CSIRO PUBLISHING

Sexual Health, 2013, 10, 316–319

http://dx.doi.org/10.1071/SH12170

The impact of living with HIV: differences in experiences

of stigma for heterosexual and homosexual people living
with HIV in Australia

Loren Brener A,C, Hannah Wilson A, Sean Slavin B and John de Wit A
A
National Centre in HIV Social Research, University of New South Wales, Level 3, Goodsell Building Sydney,
Sydney, NSW 2035, Australia.
B
National Association of People Living with HIV/AIDS, Sydney, NSW 2052, Australia.
C
Corresponding author. Email: l.brener@unsw.edu.au

Abstract. Background: HIV in Australia has been closely aligned with the gay community and continues to
disproportionately affect members of this community. Although heterosexual transmission remains low, recently there
has been an increase in new HIV diagnoses attributable to heterosexual sex. This highlights the need to address the health
and social consequences for heterosexual people living with HIV (PLHIV). This subanalysis of a larger study compared the
experiences of stigma, health and wellbeing of a sample of gay and heterosexual PLHIV. Methods: Data were drawn from a
study of experiences of stigma among PLHIV in Australia. All 49 participants who reported being heterosexual were
included, as were 49 participants randomly selected from the 611 gay participants. The samples were compared on
perceived HIV stigma, HIV treatment-related stigma, perceived negative reactions of others, HIV status disclosure, and
health and wellbeing measures. Results: The findings illustrate that heterosexual PLHIV have more negative experiences in
terms of both general HIV stigma and treatment-related stigma than gay PLHIV. The heterosexual PLHIV also perceived
greater negative reactions in relation to their HIV status by different people in their social environment and were less likely
to access treatment than the gay PLHIV. There were no differences between the two groups in any of the health and
wellbeing measures. Conclusions: This study shows that in the Australian context, heterosexual PLHIV may feel more
stigmatised than gay PLHIV. In view of lower HIV treatment uptake in heterosexual PLHIV, addressing HIV-related
stigma could contribute to increasing access to HIV treatment.

Additional keywords: gay, negative reactions, treatment uptake, wellbeing.

Received 10 October 2012, accepted 2 April 2013, published online 17 May 2013

Introduction impact of stigma and discrimination for people living with

In Australia, the HIV epidemic disproportionately affects gay
men,1 and prevention, treatment and care have hence also largely
targeted gay men.2 Although heterosexual transmission remains
low in Australia, there has been an increase in the number of new
diagnoses attributable to heterosexual sex.3 The 2012
surveillance report on HIV, viral hepatitis and sexually
transmissible infections in Australia documents that new
diagnoses of HIV attributable to heterosexual contact
increased by 31%, from 583 in 2002–06 to 764 in 2007–11.4
This increase in HIV diagnosis among heterosexuals has
highlighted the need to address the health and social
consequences of living with a stigmatised illness for this group.
Goffman described stigma as a social phenomenon in which
an identity is seen as spoiled, and the individual or group holding
that identity is devalued and discredited. Members of a
stigmatised group may experience prejudice or discrimination
on the basis of the stigmatised attribute.5,6 Research on the
HIV (PLHIV) has noted a range of negative consequences
for their health and wellbeing.7–13 As summarised in a meta-
analysis,11 higher levels of stigma reported by PLHIV are
consistently associated with poorer mental and physical
health, and with less social support. Being part of a
stigmatised group is stressful, which in itself can lead to poor
health.14,15 Furthermore, prejudice and discrimination within
the health sector have been shown to impact on HIV-status
disclosure, health-seeking behaviour, and HIV testing and
treatment uptake.16–18
There is currently a growing body of literature highlighting
differences in experiences for gay and heterosexual PLHIV
in developed countries1,19,20. Research suggests that health
services for PLHIV may not be optimally accessible to
members of the heterosexual community.19 Australian
research indicates that HIV is seen as foreign to the
heterosexual community and suggests that where it does

Journal compilation
CSIRO 2013 www.publish.csiro.au/journals/sh

Differences in experiences of stigma Sexual Health 317

occur, it is deemed to afflict those who engage in behaviours Responses for each social referent were dichotomised (‘I
seen as morally reprehensible, such as promiscuous sex and have not disclosed’ or ‘I have disclosed to someone’).
drug use.20 Persson1 found that HIV-positive heterosexual
men felt that they no longer belonged to the heterosexual Perceived negative reactions
community but also did not want to identify as gay. The Participants were asked if they had felt blame, shame,
importance of community belonging for stigmatised rejection or awkwardness from social referents (see above);
individuals has been recognised as presenting a positive responses ranged from ‘none’ to ‘all’. Negative reactions
frame of reference, which may buffer individuals from the were averaged across experiences and referents; higher scores
negative effects of stigma.21,22 indicate more negative reactions.
It may be that heterosexual PLHIV are particularly concerned
about their HIV status and do not want to be identified with Health and wellbeing
groups they perceive as deviant.1 Therefore, they may disclose Standardised measures were included to assess self-esteem
less, have less social support20 and access health care less.19 (Rosenberg self-esteem scale27), depression, anxiety and stress
Consequently, they may experience greater psychological, (DASS 2128); social support (Multidimensional Scale of
social and health stresses associated with living with Perceived Social Support29) and resilience (Connor–Davidson
HIV. Although there are numerous studies on stigma Resilience Scale30). Perceived quality of life and health
comprising samples of both heterosexual and gay satisfaction were each measured with one item. Participants
PLHIV,18,23,24 there is little in the way of group comparisons. were also asked length of time since their HIV diagnosis and
This research aimed to compare the experiences of stigma whether they were on HIV treatment.
and the health and wellbeing of a sample of gay and
heterosexual PLHIV in Australia. It is hypothesised that, in Results
the context of an HIV epidemic that primarily affects gay
The sample comprised 71 men and 27 women (Table 1) aged
men, heterosexual PLHIV are likely to experience greater
22–65 years (mean: 43.0, s.d.: 10.1). The average time since
levels of stigma, resulting in poorer health and health-related
diagnosis was 12 years (s.d.: 8.4, range: 1–28 years); 81.6%
behaviours.
were on HIV treatment.
Independent sample t-tests and Chi-square analysis
Method (Table 1) revealed no significant differences in age, place of
Participants and procedures birth or time since diagnosis between the two groups. However,
Data are drawn from a larger study of experiences of stigma gay respondents were significantly more likely to be on
among PLHIV in Australia. Participants who were HIV- treatment than heterosexuals (89.9% v. 73.5%, c2= 4.356,
positive, over 18 years and residing in Australia were d.f. = 1, P = 0.04). As expected, there was a significant gender
recruited through advertisements on targeted internet sites. difference.
Respondents were provided with detailed study information Independent sample t-tests showed that gay and heterosexual
and online informed consent. The study was approved by the participants differed significantly in their experiences of
Human Research Ethics Committee of the University of New HIV-related stigma, treatment-related stigma and perceived
South Wales. A total of 849 people began the survey; 697 negative reactions from some social referents (see
completed it. The sample consisted of 662 men, 32 women and 3 Table 2), with heterosexual respondents reporting more
transgender participants. Of participants, 611 identified as gay, negative experiences. Gay respondents were more likely than
49 as heterosexual, 25 as bisexual and 12 as other.25 The dataset heterosexuals to disclose their HIV-positive status to friends
for this subanalysis was created by selecting all participants who (91.1% v. 75.5%, c2 = 4.042, d.f. = 1, P = 0.04). Reported self-
reported being heterosexual (n = 49) and randomly selecting 49 esteem, depression, stress, anxiety, social support, resilience,
participants, to match the number of heterosexuals, from the 611 quality of life and health satisfaction were no different across
gay participants (excluding bisexual and other sexual the two groups.
orientations). Table 1. Demographics by sexuality
*P  0.001; **P  0.05
Measures
Total Heterosexual Homosexual
HIV-related stigma Mean (s.d.) Mean (s.d.) Mean (s.d.)
Perceived HIV stigma was assessed with a 35-item scale
Age 43.0 (10.1) 41.7 (10.0) 44.3 (10.1)
based on the HIV Stigma Scale;7 higher scores indicate greater
perceived stigma. Five new items focusing on HIV treatment- Length of diagnosis 12.3 (8.5) 12.2 (8.3) 12.5 (8.7)
related stigma were included and scaled separately. n (%) n (%) n (%)
Gender
HIV-status disclosure Male 71 (72.4) 22 (44.9) 49 (100.0)*
Participants were asked if they had informed various different Female 27 (27.6) 27 (55.1) 0 (0.0)
social referents about their HIV status,26 including friends, Born in Australia 67 (68.4) 32 (65.3) 35 (71.4)
family, sexual partners, health care providers, coworkers,
Currently on treatment 80 (81.6) 36 (73.5) 44 (89.8)**
people where they live and others in the community.
318 Sexual Health L. Brener et al.

Table 2. Health, wellbeing and experiences of stigma by sexuality participants. Research suggests that women living with HIV
*P  0.01; **P  0.05; ***P  0.001. DASS21, depression, anxiety and are positioned as sexually and socially immoral and assumed
stress scale to be sex workers or injecting drug users,32–34 far removed from
Alpha Total Heterosexual Homosexual the ideal depiction of the traditional woman.35 Hence they may
Mean (s.d.) Mean (s.d.) Mean (s.d.) face particular stigma and social exclusion.34 However, there is
also research indicating that, in the developed world, it is HIV-
HIV-related stigma 0.957 108.3 (27.2) 115.9 (24.9)* 100.8 (27.5) positive heterosexual men who are most stigmatised.19 A recent
HIV treatment stigma 0.919 15.7 (27.2) 17.0 (5.3)* 14.3 (6.4) Canadian study found that HIV-positive heterosexual men
perceived themselves most marginalised in relation to HIV
Negative HIV experiences
Family 0.922 2.0 (1.1) 2.1 (1.1) 1.8 (1.1) health care, which they felt prioritised gay men and
Friends 0.902 2.1 (1.0) 2.3 (1.0)** 1.8 (0.9) heterosexual women.19 Hence, it is possible that in a sample
Sexual partner 0.889 2.3 (1.0) 2.2 (1.0) 2.4 (1.1) of only heterosexual men, the observed differences could be
Workplace 0.950 2.3 (1.3) 2.6 (1.3) 2.1 (1.2) greater.
Healthcare 0.895 2.1 (0.9) 2.5 (0.8)*** 1.6 (0.8) HIV stigma has been shown to impact negatively on a range
Community 0.925 2.5 (1.1) 2.7 (1.1)** 2.2 (1.1) of mental and physical health outcomes.11 In this study, no
Housing 0.959 2.0 (1.3) 2.4 (1.3)* 1.6 (1.2) differences were found between heterosexual and gay PLHIV on
measures of health and wellbeing, but the observed differences
Self esteem 0.901 34.5 (8.1) 34.4 (7.7) 34.6 (8.6)
in treatment access may nevertheless be associated with
Resilience 0.931 34.2 (9.0) 34.1 (9.1) 34.3 (8.9) differences in health outcomes. Additionally, other research
DASS21: stress 0.931 12.5 (6.8) 12.7 (6.4) 12.2 (7.2) has found evidence that HIV-positive heterosexuals present
DASS21: depression 0.957 11.7 (8.2) 12.0 (7.7) 11.3 (8.8) for screening later than gay men and consequently have
DASS21: anxiety 0.888 8.7 (6.3) 9.1 (6.2) 8.4 (6.3) poorer treatment outcomes.36,37 Addressing stigma and
Social support 0.902 35.7 (9.1) 36.4 (7.8) 34.9 (10.3) ensuring appropriate access to HIV treatment and care for
heterosexual PLHIV is particularly important in light of the
Quality of life – 3.7 (1.1) 3.6 (1.1) 3.8 (1.1)
small but steady increase in heterosexual HIV notifications in
Health satisfaction – 3.1 (1.2) 3.1 (1.2) 3.1 (1.2) Australia.

Discussion
The findings suggest that heterosexual PLHIV may have more
negative experiences of HIV stigma in general than gay PLHIV,
as well as in relation to treatment. This does, however, not
imply that the gay PLHIV are unaffected by the consequences
of HIV-related stigma; other data collected in this study
indicate an association between HIV stigma and negative
health outcomes.25 However, belonging to a gay community
in which HIV is not uncommon may offer some protection
from the negative effects of stigma.25 Heterosexual PLHIV also
reported greater perceived negative reactions from people in
their social environment. No differences were, however, found
between heterosexual and gay PLHIV on health and wellbeing
measures. This illustrates that there is no simple causal relation
between stigma experiences and health consequences. Rather,
this association may be moderated by other factors, and
heterosexual PLHIV generally may have health advantages.
For example, the health and wellbeing of nonheterosexual
people is negatively affected by minority stress not
experienced by heterosexuals.31 The gay PLHIV were more
likely to currently be on treatment than heterosexual participants.
This is in line with previous findings that heterosexual PLHIV
are less likely to access HIV health services, which may be
perceived as tailored to gay men.19
Although this study highlights the differences between
heterosexual and gay PLHIV, it is based on a small sample
and subanalysis of a larger dataset. A noted caveat is the gender
difference, with women comprising over half the heterosexual
sample. This may account for the differences found in
experiences of stigma between gay and heterosexual
Conflicts of interest
None declared.
Acknowledgements
Funding for this research was provided by the Australian Government
Department of Health and Ageing and the Levi Strauss Foundation. The
researchers thank all of the study participants who gave of their time
participate in this research.
References
1 Persson A. The undoing and doing of sexual identity among
heterosexual men with HIV in Australia. Men Masculinities 2012;
15: 311–28. doi:10.1177/1097184X12450015
2 Kippax S, Race K. Sustaining safe practice: twenty years on. Soc Sci
Med 2003; 57: 1–12. doi:10.1016/S0277-9536(02)00303-9
3 Guy R, McDonald A, Bartlett M, Murray J, Giele C, Davey T, et al.
HIV diagnoses in Australia: diverging epidemics within a low-
prevalence country. Med J Aust 2007; 187: 437–40.
4 The Kirby Institute. HIV, viral hepatitis and sexually transmissible
infections in Australia annual surveillance report 2012. Sydney: The
Kirby Institute, the University of New South Wales; 2011.
5 Jones E, Farina A, Hastorf A, Markus H, Miller DT, Scott R. Social
stigma: the psychology of marker relationships. New York: Freeman;
1984.
6 Link BG, Phelan JC. Stigma and its public health implications. Lancet
2001; 27: 363–85.
7 Buseh A, Stevens P. Constrained but not determined by stigma:
resistance by African American women living with HIV. Women
Health 2006; 44(33): 1–18.
8 Berger B, Ferrans C, Lashley R. Measuring stigma in people with
HIV: psychometric assessment of the HIV stigma scale. Res Nurs
Health 2001; 24(6): 518–29. doi:10.1002/nur.10011
Differences in experiences of stigma
9 Vanable P, Carey M, Blair D, Littlewood R. Impact of HIV-related
stigma on health behaviors and psychological adjustment among
HIV-positive men and women. AIDS Behav 2006; 10: 473–82.
doi:10.1007/s10461-006-9099-1
10 Bunn J, Solomon S, Miller C, Forehand R. Measurement of stigma in
people with HIV: a re-examination of the HIV stigma scale. AIDS
Educ Prev 2007; 19(3): 198–208. doi:10.1521/aeap.2007.19.3.198
11 Logie C, Gadalla T. Meta-analysis of health and demographic
correlates of stigma towards people living with HIV. AIDS Care
2009; 21(6): 742–53. doi:10.1080/09540120802511877
12 Tzemis D, Forrest J, Pukas C, Zhang W, Orchard T, Palmer A, et al.
Identifying self-percieved HIV-related stigma in a population
accessing antiretroviral therapy. AIDS Care 2012.
13 Peretti-Watel P, Spire B, Obadia Y, Moatti J. Discrimination against
HIV-infected people and the spread of HIV: some evidence from
France. PLoS ONE 2007; 2(5): e411. doi:10.1371/journal.pone.
0000411
14 Rosmond R. Role of stress in the pathogenesis of the metabolic
syndrome. Psychoneuroendocrinology 2005; 30: 1–10.
doi:10.1016/j.psyneuen.2004.05.007
15 Segerstrom SC, Miller GE. Psychological stress and the human
immune system: a meta-analytic study of 30 years of inquiry.
Psychol Bull 2004; 130: 601–30. doi:10.1037/0033-2909.130.4.601
16 Pascoe EA, Smart Richman L. Perceived discrimination and health:
a meta-analytic review. Psychol Bull 2009; 135(4): 531–54.
doi:10.1037/a0016059
17 Butt L. Silence speaks volumes: elite responses to AIDS in Highlands
Papua. In Butt L, Eves R, editors. Making sense of AIDS: culture,
sexuality, and power in Melanesia. Honolulu: University of Hawaii
Press; 2008. pp. 116–32.
18 Lee R, Kochman A, Sikkema K. Internalized stigma among people
living with HIV-AIDS. AIDS Behav 2002; 6(4): 309–319.
doi:10.1023/A:1021144511957
19 Antoniou T, Loutfy M, Glazier R, Strike C. ‘Waiting at the dinner
table for scraps’: a qualitative study of the help-seeking experiences of
heterosexual men living with HIV infection. BMJ 2012; 2: e000697.
20 Persson A, Richards W. From the closet to heterotopias: a conceptual
exploration of disclosure and passing among heterosexuals living
with HIV. Cult Health Sex 2008; 10(1): 73–86. doi:10.1080/1369
1050701669048
21 Phinney JS. Ethnic identity in adolescents and adults: review of
research. Psychol Bull 1990; 108: 499–514. doi:10.1037/0033-
2909.108.3.499
22 Sellers R, Shelton J. The role of racial identity in perceived racial
discrimination. J Pers Soc Psychol 2003; 84: 1079–92. doi:10.1037/
0022-3514.84.5.1079
23 Tzemis D, Forrest J, Puskas C, Zhang W, Orchard T, Palmer A, et al.
Identifying self-perceived HIV related stigma in a population
accessing antiretroviral therapy. AIDS Care 2013; 25(2): 95–102.
www.publish.csiro.au/journals/sh
Sexual Health 319
24 Varni S, Miller C, McCuin T, Solomon S. Disengagement and
engagement coping with HIV/AIDS stigma and psychological well-
being of people with HIV/AIDS. J Soc Clin Psych 2012; 31(2):
123–50. doi:10.1521/jscp.2012.31.2.123
25 Brener L, Callander D, Slavin S, de Wit J. Experiences of HIV
stigma: the role of visible symptoms, HIV centrality and
community attachment for people living with HIV. AIDS Care
2013. doi:10.1080/09540121.2012.752784
26 Stutterheim S, Bos A, Pryor J, Brands R, Liebregts M, Schaalma H.
Psychological and social correlates of HIV status disclosure: the
significance of stigma visibility. AIDS Educ Prev 2001; 23(4):
382–92. doi:10.1521/aeap.2011.23.4.382
27 Rosenberg M. Conceiving the self. New York: Basic Books; 1979.
28 Lovibond S, Lovibond P. Manual for the depression anxiety stress
scales. 2nd. edn. Sydney: Psychology Foundation; 1995.
29 Zimet G, Dahlem N, Zimet S, Farley G. The multidimensional scale
of perceived social support. J Pers Assess 1988; 52: 30–41.
doi:10.1207/s15327752jpa5201_2
30 Connor K, Davidson J. Development of a new resilience scale: the
Conner–Davidson resilience scale (CD-RISC). Depress Anxiety 2003;
18(2): 76–82. doi:10.1002/da.10113
31 Meyer IH, Schwartz S, Frost DM. Social patterning of stress and
coping: does disadvantaged social statuses confer more stress and
fewer coping resources? Soc Sci Med 2008; 67: 368–79. doi:10.1016/j.
socscimed.2008.03.012
32 Lekas H, Siegel K, Schrimshaw EW. Continuities and discontinuities
in the experiences of felt and enacted stigma among women with
HIV/AIDS. Qual Health Res 2006; 16: 1165–90. doi:10.1177/
1049732306292284
33 McDonald K. ‘You don’t grow another head’: the experience of
stigma among HIV-positive women in Australia. HIV Australia
2012; 9(4): 14–7.
34 Sandelowski M, Lambe C, Barroso J. Stigma in HIV-positive women.
J Nurs Scholarsh 2004; 36(2): 122–8. doi:10.1111/j.1547-5069.2004.
04024.x
35 Lawless S, Kippax S, Crawford J. Dirty, diseased and undeserving:
The positioning of HIV positive women. Soc Sci Med 1996; 43(9):
1371–7. doi:10.1016/0277-9536(96)00017-2
36 Manavi K, McMillan A, Ogilvie M, Scott G. Heterosexual men and
women with HIV test positive at a later stage of infection than homo-
or bisexual men. Int J STD AIDS 2004; 15(12): 811–4. doi:10.1258/
0956462042563585
37 Chadborn TR, Delpech VC, Sabin CA, Sinka K, Evans BG. The later
diagnosis and consequent short-term mortality of HIV-infected
heterosexuals (England and Wales, 2000–2004). AIDS 2006; 20
(18): 2371–9. doi:10.1097/QAD.0b013e32801138f7