The US Department of Health and Human Services (HHS) and its agencies are committed to identifying and addressing the challenges that impede people from utilizing available HIV prevention and treatment options. Among these challenges are intersectional stigma and discrimination, which HHS is working to address through its programs and initiatives, including within the Ending the HIV Epidemic in the US (EHE) initiative, which aims to reduce new HIV infections in the United States by at least 90% by 2030.1 Through EHE and other concerted programs and efforts, the goal of HHS is to develop and equitably deliver effective health-related support services to people who need them. Despite the availability of critical evidence-based options (e.g., advances in antiretroviral therapy, models of effective HIV care and prevention, pre-exposure prophylaxis, and syringe services programs), access to, uptake of, and persistent use of these options remain uneven within and across communities, regions, and demographic groups.
Interlocking systems of oppression (e.g., racism, classism, sexism, homophobia, and transphobia) are drivers of HIV-related intersectional stigma (HIVIS). Acknowledging this, HHS embraces an HIVIS perspective to address the full, inclusive spectrum of health and life experiences among people affected by HIV. This perspective acknowledges that systems of power have an adverse impact on the health of people experiencing multiple forms of oppression.
Federal efforts to address HIVIS, in partnership with communities, are contributing to achieving EHE milestones. These efforts are also important to the National HIV/AIDS Strategy for the United States 2022–2025, which states,
The United States will be a place where new HIV infections are prevented, every person knows their status, and every person with HIV has high-quality care and treatment, lives free from stigma and discrimination, and can achieve their full potential for health and well-being across the lifespan. This vision includes all people, regardless of age, sex, gender identity, sexual orientation, race, ethnicity, religion, disability, geographic location, or socioeconomic circumstance.2(p1)
Lessons learned about HIVIS can add strategies, tools, and insights to the fight against HIV in the United States and globally.
HHS addresses HIVIS through an interrelated set of approaches, exercised and shared through agency missions, which include research, surveillance, research and community input synthesis, program and communication campaign development, service delivery, and capacity building. HHS accomplishes this through partnering with communities, government agencies, academia, health and public health services, and other program entities at the local, state, tribal, national, and international levels.
A selection of key examples of HIVIS-related efforts from several HHS agencies are provided here:
Through the Minority HIV/AIDS Fund, the HHS Office of the Assistant Secretary for Health has supported demonstration and pilot projects that stress holistic and syndemic strategies to address HIV among racial and ethnic minorities.3 Minority HIV/AIDS Fund‒supported activities are designed to address racial inequities by focusing on system changes and strategic partnerships that aim to integrate biomedical, behavioral, and structural approaches for HIV, viral hepatitis, and sexually transmitted infections.4
In addition to its public health research, research synthesis, and programmatic HIVIS-related activities through funded health departments and community-based organizations, the Centers for Disease Control and Prevention monitors stigma nationally through surveillance and develops and disseminates HIV-related health communication materials under its Let’s Stop HIV Together campaign.5 These materials include messaging to prevent HIV-related stigma, such as the benefits of viral suppression for prevention, supported through public-facing resources on transmission risk estimates and an interactive risk-reduction tool.6,7
Since the inception of the Ryan White HIV/AIDS Program (RWHAP), administered through the Health Resources and Services Administration (HRSA), mitigating stigma-related barriers to accessing HIV care, treatment, and support have been addressed by organizations providing those services across the United States. With funding from HHS’s Minority HIV/AIDS Fund and input from the National Institutes of Health (NIH), HRSA recently developed a proposal to address stigma titled Reducing Stigma at Systems, Organizational, and Individual Client Levels in the RWHAP (HRSA-20-112), referred to as ESCALATE.8 This project aims to reduce stigma for people with HIV on multiple levels throughout the health care delivery system, including on the individual client, organization, and system levels. The program addresses a multidimensional model of privilege and intersectionality as well as focuses on implementing various stigma-reducing approaches to increase cultural humility (e.g., self-reflection and self-critique of biases) in care and treatment settings for people with HIV within the RWHAP.
The Indian Health Service, with its tribal and urban Indian health partners, through their Native Advocacy Workgroup for Trans Health, developed and released the Trans & Gender-Affirming Care in I/T/U Facilities Strategic Vision and Action Plan.9 The plan highlights case examples of how each agency could promote an intersectional approach (including approaches that address racism toward Indigenous peoples) in research, services, and implementation to improve health for transgender communities.
Addressing HIV-related stigma, including HIVIS, is a high research priority at NIH as stated in its FY 2021–2025 NIH Strategic Plan for HIV and HIV-Related Research.10 Working with partners, NIH is advancing HIVIS science through research programs, initiatives, and other dedicated activities. NIH organized the 2020 virtual HIVIS Research Advances & Opportunities Workshop and this special issue as part of its evolving emphasis on HIVIS. These efforts and others are catalyzing NIH-supported HIVIS science, including a keystone 2019 funding opportunity announcement, Promoting Reductions in Intersectional StigMa (PRISM) to Improve the HIV Prevention Continuum.11
The Substance Abuse and Mental Health Services Administration’s flagship HIV grant programs use an evidence-based, multilevel approach that considers the burden of stigma, social marginalization, and discrimination on prevention and treatment adherence for key populations. This approach encourages multisectoral partnerships (e.g., health care, schools, justice systems, social services, faith, and other relevant community sectors) and addresses policies and programs to meet the needs of institutions, providers, communities, and individuals simultaneously. The Prevention and Treatment of HIV Among People Living With Substance Use and/or Mental Disorders guidelines highlight effective practices utilizing this framework.12
Through EHE and other strategic collaborations, federal agencies within and outside of HHS are taking actions to address HIVIS. The way forward requires federal agencies to better address the challenges of intersectionality, including how power dynamics are perpetuating inequities. This requires federal agencies to do the following:
• Increase understanding of HIVIS within the context of HIV prevention, treatment, and care as well as within a broad structural context. • Engage collaborators in solving HIVIS challenges, including policies and programs not reaching people in need. • Work with partners to utilize the understanding of and implement solutions to address the complex systems, roles, and behaviors that enact and perpetuate intersectional stigma and discrimination.
• Identify commonalities and differences in intersectional stigma across health conditions. • Harmonize intersectional stigma and discrimination methods and measurements. • Ensure measurement and monitoring are ongoing and iterative. • Identify opportunities within, across, and beyond HHS agencies, especially within EHE geographic areas, to monitor intersectional stigma and discrimination.
• Highlight the evidence base of current interventions designed to reduce intersectional stigma and discrimination. • Examine and address laws, policies, and practices that reinforce intersectional stigma and discrimination, including HIV criminalization laws. • Develop or adapt interventions that address HIVIS at multiple socioecological levels. • Address drivers of adverse health and social outcomes. • Support integrated and braided holistic interventional approaches. • Integrate and tailor intersectional interventions to advance EHE goals and improve HIV prevention and treatment outcomes.
• Build collaborative, equitable partnerships between researchers and communities to improve health outcomes. • Ensure community perspectives and experiences inform all steps of the research and intervention development process. • Determine effective combinations of interventions and strategies for addressing HIVIS to reduce HIV transmission and disparities in HIV rates, including for gay and bisexual men, transgender persons, racial and ethnic minorities, and persons residing in domestic and global areas with the highest HIV rates. • Incorporate progress and lessons learned to address HIVIS within and outside the United States.
To effectively address the characteristics and complexities of HIVIS, the way forward requires expanded thinking and dynamic initiatives, including and beyond what has been presented in this article. Intersectional stigma, including HIVIS, is fueled by deeply embedded structural and systemic challenges that need to be identified and addressed. This approach, with focused and coordinated efforts, is key to addressing HIVIS. HHS’s role in this is an integral aspect of an all of government and all of society strategy to end HIV in the United States and globally.
CONFLICTS OF INTEREST
The authors declare that they have no conflicts of interest.
