AIDS

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Social Science & Medicine 64 (2007) 1549–1559 www.elsevier.com/locate/socscimed

Examining attribution model of self-stigma on social support and psychological well-being among people with HIV+/AIDS Winnie W.S. Maka,, Rebecca Y.M. Cheunga, Rita W. Lawb, Jean Wooa, Patrick C.K. Lic, Rita W.Y. Chungc a

The Chinese University of Hong Kong, Hong Kong, China b University of Arizona, Tucson, USA c Queen Elizabeth Hospital, Hong Kong, China Available online 16 January 2007

Abstract Among various infectious diseases, HIV/AIDS is considered to be one of the most stigmatizing conditions. Using a prospective design, the present study attempted to test the attributional pathway from perceived control to responsibility to self-blame and finally to self-stigmatization, and to examine the social and psychological sequelae of stigma among a sample of 119 people with HIV/AIDS (PWHA) in Hong Kong. Structural equation modeling findings showed that the model had good fit to the data. Although the linkage between the attributions of control, responsibility, and blame was confirmed, the relationship of blame to self-stigma was not significant. Self-stigma was found to dampen social support and lead to psychological distress half a year later. The present study challenged the adequacy of attributional factors in understanding self-stigmatization and demonstrated the impact of stigma on psychological adjustment among PWHA. r 2006 Elsevier Ltd. All rights reserved. Keywords: Hong Kong; HIV/AIDS; Self-stigma; Attribution; Social support; Psychological distress

People with HIV/AIDS (PWHA) have been victims of stigmatization ever since the epidemic began in the 1980s (Herek, 1999). As of December, 2005, an estimated 38.6 million people are living with HIV/AIDS throughout the world (UNAIDS, 2006). This chronic, life-threatening disease not only affects PWHA’s physical health, but also impacts their psychological well-being as a result of the Corresponding author. Tel.: +852 2609 6577; fax: +852 2603 5019. E-mail addresses: [email protected] (W.W.S. Mak), [email protected] (R.Y.M. Cheung), ritalaw@email. arizona.edu (R.W. Law), [email protected] (J. Woo), [email protected] (P.C.K. Li), [email protected] (R.W.Y. Chung).

0277-9536/$ - see front matter r 2006 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2006.12.003

stigma that is attached to the disease. In a metaanalysis of 21 studies, Crawford (1996) found that the degree of stigma associated with AIDS is the greatest compared to other medical conditions such as genital herpes, hepatitis, drug abuse, diabetes, and cancer. Misconceptions about HIV transmission routes, perceived contagiousness, and overestimation of the risks through casual contact can evoke stigmatization of the infected (Dijker, Koomen, & Kok, 1997; Herek, 1999; Lau, Tang, & Tsui, 2003). Moreover, HIV-related stigma is also compounded by public’s negative attitudes towards such high-risk groups as commercial sex workers (Baker, Wilson, & Winebarger, 2004; Peracca, Knodel, & Saengtienchai, 1998) and men who have sex with

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men. PWHA’s quality of life is adversely affected due to social rejection, denial of services, loss of educational and occupational opportunities, and violence (Chesney & Smith, 1999; Ford, Wirawan, Sumantera, Sawitri, & Stahre, 2004; Landau, Pryor, & Haefli, 1995; Lau & Wong, 2001; Lichtenstein, Laska, & Clair, 2002). In Hong Kong, the introduction of highly active antiretroviral therapies has transformed the disease to a chronic illness. Since 1996, the number of AIDS cases has consistently declined, resulting in the lowest number of cases in 2004 (Hong Kong Centre for Health Protection, 2005); however, the number of cases of HIV infection has also reached its highest point ever reported in the same year. As a highly stigmatizing disease, discrimination towards PWHA has been documented. According to Lau and Wong (2001), 20% of the studied companies would dismiss an employee if he or she was HIV+, and coworkers were found to bear ungrounded fear and misunderstanding about PWHA. Within a social climate where PWHA are stigmatized and shunned, few are willing to disclose their status (Gielen, O’Campo, Faden, & Eke, 1997; Lau et al., 2003; Lau & Wong, 2001). If PWHA concealed their serostatus from partners, friends, and family (Herek, 1999), they would not receive desirable support; this would further worsen their life satisfaction (Heckman, 2003) and quality of life (Chidwick & Borrill, 1996). Most of the literature on HIV/AIDS stigma focused on the public views towards individuals with HIV/AIDS without directly examining the effects of stigmatization on the targeted individuals themselves (Dijker, Kok, & Koomen, 1996; Lau & Tsui, 2003; Lee et al., 2005; Pryor, Reeder, & Landau, 1999). To directly understand the effects of stigma on PWHA’s well-being, the present study used a prospective design to test the attributional processes of self-stigmatization and the relation between self-stigma, social support and psychological distress. Self-stigma occurs when members of a devalued group, being aware of the prejudice, stereotype, and discrimination in society, endorse and internalize these beliefs, feelings, and behaviors (Corrigan & Watson, 2002). Studies have indicated that the way individuals make sense of their infection may influence PWHA’s internalization of stigma (Murphy-Berman & Berman, 1993). Such internalization may evoke feelings of shame, guilt and unworthiness, perceptions of being discredited, and behavioral intentions to conceal serostatus.

PWHA with a high level of stigma experienced a faster progression of HIV to AIDS (Leserman et al., 2002) and a greater level of psychological distress (Lee, Kochman, & Sikkema, 2002). Support of using the attribution model to understand public stigma towards mental illness (Corrigan, 2000) and infectious diseases including HIV/ AIDS (Mak et al., 2006) have been demonstrated. According to the attribution theory (Weiner, 1993), individuals’ identification of disease causes can affect their emotional and behavioral responses towards the disease carriers. Among different attributions, controllability was found to be strongly associated with stigma (Corrigan, 2000; Weiner, Perry, & Magnusson, 1988). When contraction of a disease is regarded as controllable, responsibility for acquiring the illness is likely to be inferred, which further brings about emotional reactions such as pity or blame (Corrigan, Markowitz, Watson, Rowan, & Kubiak, 2003; Corrigan et al., 2000). Research also has demonstrated the sequential relations among controllability, responsibility and blame in the attribution model (Mantler, Schellenberg, & Page, 2003). Findings from previous studies have shown that PWHA who assign high personal controllability (Murphy-Berman & Berman, 1993) and responsibility to themselves (Goffman, 1963; Herek, 1999) develop higher levels of stigma towards themselves, which in turn leads to lower perceptions of sympathy and support (Lee et al., 2002) and more hostility from the public. Using structural equation modeling, the present study tested this model to explain self-stigma among PWHA in Hong Kong. We hypothesized that (1) the sequential attribution model would account for self-stigma (namely controllability-responsibility-blame-self-stigma), and (2) self-stigma, in turn, would be related to lower perceived social support (i.e., informational, emotional, and tangible support) and higher psychological distress. Previous studies have shown that poor physical health of PWHA was associated with higher levels of self-stigma (Lee et al., 2002), lower levels of quality of life (Vassend & Esklid, 1998), and depression (Schmitz & Crystal, 2000). HIV+ men with at least one symptom or CD4+ lymphocytes below 200/mm3 have worse perceived physical and mental health than seronegative men (Bing et al., 2000). To account for the possible effect of physical status on self-stigma and mental health, the relations among multiple indicators of PWHA’s

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medical status on self-stigma and mental health were also explored. Methods Participants Participants were consecutive patients of Chinese ethnicity who came for regular medical appointments between November 2004 and January 2006, at the AIDS Clinic, the only AIDS service unit operated by the Hospital Authority in Hong Kong. Of the patients who visited the clinic during the period, 67.3% agreed to participate in the study. The final sample consisted of 150 PWHA (129 men and 21 women). They were interviewed about their infection attributions, self-stigma, perceived social support, psychological and medical status, and basic demographic information. Seventy-nine percent of the participants (119 PWHA, 102 men and 17 women) were re-interviewed at a mean lapse of seven months (SD ¼ 1:97 months) on their physical and mental health. Of the 31 participants who were lost at Time 2, 4 refused to be re-interviewed, 6 failed to show up for interview appointments, with the remaining 21 being unreachable because their regular medical appointment fell outside our time frame. Measures The following measures were assessed at Time 1. With the exception of the measures for social support and mental health, all were developed originally in Chinese. The social support and mental health measures were translated into Chinese using the independent forward and back-translation approach (Brislin, 1970). Demographics and medical information. Participants provided demographic information including age, gender, sexual orientation, educational level, employment status, marital status, and means of transmission. Information regarding participants’ medical status, including duration of infection, CD4+ count, disease stage, and physical complications associated with their infection was provided by the clinic nurses with participants’ consent. Based on current medical records, nurses marked down the relevant physical complications that participants had based on a list of 36 major physical complications common to HIV/AIDS patients (e.g., bacillary

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angiomatosis, oropharyngeal candidiassis and cervical dysplasia). Disease attributions. Participants were asked about their perceived disease attribution with one item that directly measures each of the three aspects: internal controllability (‘‘I was able to control my contraction of HIV’’), responsibility (‘‘I am responsible for my own infection’’), and blame (‘‘It is my own fault that I am infected with the disease’’). Although the single item used may be argued as less reliable, the items stated above pinpoint the latent constructs in representing controllability, responsibility, and blame. Additionally, the use of a single-item attitude measure to assess illness dimensions and attributions has been used in previous studies and was found to be as reliable and valid as multiple-item measures (Crandall & Moriarty, 1995; Dijker et al., 1996; Jaccard, Weber, & Lundmark, 1975). Participants were asked whether they agreed with the above items on a 6-point Likert scale, with higher scores indicating greater levels of internal controllability, personal responsibility for the disease, and blame for their contraction. Self-stigma. The self-stigma scale was developed based on ideas generated from focus groups with various social minorities, including people with infectious diseases, gays, lesbians, and bisexual individuals, immigrants, and mental health consumers. Research team members developed scale items to assess affective, behavioral, and cognitive dimensions of self-stigma as applicable across stigmatized groups. Twenty-two items (8 affective, 6 behavioral, 8 cognitive) were used in the present study. Exploratory factor analysis with varimax rotation and eigenvalue greater than one showed that the self-stigma scale was unidimensional and explained 45.5% of variance. Factor loadings ranged from 0.42 to 0.83. Participants rated the extent to which they endorse each item on a 6-point scale from (1) strongly disagree to (6) strongly agree. Higher scores indicated greater self-stigma. Sample items included ‘‘I am ashamed of being an HIV+/AIDS patient’’, ‘‘I don’t dare to make new friends lest they find out that I am an HIV+/AIDS patient’’, and ‘‘I lower my expectations towards life because I am an HIV+/AIDS patient’’. The scale achieved excellent reliability (Cronbach’s alpha ¼ 0.94). Social support. Perceived social support was assessed using the Medical Outcomes Study Social Support Survey (MOS-SSS), a 19-item questionnaire that examined 4 domains of social support,

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including tangible support (tangible), affectionate support (affection), positive social interaction (interaction), and emotional/informational support (emotion/information) (Sherbourne & Stewart, 1991). As opposed to the more objective measures of received support, this measure assessed perceived availability of support and has been validated among Hong Kong Chinese (Yu, Lee, & Woo, 2004). Participants rated each item on a 5-point Likert scale, from 1 (never) to 5 (always). The four MOS Social Support subscales in the present study achieved satisfactory to excellent internal consistencies (Cronbach’s alphas ¼ 0.88, 0.74, 0.90 and 0.94, respectively). Higher scores indicated greater social support. Psychological distress. The Mental Health Inventory (MHI) was used to assess the degree of distress and well-being experienced by the participants at Time 2. Developed as part of the National Health Insurance Study, the Inventory had been studied extensively in a variety of populations (Veit & Ware, 1983). It was used in this study to assess both distress and well-being among PWHA. The scale consisted of 38 items, with 6 options under each. Higher scores on the 1–6 ratings indicated more distress and well-being. Participants were instructed to choose for each statement the option that best described how things had been for them during the past month. Sample questions included ‘‘During the past month, how much of the time have you been in low or very low spirits?’’ and ‘‘How happy, satisfied, or pleased have you been with your personal life during the past month?’’ The Inventory has been validated among Chinese (Liang,Wu, Krause, Tung et al., 1992). The two subscales used in the present study achieved excellent reliabilities (Cronbach’s alphas ¼ 0.91 and 0.93 for Distress and Well-being, respectively). Procedure Interviewers who were trained on interview skills and study protocol explained the study to patients while they were waiting for medical appointments at the clinic. All available patients were invited to participate. Upon informed consent, structured interviews in Cantonese were conducted at the clinic before and/or after their medical appointment. Upon completion of each interview, a supermarket voucher of HK$50 (US$6.40) was given to the participants as a token of appreciation for their time spent on this study.

Overview of data analyses First, descriptive statistics and preliminary analyses were performed. Using multiple regressions, we examined whether any of the medical status variables (i.e., CD4 count, disease stage, and number of physical complaints) were significantly related to self-stigma, distress, and well-being. Second, confirmatory factor analysis was conducted to assess the goodness-of-fit of the measurement model and the construct validity of the latent variables in the present study. Finally, structural equation modeling was conducted to test the proposed structural model relating the three different types of disease attributions (i.e., internal controllability, perceived responsibility, and perceived blame), self-stigma, social support, and psychological distress. For the constructs of selfstigma, social support, and psychological distress groups of items were used as indicators using EQS for Windows Version 6.1 (Bentler, 2003), which uses the maximum likelihood method to examine the overall fit of the models to the observed variance/ covariance matrices. Results Sample description The mean age of the sample was 42.08 yr (SD ¼ 9:88). Close to three-fourths of the sample were heterosexual. A majority of them had a high school education and were employed. The source of transmission was predominantly sexual intercourse. The average duration of their infection was 5.02 yr (SD ¼ 3:14), with almost two-thirds of the sample having developed AIDS. The current sample closely represented the HIV/AIDS population in Hong Kong. According to the most recent statistics, 3828 persons were infected with HIV and 81.5% were male. Most are within the age range of 30–49 yr. In addition, 3000 out of 3828 (78.3%) were transmitted through sexual contacts (Virtual AIDS Office of Hong Kong, 2006, June). Please refer to Table 1 for details of the demographic and medical characteristics of the current sample. To assess whether the participants who were retained in the follow-up differed from those who were lost, chi-square tests and independent t-tests were conducted on major demographic and medical factors at Time 1. The groups were not significantly different on any variable.

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Table 1 Information on demographics, means of transmission, and medical status of retained and lost participants Retained participants (n ¼ 119)

Demographic information Age Gender Male Female Education Primary school or below Secondary school College Graduate school or above Employment Employed Marital status Single Married/cohabited Separated/divorced/widowed Sexual orientation Heterosexual Homosexual Bisexual

Mean

SD

Range

42.08

9.88

26–74

Means of transmission Use of syringe Sexual intercourse With husband or wife With fixed opposite sex partner With various opposite sex partners With fixed same sex partner With various same sex partners Blood transfusion Others Medical Status Duration of infection Disease stage Asymptomatic Symptomatic AIDS Number of physical complications

5.02

3.14

Lost participants (n ¼ 31) %

Mean

SD

Range

39.60

9.75

19–77

84.9 15.1

90.3 9.7

16.8 67.2 16.0 1.7

16.7 63.3 20.0 0.0

61.9

76.7

44.5 39.8 15.2

54.8 41.9 3.2

72.9 22.0 5.1

51.6 38.7 6.5

0.0

3.2

8.6 7.8 41.4 6.0 18.1 1.7 16.4

6.5 0.0 29.0 3.2 48.4 6.5 3.2

o1–15

5.44

2.86

1–11

17.5 17.5 64.9 1.57

1.11

0–4

%

26.7 23.3 50.0 1.57

1.98

0–10

Note: All the above variables were not significantly different across retained and lost participants, p40.05.

Preliminary analyses Multiple regression results showed that none of the medical status variables were significant predictors of self-stigma, F ð3139Þ ¼ 0:46, p40:05, R2 ¼ 0:10; distress, F ð3109Þ ¼ 0:68, p40:05, R2 ¼ 0:02; and well-being, F ð3109Þ ¼ 0:69, p40:05, R2 ¼ 0:02. As a result, indicators of medical status (i.e., CD4 counts, disease stage, and number of physical complaints) were not included in subsequent SEM analyses.

Correlations, means and standard deviations for all variables among 119 PWHA are shown in Table 2. Most variables were correlated with each other in a way that supported the hypothesized interrelations among the factors they represented. Specifically, attribution variables were not significantly correlated with self-stigma, except for internal controllability (r ¼ 0:32, po0:01). Self-stigma showed significant negative correlations (r ranged from 0.25 to 0.40, po0:01) with all four domains of social support (i.e., tangible support, affectionate

*po0.05; **po0.01

—

Internal controllability Perceived responsibility Perceived blame Self-stigma Tangible support Affectionate support Positive social interaction Informational/ emotional support Psychological distress Psychological well-being Mean Standard deviation

.02

.015

.03

.11

4.15 1.39

.23*

.074

.21*

4.55 1.34

.64** .03 .11 .01

—

Perceived responsibility

.23*

.24* .32** .22* .15

.23*

Internal controllability

Variable

3.45 .96

.49**

.26 3.74 1.30

.44**

.38**

.40**

— .25** .38**

Self-stigma

.02

.05

.03

— .17 .083 .02

Perceived blame

3.42 1.04

.39**

.27**

.66**

.70**

— .73**

Tangible support

Table 2 Intercorrelations, means, and standard deviations of the manifest variables used in the SEM model

3.09 1.01

.43**

.21*

.76**

.86**

—

Affectionate support

3.13 1.02

.46**

.20*

.77**

—

Positive social interaction

3.15 1.18

.40**

.21*

—

Informational/ emotional support

2.09 .76

.63**

—

Psychological distress

3.62 1.19

—

Psychological well-being

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support, positive social interaction, and emotional/ informational support) and well-being (r ¼ 0:49, po0:01), and a positive correlation with distress (r ¼ 0:44, po0:01). Finally, all social support variables showed significant correlations with distress (r ranged from 0.20 to 0.27, po0:05) and well being (r ranged from 0.39 to 0.46, po0:01). Measurement and structural models Confirmatory factor analysis showed that the measurement model was fit to the data, w2 ð6; n ¼ 118Þ ¼ 10:21; p ¼ 0:12; with the following satisfactory fit indices: Goodness-of-Fit Index (GFI) ¼ 0.97, Comparative Fit Index ¼ 0.99, Root Means Square Error of Approximation (RMSEA) ¼ 0.08. Structural model Results showed that the structural model was fit to the data, w2 ð24; n ¼ 118Þ ¼ 41:93, p ¼ 0:01, and resulted in the following satisfactory fit indices: GFI ¼ 0.93, CFI ¼ 0.97 and RMSEA ¼ 0.08. Fig. 1 presents the unstandardized path loadings of the final structural model. In addition, Table 3 displays detailed information on both unstandardized and standardized loadings of the structural model. Contrary to the hypothesis, although attributional factors flowed through a direct path,

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perceived blame was not significantly associated with self-stigma (b ¼ 0:12, p40:05). Increased level of self-stigma was shown to significantly reduce social support (b ¼ 0:42, po0:05) and lead to a greater level of psychological distress at Time 2 assessment (b ¼ 0:22, po0:05). Social support was negatively related to psychological distress (b ¼ 0:18, po0:05). As for the association of self-stigma and psychological distress, self-stigma was directly related to PWHA’s Time 2 psychological distress (b ¼ 0:08, po0:05). Discussion The present study used a prospective design and a social cognitive framework to test an explanatory model in understanding stigma influence on PWHA’s mental health. Multiple regression findings showed that medical status (i.e., CD4 count, disease stage and physical complications) did not contribute to PWHA’s self-stigma and mental health. Although the objective indicators of medical status are informative of PWHA’s physical health, their subjective, phenomenological experience and the social, interpersonal context in which they live are more pivotal to their overall subjective well-being. The attribution model to stigma was not supported in the present study with Hong Kong’s PWHA self-stigma. Although the paths from TS and EIS

SS1

Internal Controllability

0.23* (0.09)

0.66* Perceived Responsibility

(0.08)

Perceived Blame

0.12 (0.07)

AS and PSI

SS2 -0.42* (0.10)

Social Support -0.18* (0.06)

SelfStigma 0.22* (0.06)

Psychological Distress

PD

PW

Fig. 1. Attribution Model of Self-Stigma on Social Support and Psychological Well-Being. Notes. Hypothesized structural model relating the three different types of disease attributions (i.e., internal controllability, perceived responsibility, and perceived blame), self-stigma, social support, and distress showed acceptable fit to the data. Unstandardized path coefficients (errors) are also shown. All coefficients equal to or greater than |0.18| were significant at the po0.05 level. Each latent factor was indicated by two parcels: SS1 and SS2 to indicate self-stigma; TS (tangible) and EIS (emotion/information), AS (affection) and PSI (positive social interaction) to indicate social support; Distress and Well-being to indicate psychological distress.

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Table 3 Unstandardized and standardized loadings for the model in Fig. 1 Parameter estimate Measurement model estimates Internal controllability-V1 Perceived responsibility-V2 Perceived blame-V3 Self-stigma-V4 Self-stigma-V5 Social support- V6 Social support-V7 Psychological distress (distress)-V8 Psychological distress (well-being)-V9 Structural model Internal controllability-perceived responsibility Perceived responsibility-perceived blame Perceived blame-self-stigma Self-stigma-social support Self-stigma-psychological functioning Social support-psychological functioning

Unstandardized

Standardized

1.00 1.00 1.00 1.00 0.93* (0.07) 1.00 1.00* (0.11) 1.00 2.13* (0.38)

1.00 1.00 1.00 0.95 0.95 0.89 0.95 0.68 0.93

0.23* (0.09) 0.66* (0.08) 0.12 (0.07) 0.42* (0.10) 0.22* (0.06) 0.18* (0.06)

0.23 0.64 0.17 0.44 0.42 0.33

Note: Standard errors are in parentheses. *po0.05.

internal controllability to responsibility, and from responsibility to blame were confirmed, blame was not significantly related to self-stigma. In fact, high internal controllability was inversely correlated with self-stigma and responsibility was not correlated with self-stigma. Although the attributions of control and responsibility were high, blame was lower and self-stigma had a mean at the midpoint. The explanation for the lack of a relation between blame and self-stigma is not clear from these data. One could be the restricted range of scores. However, another is that attributions may differ in the highly urban, well-informed Hong Kong context where the main mode of transmission is from sex workers to men. Over 80% of our present sample reported contracting AIDS through sexual contacts, mostly with heterosexual partners. Men in Hong Kong are eight times more likely than women to have HIV/AIDS (Virtual AIDS Office of Hong Kong, 2006 June), and it has been suggested that they may have acquired it from having unprotected sex with sex workers across the border at the neighboring Guangdong province of mainland China where condom use is less likely (Lau & Thomas, 2001; Lau & Wong, 2001). Nevertheless, one cannot rule out the possibility that Hong Kong women underreported and delayed testing of HIV infection due to shame (Lau, Tang, Siah, & Tsui, 2002; Tang, Wong, & Lee, 2001). In addition, PWHA in Hong Kong might intentionally misre-

port their sources as sex workers rather than homosexual contacts or drug abuse. Although the attribution model may be useful in understanding the development of stigma in the general public, other psychosocial and contextual factors may be more pivotal in affecting the internalization of stigma among PWHA. To effectively reduce self-stigma among PWHA, future studies should look into other possible factors such as social rejection (Kang, Rapkin, Remien, Mellins, & Oh, 2005) and the prevailing sociocultural climate that might influence the social perceptions of HIV/AIDS. An example of such culturally salient factors is face concern. Face has been identified as a key interpersonal dynamic in East Asian cultures (Bond, 1991; Ting-Toomey, 1994). Due to the importance of face and interpersonal relatedness in social relationships, AIDS infection may not only affect the infected individuals themselves, it may also impact the social integrity of the families and groups to which they belong (Chin & Kroesen, 1999; Hung, 2004; Leung, 1998; Ow & Katz, 1999). Future studies should focus on the process of self-stigmatization in the context of social relationships. Another important aim of this study was to examine the effect of self-stigma on psychological distress. Using a prospective design, the present study found that self-stigma of PWHA negatively impacts their psychological well-being seven months

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later. Self-stigma also dampened their level of perceived support, which serves to ameliorate psychological distress. In line with previous studies that have shown self-stigma to be positively related to fear of disclosure (Gielen et al., 1997; Lau et al., 2003; Lau & Wong, 2001) and social distancing (Davison, Pennebaker, & Dickerson, 2000), PWHA who have internalized HIV/AIDS stigma towards themselves are likely to perceive less support from others and experience distress. The present study highlights the impact of selfstigma on PWHA’s mental health. By reducing the extent of self-stigmatization, PWHA’s social relationships and long-term adjustment can be sustained. Studies have shown that PWHA tended to seek support from people with similar conditions, such as other PWHA, rather than close friends and family due to the issue of disclosure and social acceptance (Davison, Pennebaker, & Dickerson, 2000). Moreover, support from professional staff is found to play a significant role among PWHA (Saunders & Burgoyne, 2001). Although more research is required to understand the mechanisms of self-stigma, reinforcing mutual support groups among PWHA and enlisting health care workers to serve as reliable allies can provide PWHA alternative channels to raise their concerns and problems.

Limitations The current study has several limitations that should be borne in mind. First, the generalizability of the current findings to other cultural settings must be made carefully. Given the social dynamics among Chinese is different from that observed in Western countries, more studies should be conducted in China and other Chinese societies where HIV infection and AIDS has become increasingly a health concern (Aceijas, Stimson, Hickman, & Rhodes, 2004; Liu et al., 2006). It is also important to directly assess specific sociocultural variables (e.g., face concern, interpersonal relatedness) to account for possible cultural influence in the stigma experience and the treatment process. Attribution measures would have demonstrable reliability if more items were included. Notwithstanding the above limitations, the present study is a step forward in understanding stigma of HIV/AIDS patients and its effects on their psychological well-being.

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Acknowledgement This study is supported by Research Grant CUHK-PH-002 from the Research Fund for the Control of Infectious Diseases (RFCID). Mak and Woo are also affiliated with the Center for Emerging Infectious Diseases. We would like to express our heartfelt thanks to Phoenix K. H. Mo and Loraine Y. K. Pun for their assistance in data collection and the Center for Emerging Infectious Diseases, Health, Welfare and Food Bureau, and Research Fund for the Control of Infectious Diseases for their support.

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