According to the Centers for Disease Control and Prevention (CDC), approximately 36,400 new HIV infections have been reported in the US in 2020 [1]. This has resulted in a total of 1.2 million people currently living with HIV [2]. Gay and bisexual men as well as other men who have sex with men (MSM) make up a small proportion of the general population but bear the highest burden of HIV [3, 4]. About 69% of new HIV infections have been attributed to this marginalized population [1]. 15% of people living with HIV (PLWH) are unaware of their HIV status and thus remain undiagnosed [5, 6], accounting for approximately 40% of ongoing transmissions in the U.S [7]. Research indicates that individuals who are unaware of their status contribute to these annual new infections by engaging in certain high-risk behaviors and have higher viral loads due to an absence of treatment [7]. The transmission rate among individuals who are acutely infected but remain unaware is high—16.1 per 100 persons [8].
To understand the high rate of HIV transmission among MSM, health disparities researchers have relied on theories of stigma [9, 10]. One type of stigma is perceived HIV stigma, which refers to negative attitudes towards individuals at risk of HIV or those living with HIV. Studies have shown that perceived HIV stigma contributes to the disproportionate burden of HIV among MSM [11, 12]. It is considered as one of the primary factors that may discourage some people from engaging in safer-sex or getting tested for HIV [13, 14]. There is further discrimination among racial and ethnic minority groups [15]. In a study of sexual mixing, i.e. sexual partnerships between people with similar or different level of risk, it was reported that Black MSM had a three-fold higher level of same race sexual partnering due to segregation based on HIV status and race based stigma [16]. Black MSM are also considered to be at the highest risk of perceived HIV stigma and are thus further segregated by other non-infected and non-Black MSM [17]. Therefore, it is very important to operationalize and understand HIV stigma to form a basis for intervention and treatment among this marginalized population. Negative correlates such as social discrimination related to stigmatizing beliefs about having HIV can severely impact the well-being of MSM and thus influence their decision to seek care and may act as a barrier to testing, healthcare access, and treatment adherence [18, 19].
Another type of stigma that is frequently used to understand health disparities among MSM is enacted stigma. This refers to the actual experience of prejudice and discrimination that occur among men because of their sexual orientation or sexual behavior or their perceived or confirmed health status [20]. Occurrences of gay-related enacted stigma in the form of either verbal harassment or physical assault among MSM has been associated with HIV related risk behaviors and poorer health related outcomes [21, 22]. In a study assessing this association, 24% reported one type of enacted stigma, 13% reported two types, and 4% reported all three types of enacted stigma [23]. Experiencing this stigma results in lower level of HIV testing and initiation of therapy or continuation of treatment/care [12].
Despite increases in social acceptance and advances in legal rights for LGBTQ people, they still continue to face difficulties. The Bible belt is a region in the southern United States defined by conservative politics and traditional values [24]. Various state policies in this region perpetuate homophobia by criminalizing MSM or neglecting their basic human rights [25–27]. These anti-LGBTQ law/policies have a negative impact on the health consequences of MSM due to concurrent psychosocial problems that are simultaneously acting together. These multiple health factors along with mental health conditions such as depression, anxiety, stress results in a cocktail of syndemic conditions amplifying the risk of HIV [28–31]. MSM in the South are also more likely to engage in risky sexual behaviors. There is stigmatization even in the healthcare settings leading to lower knowledge of HIV status, linkage to care, and viral suppression eventually affecting the ability of individuals to manage their illness [32, 33]. Very few studies in the region have been conducted to understand the effect of stigma among racial/ethnic minorities [12]. On the other hand, support for this population has been stronger in areas of the Northeast and the West coast, identifying the geographic regions that are most affected by stigma is of critical importance, as it will allow for much more focused HIV testing and prevention activities as the distributions of HIV infections is not uniform [1, 2, 34]. In addition to ascertaining the regions, it is essential to have a better understanding of the characteristics of this undiagnosed population (e.g., race, socioeconomic status) to decrease the size of this population and eventually increase the number of individuals being linked to care.
When examining geographic regions across the United States, among persons living with HIV, the largest percentage of persons with undiagnosed HIV infection were in the Midwest (15.4%), followed by the South (15.1%), West (14.4%), and Northeast (9.5%) [1]. It is essential to first compare and contrast the data across different metropolitan statistical areas (MSA). Studies have been conducted to assess the prevalence of these undiagnosed infections in these areas; however, at present, there is no published study that compares and evaluates the association of these two different types of stigma and undiagnosed HIV infections among MSM across the major cities in United States. The purpose of this ecological study is to assess whether stigma is similar or different by comparing eight different tiered cities in the United States and to examine the aggregate relationship between perceived HIV stigma, gay related enacted stigma, and undiagnosed HIV infections among this high-risk population [35, 36].
This study is guided by two main hypothesis. First, different cities will group together if the prevalence of stigma is similar among them. Second, there will be a positive association between perceived HIV stigma, gay related enacted stigma, and undiagnosed HIV infections by geographic regions. The results from this analysis can then further be used to identify priority areas that are amenable to intervention.