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The Multiple Stigma Experience and Quality of Life in Older Gay Men With HIV
Accepted Manuscript The Multiple Stigma Experience and Quality of Life in Older Gay Men with HIV Larry Z. Slater, PhD, RN-BC, CCRN Linda Moneyham, PhD, RN, FAAN David E. Vance, PhD, MGS James L. Raper, PhD, CRNP, JD, FAANP, FAAN, FIDSA Michael J. Mugavero, MD, MHS Gwendolyn Childs, PhD, RN PII:
S1055-3290(14)00140-X
DOI:
10.1016/j.jana.2014.06.007
Reference:
JANA 663
To appear in:
Journal of the Association of Nurses in AIDS Care
Received Date: 10 March 2014 Accepted Date: 29 June 2014
Please cite this article as: SlaterL.Z., MoneyhamL., VanceD.E., RaperJ.L., MugaveroM.J. & ChildsG., The Multiple Stigma Experience and Quality of Life in Older Gay Men with HIV, Journal of the Association of Nurses in AIDS Care (2014), doi: 10.1016/j.jana.2014.06.007. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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The Multiple Stigma Experience and Quality of Life in Older Gay Men with HIV
Larry Z. Slater, PhD, RN-BC, CCRN, is Clinical Assistant Professor, College of Nursing, New
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York University, New York, New York, USA; Linda Moneyham, PhD, RN, FAAN, is Professor and Senior Associate Dean, School of Nursing, University of Alabama at Birmingham,
Birmingham, Alabama, USA; David E. Vance, PhD, MGS, is Associate Professor, School of
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Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA; James L. Raper, PhD, CRNP, JD, FAANP, FAAN, FIDSA, is Director, 1917 Clinic, and Professor, School of
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Medicine and School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA; Michael J. Mugavero, MD, MHS, is Associate Professor, School of Medicine, Internal Medicine/Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA; Gwendolyn Childs, PhD, RN, is Assistant Professor, School of Nursing, University of
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Alabama at Birmingham, Birmingham, Alabama, USA.
Disclosures: The authors report no real or perceived vested interests that relate to this article that
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could be construed as a conflict of interest.
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Acknowledgements: This research was funded in part through an educational GAANN (Graduate Assistance in Areas of National Need) grant through the School of Nursing at the University of Alabama at Birmingham, Birmingham, Alabama, USA.
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Abstract Older HIV-infected gay men may experience multiple forms of stigma related to sexual orientation (homonegativity), HIV (HIV stigma), and age (ageism), all of which can negatively
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impact quality of life (QOL). Our purpose was to determine predictors of homonegativity, internalized HIV stigma, and ageism, and stigma experiences that were predictive of QOL. Sixty HIV-infected gay men, ages 50-65 participated. Younger age and emotion-focused coping were
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significantly predictive of homonegativity, accounting for 28% of variance. Younger age,
support group participation, medications per day, social support, and emotion-focused coping
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predicted internalized HIV stigma, accounting for 35% of variance. Problem-focused coping predicted ageism, accounting for 7% of variance. In regression analysis, the 3 types of stigma accounted for 39% of variance in QOL (homonegativity 19%, internalized HIV stigma 19%, ageism 0.5%). Study findings may help researchers develop interventions to alleviate multiple
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stigma experiences of HIV-infected older gay men, thus improving QOL.
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Key words: aging, gay, HIV, quality of life, stigma
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The Multiple Stigma Experience and Quality of Life in Older Gay Men with HIV Goffman (1963), who is widely considered the father of social stigma theory, described stigma as someone’s unacceptable or undesirable characteristics that are deeply discrediting and
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that impact his/her place in society. This stigmatizing characteristic may be visible or known to others, which can lead to stress for the stigmatized individual in anticipation of or during social contacts where s/he must face potential negative reactions from others due to the stigmatizing
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characteristic (actual stigma). The stigmatizing characteristic may also be nonvisible or
unknown to others. In such cases, the stigmatized individual may choose to conceal his/her
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stigma to avoid prejudice and discrimination. Such individuals can still experience stress with social contacts, related to either fear of discovery or perceptions of how others may feel or react to a person with the stigmatizing characteristic (perceived stigma). Stress related to actual or perceived stigma not only affects social contacts but also may have a direct impact on an
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individual’s adaptational outcomes (Lazarus & Folkman, 1984), including life satisfaction or quality of life (QOL).
Forms of Stigma
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Older gay men with HIV are prone to several forms of actual and perceived social stigma that may affect QOL. They may feel stigmatized due to sexual orientation (homonegativity),
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whether they are openly gay or remain closeted. They may also experience stigma related to their HIV status (HIV stigma), whether or not they choose to disclose that they are HIV infected. Finally, they may feel stigmatized due to their age (ageism), particularly considering the emphasis that gay culture places on youth (Robinson, 2011). Homonegativity Growing up in what is traditionally seen as a heterosexist and antigay society has a great
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influence on the development of gay men (Mayfield, 2001). This influence may be cultural, such as experiencing negative societal attitudes toward homosexuality, or internal, such as negative self-attitudes toward same-sex attraction, behavior, and relationships (Shidlo, 1994). The
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negative attitudes a person has to his own homosexuality, or the internal stigma he experiences related to sexual orientation, have been termed homonegativity (Weinberg, 1973). Studies have found that homonegativity is higher among older gay men than younger gay men and higher
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among African Americans than Caucasians and Hispanics (David & Knight, 2008). The experience of homonegativity may also negatively affect the personality, emotion, and
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behavioral characteristics of gay men (Mayfield, 2001). Higher levels of homonegativity have been correlated with risky sexual behaviors in gay men (Kuyper & Vanwesenbeeck, 2011), an increase in relationship problems (Frost & Meyer, 2009), and a decrease in relationship satisfaction (Mohr & Daly, 2008). In addition, studies have demonstrated that increased
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homonegativity has a significant correlation to poor mental health outcomes (Frost & Meyer, 2009). HIV Stigma
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Herek et al. (1998) defined stigma related to HIV as “prejudice, discounting, discrediting, and discrimination directed at people perceived to have AIDS or HIV” (p. 36). They further
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acknowledged that HIV stigma creates significant internalized stress due to actual or perceived (internalized) HIV stigma, which interferes with coping and adjustment; it can also affect QOL. HIV-infected individuals of different ages and races/ethnicities may have additional societal and cultural values imposed on them, further exacerbating their stigma experiences, but recent studies have shown equivocal findings related to HIV stigma, age, and race/ethnicity. One study found that older adults experienced higher levels of HIV stigma than younger adults (Vance,
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2006), while another showed that older adults experienced lower levels of HIV stigma than younger adults (Logie & Gadalla, 2009). Similarly, one study has shown that African Americans experience higher levels of HIV stigma than Caucasians and/or Hispanics (Sayles et al., 2008),
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while another demonstrated no such differences (Holzemer et al., 2009). Despite using vastly different measures for HIV stigma and QOL, studies have consistently demonstrated a
related to lower QOL (Holzemer et al., 2009; Vance, 2006). Ageism
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significant negative relationship between HIV stigma and QOL, with higher levels of stigma
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Ageism is a negative attitude toward aging, often based on a belief that older adults are less attractive, asexual, unable to work, and less mentally competent (Atchley & Barusch, 2004). Being exposed to ageist attitudes throughout their lifetimes, older adults may, as they age, direct these attitudes and stereotypes inward (Levy, 2001). Ageism may be especially prevalent among
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older gay adults, as several studies have reiterated a commonly held belief that the gay community places an emphasis on youth (Robinson, 2011). Research on ageism in older adults with HIV is extremely limited. Emlet (2006) examined ageism in 25 older adults with HIV and
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found that one third of participants expressed sentiments or beliefs that they experienced stigma related to their older age. David and Knight (2008) determined that older African American men
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experienced higher levels of ageism than older Caucasian men. Purpose
The experience of multiple stigmas in older gay men with HIV may have a more significant impact on QOL than when considering the stigmas individually. No previous studies, however, were found that examined the combined experiences of homonegativity, internalized HIV stigma, and ageism in older gay men with HIV. The purpose of our study was to examine
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the multiple stigma experience (homonegativity, internalized HIV stigma, ageism) of older gay men with HIV and its affect on QOL. The aims of the study were: 1. To explore the relationships among social stigma (homonegativity, internalized HIV
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stigma, ageism) and sociodemographic characteristics, social support, coping, and QOL;
2. To determine the predictors of homonegativity, internalized HIV stigma, and ageism
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in older gay men with HIV from a set of sociodemographic, social support, and coping variables; and
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3. To determine the extent to which the three types of stigma account for QOL in older gay men with HIV.
Methods
This study is a secondary analysis of data collected for a quantitative, cross-sectional
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study examining support, stigma, health, coping, and quality of life in older gay men with HIV (Slater et al., 2013). For inclusion in the original study, participants had to self-identify as gay, age 50 or older, HIV infected, and English-speaking. Initial contact was made with 105 potential
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participants who were recruited through clinician referral from and placement of flyers/brochures in HIV clinics and AIDS service organizations in Alabama, Georgia, and North Carolina.
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Network sampling was also used to recruit additional participants. Sixty older (age 50+) gay men with HIV participated in the original study, with the remainder of contacts not meeting all inclusion criteria, declining to participate, or not responding after initial contact. The details of this study are found in Slater et al. (2013), including a detailed description of study procedures. The study was approved by the Institutional Review Board at the University of Alabama at Birmingham.
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Measures Stigma predictors. In a researcher-generated sociodemographic measure, participants were asked their age (in years), race (minority or nonminority), living status (alone, with
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significant other, with family/friends, in group home), education level (high school or less, some college, college graduate), annual household income (less than $20,000, $20,000-$39,999, greater than $40,000), employment (yes or no), availability of a car (yes or no), years living with
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HIV, hospitalizations due to HIV (yes or no), HIV support group participation (yes or no), the total number of medications taken per day, and whether or not they had any of 22 listed medical
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comorbidities other than HIV. The list of medical conditions was taken from a study on comorbidities in PLWH (Vance, Mugavero, Willig, Raper, & Saag, 2011). Participants also completed previously developed and validated measures for social support and coping. Type of social support was measured using the Medical Outcomes Study
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Social Support Survey (MOS-SSS; Sherbourne & Stewart, 1991), with four subscales: emotional/informational support, affection, tangible support, and positive interaction. Availability of social support and satisfaction with social support were measured using the brief
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Social Support Questionnaire (SSQ6; Sarason, Sarason, Shearin, & Pierce, 1987). Coping was measured using the Family Coping Project Coping Scale (Moneyham et al., 1997-1998), with
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subscales for problem-focused and emotion-focused coping. For our study, internal consistency reliability (Cronbach’s alpha) for the social support measures ranged from 0.89 to 0.95 and for the coping measures ranged from 0.76 to 0.88. Stigma measures. Homonegativity was measured using the Internalized Homonegativity Inventory (IHNI; Mayfield, 2001), which contains 23 items in three subscales: personal homonegativity, gay affirmation, and morality of homosexuality. The personal
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homonegativity subscale measures negative emotions and negative attitudes gay men may have about their homosexuality, such as shame, embarrassment, resentment, and depression. The gay affirmation subscale measures how gay men may feel that their homosexuality is a vital and
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positive part of their being. The morality of homosexuality subscale measures the negative attitudes gay men may have about the moral implications of their homosexual attraction and behavior. Items are rated on a 6-point scale ranging from 1 (strongly disagree) to 6 (strongly
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agree) and 7 items are reverse-scored. Higher scores indicate higher levels of internalized
homonegativity. For our study, the Cronbach’s alphas were 0.92 for personal homonegativity,
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0.81 for gay affirmation, 0.88 for morality of homonegativity, and 0.94 for the overall measure. Internalized HIV stigma was measured using the Internalized HIV Stigma instrument (Sayles et al., 2008), which contains 28 items representing four subscales: stereotypes, disclosure concerns, social relationships, and self-acceptance. The stereotypes subscale measures the HIV-
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infected individual’s perceptions of how society, coworkers, and medical providers feel about people living with HIV. The disclosure concerns subscale measures how worried the HIVinfected individual feels about others finding out about his/her HIV status. The social
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relationships subscale measures how having HIV may affect the individual’s relationships with family, friends, and medical providers. The self-acceptance subscale measures how well the
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HIV-infected individual has moved from feelings of shame to acceptance. Items are rated as to the frequency of the experience on a 6-point scale ranging from 0 (none of the time) to 5 (all of the time), with 2 items using reverse scoring. Higher scores indicate higher levels of internalized HIV stigma. For our study, the Cronbach’s alphas were 0.90 for stereotypes, 0.77 for disclosure concerns, 0.81 for social relationships, 0.77 for self-acceptance, and 0.92 for the overall measure. Ageism was measured using the Ageism Survey (Palmore, 2001), which contains 20
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questions related to actual experiences of ageism. For each question, responses indicate the frequency with which each example of ageism is experienced on a 3-point response format including 0 (never), 1 (once), or 2 (more than once). Scores are summed for a possible range of
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scores from 0 to 40, with higher scores indicating more experiences of perceived ageism. For our study, the Cronbach’s alpha was 0.79.
QOL. QOL was measured using the HIV/AIDS-Targeted Quality of Life instrument
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(HAT-QoL; Holmes & Shea, 1997), which consists of 34 items rated on a 5-point response format, ranging from 1 (all of the time) to 5 (none of the time). Eight negatively phrased
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questions are reverse scored. Higher scores indicate greater perceived QOL. For the current study, the Cronbach’s alpha was 0.93 for the overall QOL index. Data Analysis
Data were coded and verified by the principal investigator (LZS). Any missing data were
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replaced with the average imputed value (single imputation) of the remaining questions for the appropriate subscale or overall instrument. No questionnaires were excluded due to missing data (i.e., more than 20% missing items). Data were analyzed using SPSS version 19.0 with two-
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tailed tests and an alpha of 0.05 used for all tests for statistical significance. Descriptive statistics for all study variables were calculated, including frequencies, ranges, means, and standard
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deviations as indicated (Table 1). Pearson product-moment correlations or Spearman rho correlations were calculated to examine bivariate relationships among the predictor variables and the stigma scales (Table 2). Stepwise linear regression was then used to determine the predictors of the stigma scales. Predictor variables were included in the regression analysis if they had a significant bivariate correlation with at least one of the stigma subscales at the p < 0.05 level. Significant correlates
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were then added in a series of three steps to determine the predictors of each stigma scale. The first step included significant sociodemographic variables; the second step included significant social support variables; the third step included significant coping variables. If a variable proved
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significant at p < .05 at any step in each stepwise regression analysis, it was retained for the remaining steps (Table 3). Finally, the stigma scales were used in a three-step regression
analysis to determine their respective amounts of variance in QOL. Homonegativity was entered
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first, internalized HIV stigma second, and ageism third (Table 4).
With 11 predictor variables for each stigma scale, the current sample of 60 older gay men
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with HIV achieved 80% power to detect an R2 of 0.26 using an F-test with a significance level of 0.05 (based on post hoc analysis), which would be considered a large effect size (Cohen, 1998). Based on regression analyses for the current study, the sample achieved greater than 80% power for the internalized homonegativity and HIV stigma measures but not for the ageism measure.
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For three stigma predictors for QOL, the sample achieved 80% power to detect an R2 of 0.22. As the final QOL regression analysis R2 was 0.39 (see Results below), the sample of 60 achieved 99.9% power using an F-test with a significance of 0.05. (Note: As the study was exploratory
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and not confirmatory, correction for multiple testing was not applied.) Results
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Table 1 provides the sociodemographic characteristics of the sample of 60 older gay men with HIV who participated in the study. The participants ranged in age from 50 to 65 years. A majority of participants were White/Caucasian (nonminority; 57%), lived alone (53%), had at least some college education or were college graduates (80%), had an annual income less than $20,000 (54%), were unemployed (63%), and owned or had access to a car (82%). Participants had been living with HIV for an average of 18 years, were taking an average of 7.5 medications
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per day, had an average of 5.5 medical comorbidities other than HIV, and had an average of 4 routine HIV care visits per year. Only 28% had ever been hospitalized due to HIV; 35% participated in HIV support groups.
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The individual bivariate relationships between the study variables and the stigma scales were first analyzed to determine statistically significant correlates (p < 0.05) that would be included in the regression model. Table 2 provides the correlations among the study variables
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and the stigma scales. Of the sociodemographic variables, only age, HIV support group
participation, and medications taken per day were significantly correlated with at least one
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stigma scale and were therefore included in the stepwise regression analysis. All social support and coping variables were also significantly correlated with at least one stigma scale and were retained for stepwise regression analysis. All of the stigma scales were significantly correlated with QOL.
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The results of the stepwise regression analyses for each stigma scale are provided in Table 3. Age and emotion-focused coping were predictors of homonegativity, accounting for 28% of its variance. Age, HIV support group participation, total medications, availability of
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support, and emotion-focused coping were predictors of internalized HIV stigma, accounting for 35% of its variance. Only problem-focused coping predicted ageism, accounting for just 7% of
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its variance. Table 4 provides the results of the regression analysis for QOL. Homonegativity, which was added first, accounted for 19% of the variance in QOL. Internalized HIV stigma then added an additional 19%, with ageism finally adding only an additional 0.5%. All three stigma measures accounted for 39% of the total variance in QOL. Figure 1 provides a visual representation of all relationships that emerged among the stigma predictors, social stigma scales, and QOL from the stepwise regression analyses, using standardized beta coefficients.
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Discussion Although stigma and QOL research is prevalent in the literature, few studies have examined the experience of multiple stigmas on populations with multiple health disparities and
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their combined effect on QOL. Older gay men with HIV may experience stigma related to their sexual orientation, HIV status, and age, which together may have a greater detrimental effect on QOL than when independently considering individual stigmas. No literature to date has
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examined homonegativity, internalized HIV stigma, and ageism in a sample of older gay men with HIV.
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Age was significantly and negatively correlated with homonegativity, with those who were older reporting lower levels of homonegativity, and age remained a significant predictor of homonegativity in multivariate analysis. This is contrary to the findings of David and Knight (2008). Their study of 383 younger, middle-age, and older gay men, found that older age was
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associated with higher levels of homonegativity. However, David and Knight (2008) compared homonegativity between an older age group (age 55+) and a younger age group (age 18-34). As our study only examined older adults (age 50+), it is possible that such an attenuated age range
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could account for the difference. In their meta-analysis examining sociodemographic predictors of HIV stigma, Logie and Gadalla (2009) found that older adults experienced lower levels of
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HIV stigma than younger adults, possibly due to stigma competence, which is the development of skills necessary to overcome actual and perceived stigma experiences. Although age was not significantly correlated with HIV stigma in our study, it was a significant predictor of HIV stigma based on multivariate analysis. Similarly, stigma competence may be another factor that could account for age-related differences in homonegativity found in our study. Participation in HIV support groups was significantly and inversely correlated with
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internalized HIV stigma, showing that those who participated in HIV support groups experienced significantly less internalized HIV stigma, which was also observed in multivariate analysis. Goffman (1963) discussed this phenomenon, stating that support groups can become a place of
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acceptance and understanding among individuals with a shared stigma experience, in this case HIV. In comparing a group with high internalized HIV stigma to that with low internalized HIV stigma, Lee, Kochman, and Sikkema (2002) found that individuals in the group with high
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reported stigma were significantly less likely to have attended an HIV support group.
Interestingly, Lee et al. (2002) also noted that those who participated in HIV support groups had
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been living with HIV longer than those who had not, thus underlying stigma competence could possibly explain the association between HIV support group participation and decreased stigma. However, in our study, years living with HIV was not significantly correlated with internalized HIV stigma.
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Medications taken per day was significantly and directly correlated with internalized HIV stigma; thus participants with more total medications had higher levels of internalized HIV stigma. It was also a significant predictor of internalized HIV stigma in multivariate analysis.
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Older adults living with HIV have been shown to have more medical comorbidities and take more medications per day than younger adults with HIV (David & Knight, 2008; Vance,
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Mugavero, Willig, Raper, & Saag, 2011). No studies, though, have examined the relationship between total medications and internalized HIV stigma. Increased medication usage can lead to more side effects, complicated drug-drug interactions, and problems with adhering to dosing schedules, which may place added stress on the older adult with HIV. Although this may impact QOL (Slater et al., 2013), it is unclear why the current study showed this relationship between total medications and internalized HIV stigma. Rintamaki, Davis, Skripkauskas, Bennett, and
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Wolf (2006) found that high HIV stigma was significantly correlated to non-adherence to HIV medications. However, they did not discuss if taking HIV medications in and of itself was correlated with increased HIV stigma.
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All social support measures were significantly and inversely correlated with internalized HIV stigma; thus, those who reported higher levels of support reported lower levels of
internalized HIV stigma. In multivariate analysis, only availability of support was predictive of
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internalized HIV stigma. In a study of older adults living with HIV in Canada, Emlet et al. (2013) found that higher levels of emotional/informational support were correlated with lower
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levels of HIV stigma. Also in that study, emotional/informational support was a significant predictor of HIV stigma in multivariate analysis. Sherbourne and Stewart (1991) described emotional/informational support as an avenue for receiving empathic understanding, expressing feelings, and receiving advice, information, guidance, and feedback. This type of support could
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help improve stigma competence and thus decrease internalized HIV stigma. While emotional/informational support was highly correlated with internalized HIV stigma in our study, similar to availability of support, it was availability of support that was significant in the
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multivariate model. However, due to the high correlation between social support variables, it is likely that emotional/information support and availability of support can both impact internalized
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HIV stigma experiences.
Availability of support was significantly and inversely correlated with homonegativity. Other studies have demonstrated a relationship between increased homonegativity and strained social relationships (Frost & Meyer, 2009), indicating a decrease in satisfaction of support, but not necessarily availability of support. However, similar to the relationship of availability of support and decreased HIV stigma, support mechanisms can also serve as a buffer to internalized
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stigma related to homosexual identity. In multivariate analysis, however, availability of support was not a significant predictor of homonegativity. Emotion-focused coping was significantly and inversely associated with both
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homonegativity and internalized HIV stigma, with participants using more emotion-focused coping strategies reporting higher levels of stigma. Emotion-focused coping was also a
significant predictor of both homonegativity and internalized HIV stigma in multivariate
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analysis. The aforementioned study by Emlet et al. (2013) identified maladaptive coping
(similar to problem-focused coping in that the individual uses mechanisms such as denial, self-
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distraction, or self-blame) as a significant predictor of internalized HIV stigma, with those using more maladaptive coping techniques exhibiting higher levels of stigma. David and Knight (2008) found significant racial/ethnic differences in coping styles among gay men, with older gay African American men reporting greater use of disengaged, or emotion-focused, coping than
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older gay Caucasian men. Although the current study of gay men did not take into account racial/ethnic differences in coping, the use of emotion-focused coping still represented a significant effect on both internalized HIV stigma and homonegativity.
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Problem-focused coping was significantly and directly correlated with ageism, with higher reporting of more problem-focused coping strategies associated with lower reported levels
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of ageism. Problem-focused coping remained a significant predictor of ageism in multivariate analysis. Vance, Brennan, Enah, Smith, and Kaur (2011) postulated that ageism, as well as HIV stigma, could have a negative effect on active engagement in life and was thus a barrier to successful aging with HIV. Thus, instilling more problem-focused coping strategies in lieu of emotion-focused strategies may alleviate stigma experiences and in turn improve QOL, leading to successful aging.
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In examining the social stigma contributions to QOL, homonegativity and internalized HIV stigma were significantly and inversely associated, while ageism was not. Together, all three stigma predictors accounted for 39% of the variance in QOL (homonegativity 19%,
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internalized HIV stigma, 19%, ageism 0.5%). No research was found that examined the
relationship between homonegativity and QOL. However, studies have shown that higher levels of homonegativity are significantly associated with poor mental health outcomes (i.e.,
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depression) and poor overall sexual health (Frost & Meyer, 2009). As the HAT-QoL, used to measure QOL in the current study, includes domains for “worries” (health, finances,
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medications, disclosure) and sexual function (Holmes & Shea, 1997), our study shows similar findings to this previous research.
Much research has been done on the effect of HIV stigma on QOL. In a meta-analysis of HIV stigma research from 2000 to 2007 conducted by Logie and Gadalla (2009), high HIV
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stigma levels were consistently and significantly associated with poor QOL, despite wide variation in conceptual definitions and measurement of HIV stigma. As some studies have shown that older adults report higher levels of HIV stigma than younger adults (i.e., Vance,
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2006), it is imperative to address HIV stigma (and homonegativity) in older gay men living with
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HIV to greatly enhance QOL.
Implications for Practice
Health care workers, social workers, case managers, and community organizations have been playing a vital role in the lives of PLWH since the beginning of the epidemic. As the number of older adults living with HIV continues to grow in the coming years, it will be vital that these engaged parties begin to address the distinct needs of their older adult clients, particularly older gay men with HIV, who still represent the largest percentage of older PLWH.
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As HIV support groups have been shown to help decrease perceived stigma, developing and promoting support groups specifically for older gay men living with HIV, or incorporating programs geared toward them in existing support groups, can improve their QOL through
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addressing their multiple stigma issues related to homonegativity, internalized HIV stigma, and ageism. Providing other social support options, outside of specific HIV support groups, may also enhance stigma competency and improve QOL. Interventions aimed at improving coping
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skills, particularly promoting more problem-focused coping strategies, which address active ways to directly tackle the situation that caused stress, over emotion-focused strategies, which
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are used to handle feelings of distress rather than the actual problem situation, may help alleviate stigma and improve QOL. Finally, given the paucity of research on the multiple stigma experience for older gay men with HIV, more expansive research may shed additional light on its effects on QOL and provide further insight into potential interventions.
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Limitations
The study has several limitations. The study was cross-sectional and observational; therefore, no specific causal relationships can be inferred. Also, a nonprobability convenience
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sample was used in the initial study (Slater et al., 2013) so it cannot be assumed that the sample for the current study is representative of the general population of older gay men living with HIV
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and the results may not be generalizable to other populations of older adults living with HIV. Finally, for the initial study the principal investigator (LZS) asked all questions instead of having participants self-complete questionnaires. This protocol may have resulted in self-reporting bias, as participants may have provided socially desirable answers, or answers they felt the researcher wanted to hear. Conclusions
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Older gay men living with HIV encounter multiple experiences of stigma related to their sexual orientation, their HIV-positive status, and their age. This combination of experiences can have a significant impact on perceived QOL, particularly homonegativity and internalized HIV
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stigma. Our study examined the predictors of homonegativity, internalized HIV stigma, and ageism in a group of older gay men living with HIV and the impact of multiple stigmas on QOL. As the current study demonstrates, social support, HIV support group participation, and use of
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problem-focused coping strategies may help combat homonegativity, internalized HIV stigma,
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and ageism and, in turn, improve QOL for older gay men living with HIV.
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References Atchley, R. C., & Barusch, A. S. (2004). Social forces and aging: An introduction to social gerontology (10th ed.). Belmont, CA: Wadsworth/Thompson Learning.
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Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum Associates.
David, S., & Knight, B. G. (2008). Stress and coping among gay men: Age and ethnic
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differences. Psychology and Aging, 23(1), 62-69. doi:10.1037/0882-7974.23.1.62
Emlet, C. A. (2006). “You’re awfully old to have this disease”: Experiences of stigma and
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Emlet, C. A., Brennan, D. J., Brennenstuhl, S., Rueda, S., Hart, T. A., & Rourke, S. B. (2013). Protective and risk factors associated with stigma in a population of older adults living
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Frost, D. M., & Meyer, I. H. (2009). Internalized homophobia and relationship quality among
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Herek, G. M., Mitnick, L., Burris, S., Chesney, M., Devine, P., Fullilove, M. T., … Sweeney, T. (1998). Workshop report: AIDS and stigma: A conceptual framework and research agenda. AIDS & Public Policy Journal, 13(1), 36-47. Holmes, W. C., & Shea, J. A. (1997). Performance of a new HIV/AIDS-targeted quality of life
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(HAT-QoL) instrument in asymptomatic seropositive individuals. Quality of Life Research, 6(6), 561-571. doi:10.1023/A:1018464200708 Holzemer, W. L., Human, S., Arudo, J., Rosa, M. E., Hamilton, M. J., Corless, I., . . . Maryland,
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Kuyper, L., & Vanwesenbeeck, I. (2011). Examining sexual health differences between lesbian, gay, bisexual, and heterosexual adults: The role of sociodemographics, sexual behavior
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Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York, NY: Springer. Levy, B. R. (2001). Eradication of ageism requires addressing the enemy within. The
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Gerontologist, 41(5), 578-579. doi:10.1093/geront/41.5.578 Logie, C., & Gadalla, T. M. (2009). Meta-analysis of health and demographic correlates of stigma towards people living with HIV. AIDS Care, 21(6), 742-753.
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Lee, R. S., Kochman, A., & Sikkema, K. J. (2002). Internalized stigma among people living with
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HIV-AIDS. AIDS and Behavior, 4(6), 309-319. doi:10.1023/A:1021144511957 Mayfield, W. W. (2001). The development of an Internalized Homonegativity Inventory for gay men. Journal of Homosexuality, 41(2), 53-76. doi:10.1300/J082v41n02_04 Mohr, J. J., & Daly, C. A. (2008). Sexual minority stress and changes in relationship quality in same-sex couples. Journal of Social and Personal Relationships, 25(6), 989-1007. doi:10.1177/0265407508100311
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Moneyham, L., Demi, A., Mizuno, Y., Sowell, R., Seals, B., & Guillory, J. (1997-1998). Development and testing of a contextually and culturally relevant measure of coping for use with women infected with HIV. OMEGA – Journal of Death and Dying, 3(4), 377-
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Palmore, E. (2001). The Ageism Survey. The Gerontologist, 41(5), 572-575. doi:10.1093/geront/41.5.572
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359-368. doi:10.1089/apc.2006.20.359
Robinson, P. (2011). The influence of ageism on relations between old and young gay men. In Y. Smaal & G. Willett (Eds.), Out here: Gay and lesbian perspectives VI (pp. 188-200). Clayton, Australia: Monash University Publishing.
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Sarason, I. G., Sarason, B. R., Shearin, E. N., & Pierce, G. R. (1987). A brief measure of social support: Practical and theoretical implications. Journal of Social and Personal Relationships, 4, 497-510. doi:10.1177/0265407587044007
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Sayles, J. N., Hays, R. D., Sarkisian, C. A., Mahajan, A. P., Spritzer, K. L., & Cunningham, W. E. (2008). Development and psychometric assessment of a multidimensional measure of
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internalized HIV stigma in a sample of HIV-positive adults. AIDS and Behavior, 12, 748758. doi:10.1007/s10461-008-9375-3 Sherbourne, C. D., & Stewart, A. L. (1991). The MOS social support survey. Social Science and Medicine, 32(6), 705-714. doi:10.1016/0277-9536(91)90150-B Shidlo, A. (1994). Internalized homophobia: Conceptual and empirical issues in measurement. In B. Greene & G. M. Herek (Eds.), Lesbian and gay psychology: Theory, research, and
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clinical applications (pp. 176-205). Thousand Oaks, CA: Sage. Slater, L. Z., Moneyham, L., Vance, D. E., Raper, J. L., Mugavero, M. J., & Childs, G. (2013). Support, stigma, health, coping, and quality of life in older gay men with HIV. Journal of
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the Association of Nurses in AIDS Care, 24(1), 38-49. doi:10.1016/j.jana.2012.02.006 Vance, D. E. (2006). Self-rated emotional health in adults with and without HIV. Psychological Reports, 98, 106-108. doi:10.2466/pr0.98.1.106-108
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Vance, D. E., Brennan, M., Enah, C., Smith, G. L., & Kaur, J. (2011). Religion, spirituality, and older adults with HIV: Critical personal and social resources for an aging epidemic.
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Clinical Interventions in Aging, 6, 101-109. doi:10.2174/CIA.S16349 Vance, D. E., Mugavero, M., Willig, J., Raper, J. L., & Saag, M. S. (2011). Aging with HIV: A cross-sectional study of comorbidity prevalence and clinical characteristics across decades of life. Journal of the Association of Nurses in AIDS Care, 22(1), 17-25.
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doi:10.1016/j.jana.2010.04.02
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Weinberg, G. (1973). Society and the healthy homosexual. Garden City, NY: Anchor Books.
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Table 1 Sociodemographic Characteristics of the Sample Maximum
Mean
SD
Age
50.0
65.0
54.6
3.8
Years living with HIV
1.2
29.7
17.9
7.5
Annual Routine HIV Care Visits
2
24
4.3
3.3
Medications Taken per Day
1
20
7.5
4.6
Comorbidities Other than HIV
0
11
5.5
2.8
Characteristic Racea Minority Nonminority
n
Living Status Alone With others
%
43.3 56.7
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26 34
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Minimum
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Characteristic
32 28
53.3 46.7
12 48
20.0 80.0
32 27
54.2 45.8
38 22
63.3 36.7
Owns or Has Access to Car No Yes
11 49
18.3 81.7
Ever Hospitalized Due to HIV No Yes
37 23
61.7 38.3
HIV Support Group Participation No Yes
39 21
65.0 35.0
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Education High school or less Some college or college graduate
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Has a Job that Pays No Yes
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Annual Incomeb < $20,000 $20,000 +
a. Minority includes African American/Black (n = 25) and Asian Indian (n = 1) participants. Nonminority includes Caucasian/White participants. b. Based on 59 participants (one declined to answer the question).
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Table 2 Correlations Among Study Variables and Stigma Measuresa
Quality of life
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Coping Problem-focused coping Emotion-focused coping
-.332c -.214 -.021 -.154 -.193 .024 -.200 -.083 .172 .167 -.135 .001 .104
-.202 .091 -.063 -.100 -.118 -.129 -.167 -.017 0.20 .221 -.269c .255b .240
.009 -.035 .017 .089 .089 .021 -.069 .018 .131 .191 -.180 .163 .164
-.132 .015 -.180 -.027 -.306c -.041
-.437c -.299b -.383c -.334c -.439c -.294b
-.251 -.190 -.188 -.224 -.098 -.081
.038 .509c
-.245 .423c
-.291b .022
-.449c
-.590c
-.339c
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Social Support Emotional/informational support Tangible support Positive interaction Affection Availability of support Satisfaction with support
Internalized HIV Stigma
Ageism
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Sociodemographics Age Race Living status Education Annual income Has a job that pays Owns or has access to car Years living with HIV Ever hospitalized due to HIV Annual routine HIV care visits HIV support group participation Medications taken per day Comorbidities other than HIV
Homonegativity
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Study Variable
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a. Pearson product moment correlations were used for age, years living with HIV, annual routine HIV care visits, medications taken per day, comorbidities other than HIV, and all social support, coping, and quality of life measures. Spearman rho correlations were used for the remaining variables. b. p < .05. c. p < .01.
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Table 3 Significant Social Stigma Predictors
Homonegativity Age Emotion-focused coping
-1.10 1.64
Internalized HIV stigma Age HIV support group participation Total medications Availability of support Emotion-focused coping
-.15
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a. p < 0.05. b. p < 0.01.
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p
F
Adj. R2
12.39
.279b
-.22 .45b
.000 .063 .000
.58 .41
.000 .229 .022 .113 .019 .018
7.37
.351b
.59 4.14 .48 .25 .39
.024 .024
5.36
.069a
-.15 -.26a .20 -.30a .28a
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Ageism Problem-focused coping
-.72 -9.77 .78 -.62 .94
β
SE
.07
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B
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Measure
-.29
a
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Table 4 Stigma Predictors of Quality of Life
Model 1 Homonegativity
-.37
Model 2 Homonegativity Internalized HIV Stigma
-.21 -.42
Model 3 Homonegativity Internalized HIV Stigma Ageism
-.21 -.38 -.33
β
p
F
Adj. R2 .188b
.10
.000 .000
14.68
b
.000 .023 .000
19.41
.384b
.000 .021 .001 .231
13.54
.389b
-.45
.09 .10
-.26a -.49b
.09 .10 .27
a
-.26 -.43b -.13
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a. p < 0.05. b. p < 0.01.
SE
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B
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Measure
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Running head: STIGMA AND QUALITY OF LIFE
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Figure 1. Visual representation of the relationships that emerged from regression analysis using standardized betas.
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Key Considerations •
It is imperative that health care providers address the distinct needs of an aging population of gay men with HIV. Developing and promoting support groups specifically for older gay men with HIV may help decrease perceived stigma and positively impact quality of life.
Encouraging additional social support options for older gay men with HIV may enhance stigma competency and improve quality of life.
Interventions aimed at increasing the use of problem-focused coping strategies over emotion-
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focused coping strategies for older gay men with HIV may help alleviate stigma and improve
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quality of life.
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•
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•
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•
S1055-3290(14)00140-X
DOI:
10.1016/j.jana.2014.06.007
Reference:
JANA 663
To appear in:
Journal of the Association of Nurses in AIDS Care
Received Date: 10 March 2014 Accepted Date: 29 June 2014
Please cite this article as: SlaterL.Z., MoneyhamL., VanceD.E., RaperJ.L., MugaveroM.J. & ChildsG., The Multiple Stigma Experience and Quality of Life in Older Gay Men with HIV, Journal of the Association of Nurses in AIDS Care (2014), doi: 10.1016/j.jana.2014.06.007. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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The Multiple Stigma Experience and Quality of Life in Older Gay Men with HIV
Larry Z. Slater, PhD, RN-BC, CCRN, is Clinical Assistant Professor, College of Nursing, New
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York University, New York, New York, USA; Linda Moneyham, PhD, RN, FAAN, is Professor and Senior Associate Dean, School of Nursing, University of Alabama at Birmingham,
Birmingham, Alabama, USA; David E. Vance, PhD, MGS, is Associate Professor, School of
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Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA; James L. Raper, PhD, CRNP, JD, FAANP, FAAN, FIDSA, is Director, 1917 Clinic, and Professor, School of
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Medicine and School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama, USA; Michael J. Mugavero, MD, MHS, is Associate Professor, School of Medicine, Internal Medicine/Infectious Diseases, University of Alabama at Birmingham, Birmingham, Alabama, USA; Gwendolyn Childs, PhD, RN, is Assistant Professor, School of Nursing, University of
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Alabama at Birmingham, Birmingham, Alabama, USA.
Disclosures: The authors report no real or perceived vested interests that relate to this article that
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could be construed as a conflict of interest.
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Acknowledgements: This research was funded in part through an educational GAANN (Graduate Assistance in Areas of National Need) grant through the School of Nursing at the University of Alabama at Birmingham, Birmingham, Alabama, USA.
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Abstract Older HIV-infected gay men may experience multiple forms of stigma related to sexual orientation (homonegativity), HIV (HIV stigma), and age (ageism), all of which can negatively
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impact quality of life (QOL). Our purpose was to determine predictors of homonegativity, internalized HIV stigma, and ageism, and stigma experiences that were predictive of QOL. Sixty HIV-infected gay men, ages 50-65 participated. Younger age and emotion-focused coping were
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significantly predictive of homonegativity, accounting for 28% of variance. Younger age,
support group participation, medications per day, social support, and emotion-focused coping
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predicted internalized HIV stigma, accounting for 35% of variance. Problem-focused coping predicted ageism, accounting for 7% of variance. In regression analysis, the 3 types of stigma accounted for 39% of variance in QOL (homonegativity 19%, internalized HIV stigma 19%, ageism 0.5%). Study findings may help researchers develop interventions to alleviate multiple
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stigma experiences of HIV-infected older gay men, thus improving QOL.
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Key words: aging, gay, HIV, quality of life, stigma
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The Multiple Stigma Experience and Quality of Life in Older Gay Men with HIV Goffman (1963), who is widely considered the father of social stigma theory, described stigma as someone’s unacceptable or undesirable characteristics that are deeply discrediting and
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that impact his/her place in society. This stigmatizing characteristic may be visible or known to others, which can lead to stress for the stigmatized individual in anticipation of or during social contacts where s/he must face potential negative reactions from others due to the stigmatizing
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characteristic (actual stigma). The stigmatizing characteristic may also be nonvisible or
unknown to others. In such cases, the stigmatized individual may choose to conceal his/her
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stigma to avoid prejudice and discrimination. Such individuals can still experience stress with social contacts, related to either fear of discovery or perceptions of how others may feel or react to a person with the stigmatizing characteristic (perceived stigma). Stress related to actual or perceived stigma not only affects social contacts but also may have a direct impact on an
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individual’s adaptational outcomes (Lazarus & Folkman, 1984), including life satisfaction or quality of life (QOL).
Forms of Stigma
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Older gay men with HIV are prone to several forms of actual and perceived social stigma that may affect QOL. They may feel stigmatized due to sexual orientation (homonegativity),
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whether they are openly gay or remain closeted. They may also experience stigma related to their HIV status (HIV stigma), whether or not they choose to disclose that they are HIV infected. Finally, they may feel stigmatized due to their age (ageism), particularly considering the emphasis that gay culture places on youth (Robinson, 2011). Homonegativity Growing up in what is traditionally seen as a heterosexist and antigay society has a great
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influence on the development of gay men (Mayfield, 2001). This influence may be cultural, such as experiencing negative societal attitudes toward homosexuality, or internal, such as negative self-attitudes toward same-sex attraction, behavior, and relationships (Shidlo, 1994). The
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negative attitudes a person has to his own homosexuality, or the internal stigma he experiences related to sexual orientation, have been termed homonegativity (Weinberg, 1973). Studies have found that homonegativity is higher among older gay men than younger gay men and higher
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among African Americans than Caucasians and Hispanics (David & Knight, 2008). The experience of homonegativity may also negatively affect the personality, emotion, and
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behavioral characteristics of gay men (Mayfield, 2001). Higher levels of homonegativity have been correlated with risky sexual behaviors in gay men (Kuyper & Vanwesenbeeck, 2011), an increase in relationship problems (Frost & Meyer, 2009), and a decrease in relationship satisfaction (Mohr & Daly, 2008). In addition, studies have demonstrated that increased
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homonegativity has a significant correlation to poor mental health outcomes (Frost & Meyer, 2009). HIV Stigma
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Herek et al. (1998) defined stigma related to HIV as “prejudice, discounting, discrediting, and discrimination directed at people perceived to have AIDS or HIV” (p. 36). They further
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acknowledged that HIV stigma creates significant internalized stress due to actual or perceived (internalized) HIV stigma, which interferes with coping and adjustment; it can also affect QOL. HIV-infected individuals of different ages and races/ethnicities may have additional societal and cultural values imposed on them, further exacerbating their stigma experiences, but recent studies have shown equivocal findings related to HIV stigma, age, and race/ethnicity. One study found that older adults experienced higher levels of HIV stigma than younger adults (Vance,
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2006), while another showed that older adults experienced lower levels of HIV stigma than younger adults (Logie & Gadalla, 2009). Similarly, one study has shown that African Americans experience higher levels of HIV stigma than Caucasians and/or Hispanics (Sayles et al., 2008),
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while another demonstrated no such differences (Holzemer et al., 2009). Despite using vastly different measures for HIV stigma and QOL, studies have consistently demonstrated a
related to lower QOL (Holzemer et al., 2009; Vance, 2006). Ageism
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significant negative relationship between HIV stigma and QOL, with higher levels of stigma
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Ageism is a negative attitude toward aging, often based on a belief that older adults are less attractive, asexual, unable to work, and less mentally competent (Atchley & Barusch, 2004). Being exposed to ageist attitudes throughout their lifetimes, older adults may, as they age, direct these attitudes and stereotypes inward (Levy, 2001). Ageism may be especially prevalent among
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older gay adults, as several studies have reiterated a commonly held belief that the gay community places an emphasis on youth (Robinson, 2011). Research on ageism in older adults with HIV is extremely limited. Emlet (2006) examined ageism in 25 older adults with HIV and
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found that one third of participants expressed sentiments or beliefs that they experienced stigma related to their older age. David and Knight (2008) determined that older African American men
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experienced higher levels of ageism than older Caucasian men. Purpose
The experience of multiple stigmas in older gay men with HIV may have a more significant impact on QOL than when considering the stigmas individually. No previous studies, however, were found that examined the combined experiences of homonegativity, internalized HIV stigma, and ageism in older gay men with HIV. The purpose of our study was to examine
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the multiple stigma experience (homonegativity, internalized HIV stigma, ageism) of older gay men with HIV and its affect on QOL. The aims of the study were: 1. To explore the relationships among social stigma (homonegativity, internalized HIV
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stigma, ageism) and sociodemographic characteristics, social support, coping, and QOL;
2. To determine the predictors of homonegativity, internalized HIV stigma, and ageism
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in older gay men with HIV from a set of sociodemographic, social support, and coping variables; and
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3. To determine the extent to which the three types of stigma account for QOL in older gay men with HIV.
Methods
This study is a secondary analysis of data collected for a quantitative, cross-sectional
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study examining support, stigma, health, coping, and quality of life in older gay men with HIV (Slater et al., 2013). For inclusion in the original study, participants had to self-identify as gay, age 50 or older, HIV infected, and English-speaking. Initial contact was made with 105 potential
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participants who were recruited through clinician referral from and placement of flyers/brochures in HIV clinics and AIDS service organizations in Alabama, Georgia, and North Carolina.
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Network sampling was also used to recruit additional participants. Sixty older (age 50+) gay men with HIV participated in the original study, with the remainder of contacts not meeting all inclusion criteria, declining to participate, or not responding after initial contact. The details of this study are found in Slater et al. (2013), including a detailed description of study procedures. The study was approved by the Institutional Review Board at the University of Alabama at Birmingham.
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Measures Stigma predictors. In a researcher-generated sociodemographic measure, participants were asked their age (in years), race (minority or nonminority), living status (alone, with
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significant other, with family/friends, in group home), education level (high school or less, some college, college graduate), annual household income (less than $20,000, $20,000-$39,999, greater than $40,000), employment (yes or no), availability of a car (yes or no), years living with
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HIV, hospitalizations due to HIV (yes or no), HIV support group participation (yes or no), the total number of medications taken per day, and whether or not they had any of 22 listed medical
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comorbidities other than HIV. The list of medical conditions was taken from a study on comorbidities in PLWH (Vance, Mugavero, Willig, Raper, & Saag, 2011). Participants also completed previously developed and validated measures for social support and coping. Type of social support was measured using the Medical Outcomes Study
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Social Support Survey (MOS-SSS; Sherbourne & Stewart, 1991), with four subscales: emotional/informational support, affection, tangible support, and positive interaction. Availability of social support and satisfaction with social support were measured using the brief
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Social Support Questionnaire (SSQ6; Sarason, Sarason, Shearin, & Pierce, 1987). Coping was measured using the Family Coping Project Coping Scale (Moneyham et al., 1997-1998), with
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subscales for problem-focused and emotion-focused coping. For our study, internal consistency reliability (Cronbach’s alpha) for the social support measures ranged from 0.89 to 0.95 and for the coping measures ranged from 0.76 to 0.88. Stigma measures. Homonegativity was measured using the Internalized Homonegativity Inventory (IHNI; Mayfield, 2001), which contains 23 items in three subscales: personal homonegativity, gay affirmation, and morality of homosexuality. The personal
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homonegativity subscale measures negative emotions and negative attitudes gay men may have about their homosexuality, such as shame, embarrassment, resentment, and depression. The gay affirmation subscale measures how gay men may feel that their homosexuality is a vital and
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positive part of their being. The morality of homosexuality subscale measures the negative attitudes gay men may have about the moral implications of their homosexual attraction and behavior. Items are rated on a 6-point scale ranging from 1 (strongly disagree) to 6 (strongly
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agree) and 7 items are reverse-scored. Higher scores indicate higher levels of internalized
homonegativity. For our study, the Cronbach’s alphas were 0.92 for personal homonegativity,
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0.81 for gay affirmation, 0.88 for morality of homonegativity, and 0.94 for the overall measure. Internalized HIV stigma was measured using the Internalized HIV Stigma instrument (Sayles et al., 2008), which contains 28 items representing four subscales: stereotypes, disclosure concerns, social relationships, and self-acceptance. The stereotypes subscale measures the HIV-
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infected individual’s perceptions of how society, coworkers, and medical providers feel about people living with HIV. The disclosure concerns subscale measures how worried the HIVinfected individual feels about others finding out about his/her HIV status. The social
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relationships subscale measures how having HIV may affect the individual’s relationships with family, friends, and medical providers. The self-acceptance subscale measures how well the
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HIV-infected individual has moved from feelings of shame to acceptance. Items are rated as to the frequency of the experience on a 6-point scale ranging from 0 (none of the time) to 5 (all of the time), with 2 items using reverse scoring. Higher scores indicate higher levels of internalized HIV stigma. For our study, the Cronbach’s alphas were 0.90 for stereotypes, 0.77 for disclosure concerns, 0.81 for social relationships, 0.77 for self-acceptance, and 0.92 for the overall measure. Ageism was measured using the Ageism Survey (Palmore, 2001), which contains 20
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questions related to actual experiences of ageism. For each question, responses indicate the frequency with which each example of ageism is experienced on a 3-point response format including 0 (never), 1 (once), or 2 (more than once). Scores are summed for a possible range of
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scores from 0 to 40, with higher scores indicating more experiences of perceived ageism. For our study, the Cronbach’s alpha was 0.79.
QOL. QOL was measured using the HIV/AIDS-Targeted Quality of Life instrument
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(HAT-QoL; Holmes & Shea, 1997), which consists of 34 items rated on a 5-point response format, ranging from 1 (all of the time) to 5 (none of the time). Eight negatively phrased
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questions are reverse scored. Higher scores indicate greater perceived QOL. For the current study, the Cronbach’s alpha was 0.93 for the overall QOL index. Data Analysis
Data were coded and verified by the principal investigator (LZS). Any missing data were
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replaced with the average imputed value (single imputation) of the remaining questions for the appropriate subscale or overall instrument. No questionnaires were excluded due to missing data (i.e., more than 20% missing items). Data were analyzed using SPSS version 19.0 with two-
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tailed tests and an alpha of 0.05 used for all tests for statistical significance. Descriptive statistics for all study variables were calculated, including frequencies, ranges, means, and standard
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deviations as indicated (Table 1). Pearson product-moment correlations or Spearman rho correlations were calculated to examine bivariate relationships among the predictor variables and the stigma scales (Table 2). Stepwise linear regression was then used to determine the predictors of the stigma scales. Predictor variables were included in the regression analysis if they had a significant bivariate correlation with at least one of the stigma subscales at the p < 0.05 level. Significant correlates
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were then added in a series of three steps to determine the predictors of each stigma scale. The first step included significant sociodemographic variables; the second step included significant social support variables; the third step included significant coping variables. If a variable proved
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significant at p < .05 at any step in each stepwise regression analysis, it was retained for the remaining steps (Table 3). Finally, the stigma scales were used in a three-step regression
analysis to determine their respective amounts of variance in QOL. Homonegativity was entered
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first, internalized HIV stigma second, and ageism third (Table 4).
With 11 predictor variables for each stigma scale, the current sample of 60 older gay men
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with HIV achieved 80% power to detect an R2 of 0.26 using an F-test with a significance level of 0.05 (based on post hoc analysis), which would be considered a large effect size (Cohen, 1998). Based on regression analyses for the current study, the sample achieved greater than 80% power for the internalized homonegativity and HIV stigma measures but not for the ageism measure.
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For three stigma predictors for QOL, the sample achieved 80% power to detect an R2 of 0.22. As the final QOL regression analysis R2 was 0.39 (see Results below), the sample of 60 achieved 99.9% power using an F-test with a significance of 0.05. (Note: As the study was exploratory
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and not confirmatory, correction for multiple testing was not applied.) Results
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Table 1 provides the sociodemographic characteristics of the sample of 60 older gay men with HIV who participated in the study. The participants ranged in age from 50 to 65 years. A majority of participants were White/Caucasian (nonminority; 57%), lived alone (53%), had at least some college education or were college graduates (80%), had an annual income less than $20,000 (54%), were unemployed (63%), and owned or had access to a car (82%). Participants had been living with HIV for an average of 18 years, were taking an average of 7.5 medications
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per day, had an average of 5.5 medical comorbidities other than HIV, and had an average of 4 routine HIV care visits per year. Only 28% had ever been hospitalized due to HIV; 35% participated in HIV support groups.
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The individual bivariate relationships between the study variables and the stigma scales were first analyzed to determine statistically significant correlates (p < 0.05) that would be included in the regression model. Table 2 provides the correlations among the study variables
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and the stigma scales. Of the sociodemographic variables, only age, HIV support group
participation, and medications taken per day were significantly correlated with at least one
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stigma scale and were therefore included in the stepwise regression analysis. All social support and coping variables were also significantly correlated with at least one stigma scale and were retained for stepwise regression analysis. All of the stigma scales were significantly correlated with QOL.
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The results of the stepwise regression analyses for each stigma scale are provided in Table 3. Age and emotion-focused coping were predictors of homonegativity, accounting for 28% of its variance. Age, HIV support group participation, total medications, availability of
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support, and emotion-focused coping were predictors of internalized HIV stigma, accounting for 35% of its variance. Only problem-focused coping predicted ageism, accounting for just 7% of
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its variance. Table 4 provides the results of the regression analysis for QOL. Homonegativity, which was added first, accounted for 19% of the variance in QOL. Internalized HIV stigma then added an additional 19%, with ageism finally adding only an additional 0.5%. All three stigma measures accounted for 39% of the total variance in QOL. Figure 1 provides a visual representation of all relationships that emerged among the stigma predictors, social stigma scales, and QOL from the stepwise regression analyses, using standardized beta coefficients.
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Discussion Although stigma and QOL research is prevalent in the literature, few studies have examined the experience of multiple stigmas on populations with multiple health disparities and
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their combined effect on QOL. Older gay men with HIV may experience stigma related to their sexual orientation, HIV status, and age, which together may have a greater detrimental effect on QOL than when independently considering individual stigmas. No literature to date has
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examined homonegativity, internalized HIV stigma, and ageism in a sample of older gay men with HIV.
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Age was significantly and negatively correlated with homonegativity, with those who were older reporting lower levels of homonegativity, and age remained a significant predictor of homonegativity in multivariate analysis. This is contrary to the findings of David and Knight (2008). Their study of 383 younger, middle-age, and older gay men, found that older age was
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associated with higher levels of homonegativity. However, David and Knight (2008) compared homonegativity between an older age group (age 55+) and a younger age group (age 18-34). As our study only examined older adults (age 50+), it is possible that such an attenuated age range
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could account for the difference. In their meta-analysis examining sociodemographic predictors of HIV stigma, Logie and Gadalla (2009) found that older adults experienced lower levels of
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HIV stigma than younger adults, possibly due to stigma competence, which is the development of skills necessary to overcome actual and perceived stigma experiences. Although age was not significantly correlated with HIV stigma in our study, it was a significant predictor of HIV stigma based on multivariate analysis. Similarly, stigma competence may be another factor that could account for age-related differences in homonegativity found in our study. Participation in HIV support groups was significantly and inversely correlated with
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internalized HIV stigma, showing that those who participated in HIV support groups experienced significantly less internalized HIV stigma, which was also observed in multivariate analysis. Goffman (1963) discussed this phenomenon, stating that support groups can become a place of
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acceptance and understanding among individuals with a shared stigma experience, in this case HIV. In comparing a group with high internalized HIV stigma to that with low internalized HIV stigma, Lee, Kochman, and Sikkema (2002) found that individuals in the group with high
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reported stigma were significantly less likely to have attended an HIV support group.
Interestingly, Lee et al. (2002) also noted that those who participated in HIV support groups had
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been living with HIV longer than those who had not, thus underlying stigma competence could possibly explain the association between HIV support group participation and decreased stigma. However, in our study, years living with HIV was not significantly correlated with internalized HIV stigma.
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Medications taken per day was significantly and directly correlated with internalized HIV stigma; thus participants with more total medications had higher levels of internalized HIV stigma. It was also a significant predictor of internalized HIV stigma in multivariate analysis.
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Older adults living with HIV have been shown to have more medical comorbidities and take more medications per day than younger adults with HIV (David & Knight, 2008; Vance,
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Mugavero, Willig, Raper, & Saag, 2011). No studies, though, have examined the relationship between total medications and internalized HIV stigma. Increased medication usage can lead to more side effects, complicated drug-drug interactions, and problems with adhering to dosing schedules, which may place added stress on the older adult with HIV. Although this may impact QOL (Slater et al., 2013), it is unclear why the current study showed this relationship between total medications and internalized HIV stigma. Rintamaki, Davis, Skripkauskas, Bennett, and
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Wolf (2006) found that high HIV stigma was significantly correlated to non-adherence to HIV medications. However, they did not discuss if taking HIV medications in and of itself was correlated with increased HIV stigma.
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All social support measures were significantly and inversely correlated with internalized HIV stigma; thus, those who reported higher levels of support reported lower levels of
internalized HIV stigma. In multivariate analysis, only availability of support was predictive of
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internalized HIV stigma. In a study of older adults living with HIV in Canada, Emlet et al. (2013) found that higher levels of emotional/informational support were correlated with lower
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levels of HIV stigma. Also in that study, emotional/informational support was a significant predictor of HIV stigma in multivariate analysis. Sherbourne and Stewart (1991) described emotional/informational support as an avenue for receiving empathic understanding, expressing feelings, and receiving advice, information, guidance, and feedback. This type of support could
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help improve stigma competence and thus decrease internalized HIV stigma. While emotional/informational support was highly correlated with internalized HIV stigma in our study, similar to availability of support, it was availability of support that was significant in the
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multivariate model. However, due to the high correlation between social support variables, it is likely that emotional/information support and availability of support can both impact internalized
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HIV stigma experiences.
Availability of support was significantly and inversely correlated with homonegativity. Other studies have demonstrated a relationship between increased homonegativity and strained social relationships (Frost & Meyer, 2009), indicating a decrease in satisfaction of support, but not necessarily availability of support. However, similar to the relationship of availability of support and decreased HIV stigma, support mechanisms can also serve as a buffer to internalized
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stigma related to homosexual identity. In multivariate analysis, however, availability of support was not a significant predictor of homonegativity. Emotion-focused coping was significantly and inversely associated with both
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homonegativity and internalized HIV stigma, with participants using more emotion-focused coping strategies reporting higher levels of stigma. Emotion-focused coping was also a
significant predictor of both homonegativity and internalized HIV stigma in multivariate
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analysis. The aforementioned study by Emlet et al. (2013) identified maladaptive coping
(similar to problem-focused coping in that the individual uses mechanisms such as denial, self-
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distraction, or self-blame) as a significant predictor of internalized HIV stigma, with those using more maladaptive coping techniques exhibiting higher levels of stigma. David and Knight (2008) found significant racial/ethnic differences in coping styles among gay men, with older gay African American men reporting greater use of disengaged, or emotion-focused, coping than
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older gay Caucasian men. Although the current study of gay men did not take into account racial/ethnic differences in coping, the use of emotion-focused coping still represented a significant effect on both internalized HIV stigma and homonegativity.
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Problem-focused coping was significantly and directly correlated with ageism, with higher reporting of more problem-focused coping strategies associated with lower reported levels
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of ageism. Problem-focused coping remained a significant predictor of ageism in multivariate analysis. Vance, Brennan, Enah, Smith, and Kaur (2011) postulated that ageism, as well as HIV stigma, could have a negative effect on active engagement in life and was thus a barrier to successful aging with HIV. Thus, instilling more problem-focused coping strategies in lieu of emotion-focused strategies may alleviate stigma experiences and in turn improve QOL, leading to successful aging.
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In examining the social stigma contributions to QOL, homonegativity and internalized HIV stigma were significantly and inversely associated, while ageism was not. Together, all three stigma predictors accounted for 39% of the variance in QOL (homonegativity 19%,
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internalized HIV stigma, 19%, ageism 0.5%). No research was found that examined the
relationship between homonegativity and QOL. However, studies have shown that higher levels of homonegativity are significantly associated with poor mental health outcomes (i.e.,
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depression) and poor overall sexual health (Frost & Meyer, 2009). As the HAT-QoL, used to measure QOL in the current study, includes domains for “worries” (health, finances,
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medications, disclosure) and sexual function (Holmes & Shea, 1997), our study shows similar findings to this previous research.
Much research has been done on the effect of HIV stigma on QOL. In a meta-analysis of HIV stigma research from 2000 to 2007 conducted by Logie and Gadalla (2009), high HIV
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stigma levels were consistently and significantly associated with poor QOL, despite wide variation in conceptual definitions and measurement of HIV stigma. As some studies have shown that older adults report higher levels of HIV stigma than younger adults (i.e., Vance,
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2006), it is imperative to address HIV stigma (and homonegativity) in older gay men living with
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HIV to greatly enhance QOL.
Implications for Practice
Health care workers, social workers, case managers, and community organizations have been playing a vital role in the lives of PLWH since the beginning of the epidemic. As the number of older adults living with HIV continues to grow in the coming years, it will be vital that these engaged parties begin to address the distinct needs of their older adult clients, particularly older gay men with HIV, who still represent the largest percentage of older PLWH.
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As HIV support groups have been shown to help decrease perceived stigma, developing and promoting support groups specifically for older gay men living with HIV, or incorporating programs geared toward them in existing support groups, can improve their QOL through
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addressing their multiple stigma issues related to homonegativity, internalized HIV stigma, and ageism. Providing other social support options, outside of specific HIV support groups, may also enhance stigma competency and improve QOL. Interventions aimed at improving coping
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skills, particularly promoting more problem-focused coping strategies, which address active ways to directly tackle the situation that caused stress, over emotion-focused strategies, which
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are used to handle feelings of distress rather than the actual problem situation, may help alleviate stigma and improve QOL. Finally, given the paucity of research on the multiple stigma experience for older gay men with HIV, more expansive research may shed additional light on its effects on QOL and provide further insight into potential interventions.
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Limitations
The study has several limitations. The study was cross-sectional and observational; therefore, no specific causal relationships can be inferred. Also, a nonprobability convenience
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sample was used in the initial study (Slater et al., 2013) so it cannot be assumed that the sample for the current study is representative of the general population of older gay men living with HIV
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and the results may not be generalizable to other populations of older adults living with HIV. Finally, for the initial study the principal investigator (LZS) asked all questions instead of having participants self-complete questionnaires. This protocol may have resulted in self-reporting bias, as participants may have provided socially desirable answers, or answers they felt the researcher wanted to hear. Conclusions
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Older gay men living with HIV encounter multiple experiences of stigma related to their sexual orientation, their HIV-positive status, and their age. This combination of experiences can have a significant impact on perceived QOL, particularly homonegativity and internalized HIV
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stigma. Our study examined the predictors of homonegativity, internalized HIV stigma, and ageism in a group of older gay men living with HIV and the impact of multiple stigmas on QOL. As the current study demonstrates, social support, HIV support group participation, and use of
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problem-focused coping strategies may help combat homonegativity, internalized HIV stigma,
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and ageism and, in turn, improve QOL for older gay men living with HIV.
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Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum Associates.
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Herek, G. M., Mitnick, L., Burris, S., Chesney, M., Devine, P., Fullilove, M. T., … Sweeney, T. (1998). Workshop report: AIDS and stigma: A conceptual framework and research agenda. AIDS & Public Policy Journal, 13(1), 36-47. Holmes, W. C., & Shea, J. A. (1997). Performance of a new HIV/AIDS-targeted quality of life
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(HAT-QoL) instrument in asymptomatic seropositive individuals. Quality of Life Research, 6(6), 561-571. doi:10.1023/A:1018464200708 Holzemer, W. L., Human, S., Arudo, J., Rosa, M. E., Hamilton, M. J., Corless, I., . . . Maryland,
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Moneyham, L., Demi, A., Mizuno, Y., Sowell, R., Seals, B., & Guillory, J. (1997-1998). Development and testing of a contextually and culturally relevant measure of coping for use with women infected with HIV. OMEGA – Journal of Death and Dying, 3(4), 377-
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internalized HIV stigma in a sample of HIV-positive adults. AIDS and Behavior, 12, 748758. doi:10.1007/s10461-008-9375-3 Sherbourne, C. D., & Stewart, A. L. (1991). The MOS social support survey. Social Science and Medicine, 32(6), 705-714. doi:10.1016/0277-9536(91)90150-B Shidlo, A. (1994). Internalized homophobia: Conceptual and empirical issues in measurement. In B. Greene & G. M. Herek (Eds.), Lesbian and gay psychology: Theory, research, and
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clinical applications (pp. 176-205). Thousand Oaks, CA: Sage. Slater, L. Z., Moneyham, L., Vance, D. E., Raper, J. L., Mugavero, M. J., & Childs, G. (2013). Support, stigma, health, coping, and quality of life in older gay men with HIV. Journal of
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the Association of Nurses in AIDS Care, 24(1), 38-49. doi:10.1016/j.jana.2012.02.006 Vance, D. E. (2006). Self-rated emotional health in adults with and without HIV. Psychological Reports, 98, 106-108. doi:10.2466/pr0.98.1.106-108
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Vance, D. E., Brennan, M., Enah, C., Smith, G. L., & Kaur, J. (2011). Religion, spirituality, and older adults with HIV: Critical personal and social resources for an aging epidemic.
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Clinical Interventions in Aging, 6, 101-109. doi:10.2174/CIA.S16349 Vance, D. E., Mugavero, M., Willig, J., Raper, J. L., & Saag, M. S. (2011). Aging with HIV: A cross-sectional study of comorbidity prevalence and clinical characteristics across decades of life. Journal of the Association of Nurses in AIDS Care, 22(1), 17-25.
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Weinberg, G. (1973). Society and the healthy homosexual. Garden City, NY: Anchor Books.
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Table 1 Sociodemographic Characteristics of the Sample Maximum
Mean
SD
Age
50.0
65.0
54.6
3.8
Years living with HIV
1.2
29.7
17.9
7.5
Annual Routine HIV Care Visits
2
24
4.3
3.3
Medications Taken per Day
1
20
7.5
4.6
Comorbidities Other than HIV
0
11
5.5
2.8
Characteristic Racea Minority Nonminority
n
Living Status Alone With others
%
43.3 56.7
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26 34
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Minimum
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Characteristic
32 28
53.3 46.7
12 48
20.0 80.0
32 27
54.2 45.8
38 22
63.3 36.7
Owns or Has Access to Car No Yes
11 49
18.3 81.7
Ever Hospitalized Due to HIV No Yes
37 23
61.7 38.3
HIV Support Group Participation No Yes
39 21
65.0 35.0
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Education High school or less Some college or college graduate
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Has a Job that Pays No Yes
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Annual Incomeb < $20,000 $20,000 +
a. Minority includes African American/Black (n = 25) and Asian Indian (n = 1) participants. Nonminority includes Caucasian/White participants. b. Based on 59 participants (one declined to answer the question).
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Table 2 Correlations Among Study Variables and Stigma Measuresa
Quality of life
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Coping Problem-focused coping Emotion-focused coping
-.332c -.214 -.021 -.154 -.193 .024 -.200 -.083 .172 .167 -.135 .001 .104
-.202 .091 -.063 -.100 -.118 -.129 -.167 -.017 0.20 .221 -.269c .255b .240
.009 -.035 .017 .089 .089 .021 -.069 .018 .131 .191 -.180 .163 .164
-.132 .015 -.180 -.027 -.306c -.041
-.437c -.299b -.383c -.334c -.439c -.294b
-.251 -.190 -.188 -.224 -.098 -.081
.038 .509c
-.245 .423c
-.291b .022
-.449c
-.590c
-.339c
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Social Support Emotional/informational support Tangible support Positive interaction Affection Availability of support Satisfaction with support
Internalized HIV Stigma
Ageism
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Sociodemographics Age Race Living status Education Annual income Has a job that pays Owns or has access to car Years living with HIV Ever hospitalized due to HIV Annual routine HIV care visits HIV support group participation Medications taken per day Comorbidities other than HIV
Homonegativity
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Study Variable
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a. Pearson product moment correlations were used for age, years living with HIV, annual routine HIV care visits, medications taken per day, comorbidities other than HIV, and all social support, coping, and quality of life measures. Spearman rho correlations were used for the remaining variables. b. p < .05. c. p < .01.
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Table 3 Significant Social Stigma Predictors
Homonegativity Age Emotion-focused coping
-1.10 1.64
Internalized HIV stigma Age HIV support group participation Total medications Availability of support Emotion-focused coping
-.15
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a. p < 0.05. b. p < 0.01.
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p
F
Adj. R2
12.39
.279b
-.22 .45b
.000 .063 .000
.58 .41
.000 .229 .022 .113 .019 .018
7.37
.351b
.59 4.14 .48 .25 .39
.024 .024
5.36
.069a
-.15 -.26a .20 -.30a .28a
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Ageism Problem-focused coping
-.72 -9.77 .78 -.62 .94
β
SE
.07
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B
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Measure
-.29
a
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Table 4 Stigma Predictors of Quality of Life
Model 1 Homonegativity
-.37
Model 2 Homonegativity Internalized HIV Stigma
-.21 -.42
Model 3 Homonegativity Internalized HIV Stigma Ageism
-.21 -.38 -.33
β
p
F
Adj. R2 .188b
.10
.000 .000
14.68
b
.000 .023 .000
19.41
.384b
.000 .021 .001 .231
13.54
.389b
-.45
.09 .10
-.26a -.49b
.09 .10 .27
a
-.26 -.43b -.13
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a. p < 0.05. b. p < 0.01.
SE
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B
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Measure
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Running head: STIGMA AND QUALITY OF LIFE
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Figure 1. Visual representation of the relationships that emerged from regression analysis using standardized betas.
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Key Considerations •
It is imperative that health care providers address the distinct needs of an aging population of gay men with HIV. Developing and promoting support groups specifically for older gay men with HIV may help decrease perceived stigma and positively impact quality of life.
Encouraging additional social support options for older gay men with HIV may enhance stigma competency and improve quality of life.
Interventions aimed at increasing the use of problem-focused coping strategies over emotion-
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focused coping strategies for older gay men with HIV may help alleviate stigma and improve
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quality of life.
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•
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•
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•