HIV/AIDS stigma — basic problems remain

Researchers look at long-term of HIV prejudice

Twenty years ago, a researcher overheard one doctor say to another: "I'm not sure AIDS is so much a problem as it may be a solution to a problem."

This stunning example of prejudice against homosexuals, injection drug users, and other victims of the epidemic prompted the researcher to spend the next two decades studying HIV stigma.

"After pursuing that whole area, the truth is, in the medical profession, there are very strong biases," says Frederick A. Ernst, PhD, professor of psychology in the department of psychology and anthropology at the University of Texas – Pan American in Edinburg, TX. Ernst had overheard the physician's remarks, which had shocked him initially.

"I'm not shocked by those kinds of statements anymore," Ernst says. "Early on, research has shown that the attitude of primary care doctors became more negative toward homosexuals after the advent of AIDS."

American doctors more than European doctors would admit on surveys in the early 1990s that they would avoid homosexual male patients, Ernst says.

"They were afraid that their accepting AIDS patients would scare away other patients from their practices," he adds. "And when they asked patients in their practices about this, their fears were well-founded."

Ernst and colleagues developed a questionnaire in the late 1980s to discover how widely stigma and prejudice were among both health care providers and others. Called the Meharry Questionnaire, it asks for a response from 0 for strongly disagree to 5 for strongly agree to some very pointed statements, including the following:

  • AIDS is the result of God's punishment ("Divine Retribution").
  • AIDS will help society by decreasing the number of homosexuals (gay people).
  • People with AIDS have gotten what they deserve.
  • It is easier to catch the AIDS virus than the experts are leading us to believe.

The scaled response was used to encourage more candor. For instance, a person who agreed with the statement that "AIDS will help society by decreasing the number of homosexuals" might be more willing to circle a two or three than to answer affirmatively in a "yes" and "no" format.

"For me, if you look at a statement like that, why would anyone not strongly disagree with that statement?" Ernst says. "So circling 1 is just as disturbing as circling 5."

Researchers first distributed the questionnaire to groups of doctors, including the medical staff of a historically African American college, where the physicians and medical staff could be characterized as fairly liberal, Ernst says.

"The group looked very good in their responses to the survey, and we wanted to compare their responses to a group of primarily white, Southern physicians and the medical staff of a Baptist hospital," Ernst explains. "So we went to the institution, and those groups said they were not going to give the questionnaire to their people because it was too controversial."

So researchers decided to administer the survey to a group representative of the general population, but with limited funding had to find a cost-effective way of doing this, Ernst says.

Ernst convinced the Tennessee mental health agency to permit investigators to survey all people within inpatient residential facilities.

"We thought that would give us a good demographic spread of working people and of those on the front-lines of the mental health profession," Ernst says.

Findings from that 1989 survey showed that people's attitudes toward HIV/AIDS and the epidemic's victims were different according to the educational level of the person surveyed, he says.

There also appeared to be differences according to religious preference, but these also could be explained by educational level, Ernst notes.

"We found that if you were a member of the Assembly of God, you were far more conservative," Ernst says. "The most liberal were Catholics."

But when the religious groups were examined according to educational level, it showed that the least educated people surveyed had selected Assembly of God as their religious preference, and the most educated had selected Catholicism, he says.

"So we felt that the more education you have the less likely you are to endorse these sorts of condemnatory and prejudicial statements related to homosexuality and drug abuse," Ernst says.

Researchers repeated the survey in 1994 and then again in 2005 at the same locations, and they found some positive changes in the results in the latest survey, with responses showing less bias and stigma than in the previous years, he says.

"But the bad news is that for some reason we got a very different demographic mix in the 2005 sample," Ernst says. "Part of that was that after 1994, the mental health and mental retardation groups split in the state and became two different agencies, but the more important factor was that in the mid-1990s, there was a significant downsizing of the entire mental health residential facility staff."

When the facilities were downsized, the people with the least education lost their jobs and this led to the sample having a significantly better educated group in 2005, he explains.

"It could be the attitudes really have changed in a positive direction, but we can't say for sure because of an educational difference in this 2005 sample," Ernst says. "From a scientific standpoint, you can't make that conclusion because of the profound influence of the better-educated group."

For instance, the percent of people who strongly disagreed with the statement about how the AIDS epidemic is a fulfillment of biblical prophecy was 38 percent in 1989 and 58 percent in 2005, Ernst says.

Likewise, the statement about AIDS being the result of God's punishment elicited a strong disagreement from 52 percent in 1989 and 74 percent in 2005.

The statement that suggests AIDS will help society by reducing the number of homosexuals received strong disagreement by 44 percent surveyed in 1989 and by 73 percent in 2005, Ernst says.

What the study's findings suggest is that education is an answer to reducing HIV/AIDS stigma and prejudice, Ernst says.

"Being a scientist first, we're just saying we need to go back and get more data," Ernst says. "These are very interesting findings, but we have to clarify the confounding issue of having a better-educated group in 2005."

Investigators will try to break down this factor in future analyses to see what extent there might have been a shift in responses of people working in this environment to a more compassionate orientation, he says.

"We want to go back now and sample lower socio-economic groups in higher numbers to see if we can't get a more comparable sample to the 1994 group," Ernst says.

Future surveys may show that the general public has less prejudice against HIV patients today than 20 years ago, and anecdotal evidence suggests that medical professionals perpetuate less HIV stigma than they did in the past, Ernst says.

"I want to believe that we have more compassionate caregiving now," Ernst says. "I used to preach to physicians in medical school that to whatever extent they have a problem dealing with homosexuals in their practice, they are impaired physicians."

And Ernst says he does believe medical professionals now have a more compassionate attitude toward HIV/AIDS patients.

"I believe our physicians today are more compassionate by virtue of having a whole lot more training as of 2006 of all of the aspects of the AIDS epidemic, compared with 1986 when so little was known that even the physicians were uneducated," he says. "And there is significantly less prejudice about homosexuality in the medical community—at least as it interfaces with the AIDS epidemic."