Intersectional stigma and discrimination (ISD) pose critical barriers to HIV services and drive HIV inequities. This AJPH supplement represents a combination of research, theoretical articles, and community insights to move the field toward actions to reduce ISD. This focus builds on scholarship on stigma and HIV published in AJPH. In 1987, six years after the start of the US HIV epidemic, Kelly et al.1 used case vignettes in which patients were described as having either AIDS or leukemia and being either heterosexual or gay to measure physicians’ stigma. They concluded, “While some attitude negativity was anticipated, the strength and consistency of the stigmatization was disquieting.”1(p790) Also, before intersectionality was explicitly discussed in the HIV field, researchers were documenting the impact of multiple forms of stigma among sexual minority men.2,3 AJPH has since published more than 800 articles addressing HIV and stigma,4 illustrating that HIV-related stigma remains a persistent challenge to ending the HIV epidemic.
Berger,5 who first coined the term “intersectional stigma,” reminds us here in her editorial (p. S218), that citing foundational scholars6–9 such as herself is a necessary acknowledgment of Black women’s academic achievements and that not doing so renders them and their contributions invisible. Aligned with this, Smith et al. (p. S220) provide a conceptual review and integration of intersectionality and syndemics theory and argue that ISD fuels domestic HIV-related syndemics. An editorial by Bowleg (p. S224) challenges the HIV field even further by questioning the term “intersectional stigma and discrimination” itself because of how it can obscure intersectional social-structural processes.
Ancestors and elders such as those who formed the Combahee River Collective, a Black feminist lesbian organization active from 1974 to 1980, viewed resistance as essential when they joined to challenge oppression such as racism, heterosexism, and sexism.7 Several publications in this supplement echo the importance of resistance and resilience to addressing ISD. For instance, Poteat and Logie (p. S227) urge the need for HIV research to use a strengths-based lens that recognizes the value of community resources, multilevel resilience processes, and existing community assets to enhance the sustainability and contextual relevance of responses to HIV. Echoing Poteat and Logie, as well as findings from a 2018 AJPH editorial on intersectionality, resilience, and HIV stigma among Black women,10 Quinn et al.’s (p. S285) qualitative research with Black sexual minority men found that taking pride in intersectional identities, perseverance, community advocacy, and social support facilitated thriving and action against racism and heterosexism.
Authors delineate opportunities to improve methods and monitoring of ISD in HIV research. For instance, Earnshaw et al. (p. S293) propose core elements for future HIV ISD research (i.e., multidimensional, multilevel, multidirectional, action-oriented) and opportunities (e.g., reduce barriers, strengthen investment, build capacity, create pathways to structural change). A systematic review by Sanchez Karver et al. (p. S300) found measurement of HIV-related ISD to be concentrated in high-income countries and focused on the intersection of two identities (e.g., race and gender). Rodriguez-Hart et al. (p. S230) propose priorities for the intersectional implementation of Ending the HIV Epidemic monitoring activities such as ensuring access to ISD measures and support for their use, motivating use of such measures via policy and data feedback loops, and establishing equitable community partnerships. Sievwright et al. (p. S236) recommends principles for ISD interventions, including recognizing and naming how systems of power, privilege, and oppression intersect to fuel stigma; dismantling systems of power, privilege, and oppression and mitigating harms caused by those systems; ensuring community leadership and meaningful engagement; and supporting collective action, cohesion, and resistance. In implementation settings, Kerr et al. (p. S242) provided recommendations to enhance the impact of ISD interventions, including prioritizing community ownership, engagement, and connectedness; incorporating the experiences of frontline service providers; and creating an accessible, living, and open database of research and community efforts. Similarly, Nnaji and Ojikutu (p. S247) call for interventions that are culturally and linguistically tailored, multilevel, and conducted in partnership with community to address ISD for Black African immigrants living with HIV in the United States.
Two articles in the special issue focus on space and place as both reflections of historical oppression and reinforcers of ISD, which in turn negatively impact mental health and HIV outcomes. For instance, Wright et al. (p. S313) found that within-neighborhood and surrounding neighborhood characteristics (negative and positive) were associated with experiences of ISD, mental health, viral load, and medication adherence among Black women living with HIV. Consistent with these findings, Taggart et al. (p. S251) suggest conceptualizing space as a modifiable driver of ISD; using place-based methodological approaches; and investing in community-led, place-based, and systems-focused approaches to address HIV inequities.
Sexual minority men of color are disproportionately affected by HIV worldwide, and several articles focus on ISD’s impact on this group. Ogunbajo et al. (p. S254) propose a socioecological conceptual framework through which to understand ISD’s impact on HIV services among sexual minority men in sub-Saharan Africa. Among Black sexually diverse men in the United States, Lutete et al. (p. S324) used a qualitative system dynamics approach11 to characterize ISD experiences and identified three feedback loops: medical mistrust and HIV transmission, marginalization of Black and gay individuals and serosorting, and family support and internalized homophobia. Friedman et al. (p. S332) found that sexual minority men experiencing ISD had higher odds of hypertension, dyslipidemia, diabetes, depression symptoms, healthcare underuse, and suboptimal treatment adherence. Among young sexual minority men, Talan et al. (p. S278) discuss manifestations of ISD and encourage the use of event-level measures that indirectly capture experiences of ISD by documenting emotions felt across space and place. Driffin et al. (p. S257), in reflecting on the aforementioned publications and what is needed, noted that “the answer must be rooted in Blackness and queerness” and called for investments to support Black queer people living with HIV to become principal investigators.
Several notes from the field centered community voices and described current collective action in the face of ISD. A note by Nnaji et al. (p. S260) provides a glimpse into work being done by United We Rise, a collective of Black people living with HIV, activists, researchers, and health providers. The collective aims to answer the question, “What would the response to HIV look like if it were led by Black people?” It has five focus areas: intersectionality, Black community engagement, Black leadership and organizations, policy, and sexual and gender identity. Spieldenner et al. (p. S264) provide an overview of how an international coalition of sexual minority men, people who use drugs, sex workers, and transgender and gender-diverse people organized the HIV2020 Conference and leveraged this solidarity to call out ISD in a challenge to the International AIDS Society.12 Recognizing the dearth of studies exploring Latina/x/o health in the context of multiple systems of oppression, including racist xenophobia, heterosexism, ageism, and transprejudice, Arreola et al. (p. S267) call for community-based participatory research approaches, support for grassroots and community-led movements, and advocacy aimed at the decriminalization of undocumented immigrants. Arnetta Phillips (p. S270), in an inspirational first-person narrative piece, reminds us that work to address ISD ought to make tangible improvements in the day-to-day lives of people living with HIV through necessary structural changes (e.g., housing and employment).
To end the HIV epidemic, the field must be unwavering in its focus on the interplay between systems of oppression, power dynamics, community-led collective agency, and action—core tenets of intersectionality and Black feminist traditions. Collectively, the articles in this special issue of AJPH direct the field to interrogate what ISD research aims to accomplish and how research is imagined and implemented. In addition, they highlight space and place as important loci for researching and addressing ISD and the urgent need for improved methodological approaches for studying ISD. However, no analytic tool or research project will get us closer to reducing ISD without simultaneously engaging in explicit anti-ISD interventions. Ultimately, to reduce ISD and end the HIV epidemic, research and resources are needed to support programs in real-world settings that are led by people living with and disproportionately affected by HIV, not just researchers committed to ISD work.
ACKNOWLEDGMENTS
S. K. Dale was funded by the National Institute of Mental Health, National Institutes of Health (grants R01MH121194, R56MH121194, T32MH126772, and P30MH116867). C. H. Logie was funded by Canada Research Chairs (#Tier 2), the Canada Foundation for Innovation (#JELF), and the Ontario Ministry of Research and Innovation (#ERA). L. Bowleg was funded by the National Institute of Mental Health, National Institutes of Health (grant R21MH121313).
Note. The content of this publication is solely the responsibility of the authors and does not necessarily represent the official views of the funding institutions.
CONFLICTS OF INTEREST
The authors have no conflicts of interest to declare.
