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• W2909275362 abstract "To the Editors: BACKGROUND Currently, more than half of states in the United States have criminal laws related to HIV transmission. These laws have the potential to exacerbate HIV-related stigma1 and lead to lower engagement in HIV/AIDS treatment among persons living with HIV/AIDS (PLWHA),2,3 while little evidence has supported the effectiveness of these laws in reducing HIV infection.1 Despite the negative consequences of HIV laws for PLWHA, there are few quantitative studies examining correlates of these laws.4,5 HIV criminalization disproportionately targets sexual and gender minorities (SGM), which represent the largest group of individuals infected with HIV in the United States.6 Consequently, we considered whether structural stigma related to sexual orientation—defined herein as the social/cultural norms and institutional policies/practices that constrain the opportunities, resources, and wellbeing of SGM7—is associated with greater HIV criminalization. METHODS We operationalized 3 measures of HIV criminalization and analyzed them separately as dependent variables: (1) the presence of an HIV law (yes/no) obtained from WestLawNext (Thomson Reuters, Toronto, Canada),8 (2) whether the law considers HIV exposure as a felony in each state (yes/no),9 and (3) the enforcement of these laws through the proportion of arrests due to HIV exposure per 100,000 PLWHA in each state from 2008 to 2018.9 Enforcement data were retrieved from the Center for HIV Law and Policy (Brooklyn, NY), which conducts nationwide searches of publicly available news reports to ascertain the number of HIV criminalization arrests in each state.9 The independent variable of state-level structural stigma related to sexual orientation was a composite variable based on a previously developed scale.3 To summarize, this variable was developed to address the multifaceted dimensions of social prejudice at the state level, which consisted of 4 primary components: (1) density of same-sex couples per 1000 households (obtained from the 2010 US Census); (2) percentage of public high schools with gay-straight alliances for each state (obtained from the 2016 CDC School Health Profiles); (3) an ordinal summary variable of state policies and law related to sexual orientation that included, eg, nondiscrimination laws regarding sexual orientation in the workplace, hate crimes protections, and legal adoption for same-sex couples, but excluded HIV laws given overlap with our dependent variable (obtained from the Movement Advancement Project); and (4) an average value of public opinion toward sexual minorities and policies related to SGM issues (obtained from Lax and Phillips10). A z-score was calculated for each value. Regression analyses indicated that all components of structural stigma related to sexual orientation were in the same direction and relative magnitude of association with HIV criminal enforcement. Thus, we summed each value to construct a composite variable assessing structural stigma related to sexual orientation. To visualize the geospatial relationship between HIV criminalization and state-level structural stigma related to sexual orientation, we created a choropleth cartogram11 using the enforcement measure of HIV criminalization, as we hypothesized this variable would have the greatest association with structural stigma. States without HIV laws therefore have zero arrests. This mapping technique altered the size and shape of each state in accordance with their HIV criminalization, such that states with higher numbers of HIV arrests appeared larger, while states with lower numbers of HIV arrests appeared smaller. To modulate the distortion, we applied a square root transformation to the scaled criminalization variable.12 Multiple linear regression models were fit to assess the relationship between each of the 3 dependent variables and structural stigma related to sexual orientation. These models controlled for states' median age, proportion black race, and population size (obtained from the 2016 US Census Bureau's American Community Survey, 5-year estimates), as well as 2013 legislative majority party (Republican, Democratic, or split; obtained from the National Conference of State Legislatures).13 The regression models evaluating felony status of the law and arrest per 100,000 PLWHA were restricted to states with HIV criminal laws. As a sensitivity analysis, we recategorized structural stigma z-scores into quartiles and fit additional regression models. Analytic code and data set are available for download from https://doi.org/10.5281/zenodo.2210014. All analyses were conducted using R Platform for Statistical Computing version 3.2.1. (Vienna, Austria). RESULTS Figure 1 shows the choropleth cartogram created to represent the geographic relationship between structural stigma related to sexual orientation and HIV criminalization enforcement across the United States. From this map, darker shades correspond to a higher prevalence of structural stigma, whereas states that were distorted to appear larger than their original size correspond to greater levels of HIV arrests per 100,000 PLWHA. Despite variations of color/size across the United States, a clear pattern emerged. States with higher levels of structural stigma related to sexual orientation had higher rates of HIV criminalization enforcement than states with lower levels of structural stigma; this pattern was consistent with results of our regression analysis [β = 22.2; 95% confidence interval (CI): 1.59 to 42.77] after adjusting for state-level covariates. In addition, regression analyses indicated that both the presence of HIV laws (β = 0.04; 95% CI: −0.01 to 0.09) and felony status of those laws (β = 0.03; 95% CI: −0.01 to 0.08) were not significantly associated with structural stigma related to sexual orientation. Modeling structural stigma as quartiles also produced consistent results, with increasing quartiles of structural stigma related to sexual orientation being associated with higher levels of HIV criminalization enforcement (β = 44.1; 95% CI: 9.47 to 78.77).FIGURE 1.: Choropleth cartogram depicting arrests due to HIV per 100,000 people living with HIV/AIDS and state-level structural stigma related to sexual orientation. Lighter shades indicate states with lower levels of structural stigma; darker shades indicate higher levels of structural stigma. Larger states indicate a higher proportion of arrests due to HIV per 100,000 PLWHA; smaller states indicate a lower proportion of arrests due to HIV per 100,000 PLWHA.DISCUSSION The growing body of evidence documenting myriad harmful consequences related to HIV laws (eg, disrupting HIV prevention strategies and public health practices; facilitating HIV-related stigma among SGM)1,14–16 suggests a need to further understand correlates that influence the uptake of HIV criminal laws and contribute to their enforcement. Our study considered whether structural stigma related to same-sex sexuality represents one such factor because it may underlie public perceptions of HIV and its criminalization. We found support for this hypothesis. Specifically, this study demonstrated differential associations between state-level structural stigma related to sexual orientation and HIV criminalization, such that states with higher levels of structural stigma for SGM populations had higher rates of arrests due to HIV than did states with lower levels of structural stigma. However, higher (vs. lower) structural stigma states were not more likely to have HIV laws or to have laws that consider HIV exposure as a felony. Thus, structural stigma seems to be more strongly related to actual enforcement practices of HIV criminalization, rather than to the mere presence or absence of such laws. One potential explanation for this ecological relationship is that our measure of structural stigma captures environments that promulgate and reinforce stigma against sexual minorities; given the popular conflation of sexual minorities with HIV risk, our results suggest that prejudice and animus toward sexual minorities—and the attendant desire to punish “deviant” sexualities—may underlie the enhanced enforcement of HIV laws in high structural stigma states. Our data have several limitations. First, our analysis relied on aggregated reports of arrests at the state level. Arrest data were collected from news reports of more notable cases of HIV criminalization, such that the total number of arrests may be underestimated and subjected to reporting bias. Future research with more objective measures of arrest data is therefore warranted. Second, we collapsed broad periods in which our exposure and outcome were measured; consequently, future longitudinal research are needed to strengthen causal inferences regarding these relationships. Strengths of our study include the use of an innovative data visualization (ie, cartogram) to assess geographical relationships; this technique can potentially be applied in other areas of HIV research. In addition, we used arrest data as one of our dependent variables to assess the impact of structural stigma related to sexual orientation, which further enhances the sensitivity of our analysis. This preliminary work serves to generate additional hypotheses regarding mechanisms underlying the association between HIV criminalization and structural stigma among SGM groups. We recommend that future studies in this area focus in particular on the complex temporal relationship between enforcement practices of HIV-related laws, stigma, and HIV incidence using individual-level data." @default.
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• W2909275362 date "2019-04-15" @default.
• W2909275362 modified "2023-10-16" @default.
• W2909275362 title "Potential Relationship Between HIV Criminalization and Structural Stigma Related to Sexual Orientation in the United States" @default.
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