.17, 2.45). Both
Felt-normative and vicarious HIV-related stigma felt-normative (AOR 0.63, 95% CI 0.41, 0.95) and vicarious
(AOR 0.54, 95% CI 0.32, 0.90) HIV-related stigma were
The average HIV-related, felt normative, and vicarious
associated with lower likelihood of accepting a rectal mi-
stigma scores were 37.80 (SD = 22.55, range = 0–98.41),
crobicide (see Table 3).
46.56 (SD = 30.70, range = 0–100), and 28.17 (SD = 22.50,
range = 0–100), respectively. Total and felt-normative stigma
Discussion
scores were significantly lower for HIV-positive than HIV-
negative or untested participants, but there was no significant In our study among community-recruited MSM and TG in
difference in vicarious stigma scores. Table 1 shows total Pattaya and Chiang Mai, Thailand, HIV-related stigma was
stigma score differences by socio-demographic, HIV vul- significantly associated with lower HIV testing uptake, and a
nerability, and HIV prevention uptake measures. In bivariate history of forced sex, in addition to lower acceptability of a

Table 2. Odds of HIV Vulnerabilities and HIV Prevention Uptake as a Function

of Total HIV-Related Stigma
Total HIV-related stigma scale
OR 95% CI p AORa 95% CI p
Consistent condom use (vs. inconsistent) 0.87 0.70 1.06 0.168 0.88 0.71 1.08 0.215
HIV tested (vs. not tested) 0.77 0.63 0.94 0.010 0.75 0.61 0.92 0.007
Forced sex (vs. none) 1.35 1.06 1.71 0.014 1.39 1.09 1.79 0.008
Rectal microbicide acceptability (vs. unwilling/unsure) 0.60 0.42 0.86 0.006 0.57 0.39 0.83 0.003
a
Adjusted for age, education, sexual orientation/gender identity, and recruitment city (N = 389).
HIV-RELATED STIGMA FOR MSM AND TG 97

Table 3. Odds of HIV Vulnerabilities and HIV Prevention Uptake as a Function

of Felt-Normative and Vicarious HIV-Related Stigma
Felt-normative HIV-related stigma Vicarious HIV-related stigma
HIV vulnerabilities and
HIV prevention uptake OR 95% CI p AORa 95% CI p OR 95% CI p AORa 95% CI p
Consistent condom use 0.87 0.71 1.07 0.197 0.88 0.72 1.09 0.247 0.90 0.74 1.11 0.331 0.91 0.74 1.12 0.387
(vs. inconsistent)
HIV tested (vs. not tested) 0.77 0.63 0.94 0.01 0.76 0.62 0.94 0.01 0.86 0.70 1.04 0.121 0.82 0.67 1.01 0.063
Forced sex (vs. none) 1.25 0.98 1.59 0.068 1.27 0.99 1.62 0.059 1.33 1.06 1.66 0.015 1.39 1.10 1.76 0.007
Rectal microbicide 0.65 0.44 0.94 0.022 0.64 0.44 0.94 0.022 0.67 0.49 0.93 0.016 0.63 0.45 0.88 0.007
acceptability
(vs. unwilling/unsure)
a
Adjusted for age, education, sexual orientation/gender identity, and recruitment city (n = 389).

rectal microbicide. Felt-normative and vicarious HIV-related test result—and facing social and health consequences—
stigma domains were associated with lower likelihood of may partly account for the relationship between anticipated
HIV testing and lower rectal microbicide acceptability. HIV-related stigma and lower HIV testing. Earnshaw et al.49
Consistent with prior research with MSM and TG in other examined psychological processes connecting HIV-related
contexts, HIV-related stigma appears to be a deterrent to HIV stigma to lower testing rates among people who inject drugs in
testing.8,40 Our findings also corroborate qualitative research the US, and found that HIV stereotypes led to reduced HIV risk
that highlighted HIV-related stigma as a potential barrier to perceptions, which mediated the association between stigma
rectal microbicide acceptability among MSM and TG in and lower testing.
Thailand.48 This complex interplay between HIV-related stigma and
The average standardized felt normative stigma score was fear may reflect similar processes that underlie the association
47, meaning that most participants reported at least some between stigma and rectal microbicide acceptability. As
people in their community held negative beliefs and attitudes evidenced in qualitative research,48 MSM and TG believed
towards PLHIV, including beliefs that PLHIV are disgusting, that using a rectal microbicide would signify they were HIV-
shameful, and bring shame to their families. The average positive, and therefore considered ‘dirty’; and accessing
standardized vicarious stigma score was 28; this score re- rectal microbicides through the healthcare system was be-
flects that participants reported sometimes hearing stories lieved to exacerbate HIV-related stigma. The belief that
about mistreatment of PLHIV on the majority of scale people would consider them HIV-positive, and perceive them
items. These items include mistreatment by hospital staff and as ‘dirty’, is indicative of felt-normative stigma; the fear of
family, and social exclusion based on HIV-positive ser- being mistreated by others both in one’s community and
ostatus. These findings in and of themselves suggest that healthcare suggests vicarious stigma. Our finding of felt-
among a predominantly HIV-negative sample of MSM and normative and vicarious stigma as predictors of lower rectal
TG, the majority of participants have been exposed to neg- microbicide acceptability therefore contributes further evi-
ative community beliefs about PLHIV, and heard stories of dence to the important role that HIV-related stigma may play
PLHIV mistreatment. Addressing HIV-related stigma in in creating a barrier to uptake of new prevention technologies.
Thailand is therefore a pressing concern. Other variables associated with HIV-related stigma in-
Counter to what we hypothesized, we did not find associ- cluded living in Pattaya versus Chiang Mai, identifying as
ations between HIV-related stigma and condom use. A study gay, and having a history of forced sex. It is plausible that
with rural MSM in the US found that low self-esteem and MSM who identify as gay would experience and be engaged
internalized homophobia mediated the association between in more dialogue, and therefore hear more stories about
HIV-related stigma and sensation seeking, which directly HIV-related stigma due to their symbolic association with
affected sexual risk practices.32 Exploring the psychosocial HIV.22,23 Participants living in Pattaya versus Chiang Mai
impacts of HIV-related stigma, sexual stigma, and how these experienced higher HIV-related stigma; more participants in
potentially mediate sexual risk practices warrants further Pattaya than Chiang Mai were employed at gay entertainment
investigation among MSM and TG in the Thai context. Of venues, had received payment for sex, and paid for sex,
note is that two-thirds of participants in our study were em- suggesting that HIV could be viewed as more of a personal
ployed in gay entertainment venues and used condoms con- and occupational risk; this, in turn, could raise fear of HIV
sistently. Previous studies in Thailand indicate that MSM and contribute to stigma. Pattaya, with its historical reputa-
employed in the gay entertainment industry may use con- tion as a sex trade hub, in part shaped by the US military
doms more consistently than other MSM and TG,36,37 which presence,50,51 may be encumbered with greater HIV-related
may reflect the success of ongoing targeted HIV prevention stigma than other Thai cities. The perception that sex workers
programs among these populations. are responsible for HIV transmission continues to reproduce
The precise nature of the causal relationships between HIV- HIV-related stigma not only in Thailand, but in other con-
related stigma and HIV testing, and rectal microbicide ac- texts, such as India.52
ceptability, respectively, remain unclear, though psychological We found associations between experiencing forced sex
processes associated with stigma may pose barriers to testing. and HIV-related stigma; while we found no prior studies that
Golub et al.8 discussed that fear of receiving an HIV-positive explored this association, other investigations suggest that
98 LOGIE ET AL.

sexual violence survivors experience community stigma and in part by grants from the Canadian Institutes of Health Re-
social exclusion for being raped, and often have psychosocial search (OGE-111397; HIB-120230) and the Canada Re-
adjustment challenges.53 Studies with PLHIV highlight bi- search Chairs Program.
directional associations between traumatic events and HIV-
related stigma;54–56 sexual and gender minorities are often Author Disclosure Statement
stigmatized, and targets of sexual violence, and experiencing
sexual violence can, in turn, result in more stigma and trau- No competing financial interests exist.
ma. There is a need to better understand the causal mecha-
nisms between HIV-related stigma and sexual violence References
among MSM and TG in Thailand and other contexts. Sexual
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