Relationship of health rating and HIV-related stigma among people living with HIV: a community study

The purpose of this study was to understand the impact of stigma among a geographic population of people living with HIV in Maricopa County, Arizona. People living with HIV who experience stigma have lower medication adherence and fewer kept appointments. The people living with HIV patient survey was administered using both paper and online versions in the beginning months of 2019. A total of 296 respondents completed the survey for this study. Participants were recruited through multiple methods, including online sites, the Phoenix AIDS Walk, health clinics, and the identification of zip codes with high HIV prevalence rates. There was a significant relationship between health status and age, with those who reported a higher health rating, that of excellent or good, more likely to be 45 years of age or older, X2 (1, N = 296) = 4.812, p = 0.028. Researchers and health care providers must be attentive to these variations and intersecting stigmas when providing services across diverse populations, especially when working with a high-stigma population such as people living with HIV. Providers can take a more active role in helping people living with HIV to see how their perceptions and experience of HIV-related stigma may be taking a toll on their perceptions of their health, as well as their approach to treatment, and refer them to support groups or individual counseling. Strategies, policies, and messages should be tailored with cultural, social, and ethnic sensitivities in mind. To address these threats, policies must be created that reduce the impact of HIV-related stigma within various systems, including but not limited to the public health sector.


Introduction
A ccording to a meta-analysis of 64 studies, people living with HIV 1 (Joint United Nations Programme on HIV/ AIDS, 2014, p. 10) who experience stigma have lower medication adherence and fewer kept appointments (Rueda et al., 2016). Theorizing stigma and discriminatory practices holds several challenges, and once grasped, practical deployment of approaches based on those theories presents another layer of difficulty. However, once those approaches are identified, there are opportunities to improve groups' health and well-being, especially in relation to experiences of stigmatization and discrimination (Turan et al., 2019). Historically, Goffman (1963), Link and Phelan (2001), and Parker and Aggleton (2003) proffer micro, mezzo, and macro conceptualizations of social stigma. Hargreaves et al. (2015) introduced an approach to measuring stigma through an amalgamation of stigma and intersectionality that argued that addressing "multiple stigmas faced by people living with HIV, and key populations at high risk of HIV" is essential to lessening the negative impacts for those who are affected by this global epidemic (p. A203). Research shows that HIV-related stigma experienced by people living with HIV reduces their likelihood of achieving viral suppression, resulting in increased risk for illness and virus proliferation (Heijnders and Van Der Meij, 2006;Rueda et al., 2016).
Research on HIV-related stigma has resulted in typologies delineating forms of stigma (i.e., enacted, internal, perceived), which correlates with discrimination experienced by HIV-positive individuals, which include include internalized, interpersonal, and structural stigma. Stigma and discrimination impact healthseeking behaviors, such as medication adherence, seeking support for anxiety and depression, and attending health-related appointments (Blake Helms et al., 2017;Seghatol-Eslami et al., 2017). Internalized stigma occurs when a person living with HIV perceives mistreatment due to their HIV status and, therefore, adopts negative feelings towards themselves and their diagnosis. These feelings can manifest as guilt or shame for having HIV. These feelings can lead people living with HIV to be reluctant to disclose their HIV status to new partners, engage in HIV treatment, or even seek medical care at all ). An interpersonal typology includes relational forms of stigma that occur when a person living with HIV/AIDS experiences shaming or assault as a direct result of their HIV status. People living with HIV also report situations where other people avoid physical contact with them or spread rumors about their condition, which affects their relationships.
Additionally, HIV-related stigma occurs through discriminatory legislation or policies known as structural stigma. These policies can limit the access people living with HIV have to health care and resources (Hatzenbuehler, 2016). Therefore, how one views their well-being can be affected by many forces, including internal, interpersonal, and structural. These perceptions can, in turn, influence how they rate their health and how they seek treatment for HIV-related care.

Background
Disclosing one's HIV status to sexual partners is mandated in some jurisdictions, and disclosure has been proven to be tied to improved social support and medication adherence (Conserve et al., 2015). Miller et al. (2011) found that individuals' confidence in disclosing their HIV status increases when they live in a community with less HIV/AIDS discrimination. For this reason, the City of Phoenix's Fast Track Ad Hoc Committee members sought to understand the degree of HIV-related stigma experienced by people living with HIV seeking medical care in Maricopa County, Arizona. The members wanted to be a positive force in reducing stigma and increasing care by developing strategies for HIV-related stigma reduction, targeted towards individuals with HIV/AIDS and local health care providers. The issue was essential in this particular place, given that Maricopa County is currently one of the 48 counties in the United States with the highest rate of new HIV infections (U.S. Health and Human Services U.S. [HHS], 2019). In 2019, Maricopa County reported a total of 551 incident cases of individuals living with HIV/AIDS and a prevalence rate of 288.5 per 100,000 persons. Since Maricopa County has approximately 61.5% of the state population but 71.1% of the incidence cases in Arizona, it is imperative to slow down the rate of HIV infection (White et al., 2019).
To reduce the HIV infection rate, the Phoenix Fast Track Ad Hoc Committee wanted to design appropriate strategies for addressing medical care needs and strategies involving stigma reduction for people living with HIV. Thus, the Ad Hoc Committee sought to gather information related to the first-hand experiences of stigma experiences of people living with HIV in Maricopa County. The resulting study examined the demographic and health factors that influenced experiences of HIVrelated stigma and the linkages of these data to medical careseeking behaviors. Specifically, this analysis focused on the relationship between health ratings and the experiences of stigma of people living with HIV.

Literature review
A health care provider's ability to diagnose a patient's health or sickness based on self-reported measurements implicitly creates an unbalanced power dynamic. A health care provider utilizes four quantitative assessments to measure the health status of a person living with HIV: (1) T-cell count, (2) viral load, (3) adherence to the medication regimen, and (4) engagement with HIV medical care according to timeframes. If any one of these assessments is not met, the provider can relay an unhealthy status.
Another power dynamic related to HIV treatment trickles down from government funding to Community Based Organizations and AIDS Service Organizations to the HIV-positive individual vis-à-vis the HIV care continuum. The HIV care continuum in the United States is a result of a 2013 Executive Order enacted during the administration of President Barack Obama that prioritized indicators of HIV/AIDS prevention, treatment, and care as part of the Patient Protection and Affordable Care Act 2 (Kay et al., 2016). The HIV care continuum is globally recognized as a framework for HIV population health markers. The care continuum identifies four step-wise elements as indicators of patient health: (1) diagnosis, (2) linkage to care (LTC), (3) retention in care (RiC), and (4) viral suppression, which includes adherence to antiretroviral therapy (Center for Disease Prevention and Control [CDC], 2019; Kay et al., 2016). Accordingly, the CDC (2019) stated that the ultimate goal of HIV treatment is to achieve viral suppression, with the penultimate objective of adherence.
More recently, a broader emphasis on the link between quality of life (QofL) and HIV-related stigma has become apparent (Andersson et al., 2020;Chen et al., 2013;Dawson-Rose et al., 2016;Holzemer et al., 2009). In particular, literature has documented the relationships between HIV-related stigma, socioeconomic status (SES), and quality of life (Drewes et al., 2020;Flannelly and Inouye, 2001;Okuno et al., 2015). A study conducted by Dawson et al. (2016) found that the theme of trust in the provision or experience of HIV care encompassed three important subthemes: (a) respect, (b) partnership, and (c) a dynamic and continuous process of building and re-building trust over time (p. 579). The study found that when health care providers have a direct relationship with persons living with HIV, there are positive implications for patient-related health competency. This is further proof that removing power differentials between those living with HIV, their providers, and the overall health system can improve self-perceived health status, stigma, and quality of life. Additional studies also found a positive correlation between health care provider engagement, increased medication adherence, and quality of life in people living with HIV (Chen et al., 2013).
A German study on HIV, comorbidities, health-related quality of life (HRQOL), aging, and SES concluded that comorbidity burden, as well as HRQOL ratings, showed strong social inequalities across our multi-dimensional index of SES, with participants from the lowest SES group showing a significantly higher comorbidity burden, higher risk for falls and impaired HRQOL compared to participants from the highest SES group (Drewes et al., 2020).
The study of Drewes et al. (2020) demonstrated the relationship between SES and of varying health conditions, including how health is self-determined. Indeed, the self-health rating can be considered a key part of QofL as how one feels about their life may impact the attributes they assign to their everyday existence. Foth et al. (2015) analyzed the Canadian-based Seek and Treat for Optimal Prevention (STOP) approach designated by the United Nations as the most cost-effective response to the AIDS pandemic; according to the findings of Foth et al. (2015), "STOP combines antiretroviral therapy and routine HIV screening to find persons unaware that they are HIV-positive, because research has shown that people consistently change their behavior (i.e., increase condom use, have fewer partners) after an HIV diagnosis" (p. 99). Foth et al.(2015), describe STOP as innovative given that it requires a paradigm shift away from disciplining behavior by emphasizing self-control or self-responsibility in relation to health risk management (p. 99). By allowing the patient to take control of their own treatment, health care providers move away from being the "experts" on patients' wellbeing and instead individuals in the HIV/AIDS community demand to be actively involved in the management and treatment (p. 103). As Foth et. al. (2015) described, patients moved away from being passive bystanders in their own treatment to "active biological citizens" (pg. 104) as an HIV-prevention strategy. STOP is an example of the impact of empowering patients and removing silos in care, a method that is dependent on health care providers shifting to a paradigm where treatment is grounded in partnership rather than a top-down approach.
We argue that HIV disparities are influenced by intersecting lived experiences, which necessitates a deeper understanding of this phenomenon in the population under study here, those living with HIV in Maricopa County. For instance, according to the Arizona Department of Health Services (ADHS), the incidence rate in 2019 for Hispanics reached 14.1 and is substantially higher than that of Whites at 6.3. Among African Americans, not only are the rates much higher, but the rates have also increased sharply in recent years from 22 per 100,000 in 2010 to 37.7 in 2019 (Arizona Department of Health Services, 2020; White et al., 2019). Consequently, ADHS commissioned qualitative and quantitative studies on the perceptions of HIV among Hispanic Men Who Have Sex with Men (MSM) and African American men and women. This research aimed to identify drivers of fear, internalized concepts of HIV/AIDS, and perceptions of unequal treatment in order to help inform public awareness campaigns and reduce stigma. The findings showed that specific facilitators of stigma related to HIV/AIDS contribute to intersecting stigmas that include but are not limited to race, sexual identity, and socioeconomic status. For example, research with African Americans revealed that religion plays a significant role in stigma, with faith influencing health care conversations within their families. The "shame, fear and feeling of "going against God" creates unique and significant barriers to taking positive action"; there was also more stigma associated with detecting someone's status by outward appearances (Arizona Department of Health Services, 2018a, p. 39).
In interviews with the Hispanic community in Maricopa County, respondents stated they were more likely to talk about health care topics with friends rather than family. Moreover, they felt the community reaction towards them was very mixed, in that while "my family is accepting of my sexual identity," "I feel misunderstood or judged," and "it isn't something we talk about" (Arizona Department of Health Services, 2018b). These initial findings pointed to how crucial it is to understand the impact of intersecting lived experiences of HIV-related stigma and discrimination on those living with and seeking HIV/AIDS care.
The health equity initiative Undetectable = Untransmittable (U = U) was initiated in February 2016 by the Prevention Access Campaign, a group of people living with HIV/AIDS in the United States. Now U = U is a global community of HIV/AIDS advocates, activists, researchers, and community partners from 71 countries whose unified goals are to spread the fact that "a person living with HIV who is on treatment and has an undetectable viral load cannot transmit HIV through sex" (Prevention Access Campaign, 2016, pg. 2) The Campaign created a Consensus Statement, backed by global experts, to clarify the science behind U = U 3 . The U = U Consensus Statement reads: People living with HIV on ART [Anti-Retroviral Therapy] with an undetectable viral load in their blood have a negligible risk of sexual transmission of HIV. Depending on the drugs employed, it may take as long as six months for the viral load to become undetectable. Continued and reliable HIV suppression requires the selection of appropriate agents and excellent adherence to treatment. HIV viral suppression should be monitored to assure both personal health and public health benefits. (Prevention Access Campaign, 2016, p. 1).
The U = U health equity initiative was aimed to end the dual epidemics of HIV/AIDS and HIV-related stigma by empowering people with accurate and meaningful information about their social, sexual, and reproductive health (Prevention Access Campaign, 2016).

HIV-related stigma and discrimination framework
Several research studies related to HIV-and AIDS-related stigma have concluded that stigma is strongly associated with an individual's health-seeking behavior (Parker and Aggleton, 2003;Stangl et al., 2019;Stuber et al., 2008). Parker and Aggleton (2003) proposed a conceptual framework aimed at dismantling the negative interpretation of HIV-and AIDS-related stigmatization by recognizing that HIV-and AIDS-related stigma is closely associated with "the reproduction of social difference" (p. 13). Stangl et al. (2019) proposed an ecological model called the Health Stigma and Discrimination Framework (HSDF), which accounts for the varying systems where stigma exists (i.e., individual, interpersonal, organizational, community, and public policy). The HSDF actualizes "the stigmatization process as it unfolds across the socio-ecological spectrum in the context of health, which can vary across economic contexts in low-, middle-, and high-income countries" (p. 2). This framework has been applied to a myriad of health conditions in addition to HIV/AIDS that hold related stigmas and discrimination (e.g., leprosy, epilepsy, mental health, cancer, HIV/AIDS, obesity/overweight). Stigma intersects with social locations that impact population health outcomes, quality of life, and advancements in HIV/AIDS technologies (Stangl et al., 2019). The domains of Stangl et al.'s (2019) framework include: (1) the factors that drive or facilitate health-related stigma; (2) stigma "marking," whereby a particular stigma is applied to people or groups according to a specific health condition or other perceived difference (e.g., race, class, gender); (3) stigma manifestations through experiences and practices; and (4) outcomes for affected populations (e.g., access to and acceptability of health care services), and (5) organizations and institutions (Stangl et al., 2019). The HSDF promotes the use of a collective praxis to identify connections and disparities in stigma processes across conditions, increasing efforts to impact root cause issues associated with adverse health outcomes (Stangl et al., 2019).
The HSDF framework identifies intersecting stigmas, which have co-constitutive contributions to drivers and facilitators in their modeling. The intersectional stigma concept is the union of "multiple stigmatized identities within a person or group and addresses their effects on health" (Turan et al., 2019). Intersectional stigma merges two theoretical, methodological, and process-driven frameworks, centering differentials in relationality and power, intersectionality, and stigma. The health and social impacts discussed in the HSDF assist in contextualizing power dynamics, health ratings, and U = U-focused health care as a useful stigma reduction tool.

Methods
Study objectives. This study aimed to examine relationships between health ratings and HIV-related stigma experiences of people living with HIV/AIDS in the Phoenix Metro Area. Such findings may be useful in designing strategies to encourage people living with HIV/AIDS to seek care and to help medical providers to enhance outreach efforts and provide health care that meets their patients' needs. HIV/AIDS-related stigma remains a significant concern and health barrier for people living with HIV/ AIDS, as well as those who care for them. Such stigma contributes to the disproportionate prevalence rates of HIV/AIDS for particular racial and ethnic groups related to prevention, treatment, and care (Baugher et al., 2017). Any strategies and recommendations that result from examining relationships of individual perceptions of health, alongside HIV-related stigma experiences, could be used by the Phoenix Ad Hoc Committee and other groups to inform people living with HIV/AIDS of issues around receiving care and to educate HIV/AIDS providers and advocates about the negative impact HIV-related stigma has on the people they strive to serve.

Study design and sampling
Institutional review board (IRB). The protocols used in the study were approved by the City of Phoenix Fast Track Cities Zero Stigma subcommittee, and the research analysis was approved by the IRB at Arizona State University.
Recruitment and inclusion criteria. Participants were recruited through multiple methods, including online (e.g., Facebook, City of Phoenix, Aunt Rita's, and Grindr websites), events such as the Phoenix AIDS Walk, and local health clinics. Additionally, the evaluation team identified zip codes with high HIV/AIDS prevalence rates and distributed promotional materials about the study within those geographical areas.
A screener was administered to participants to determine study eligibility. This screener included demographic questions and asked respondents to identify their HIV/AIDS status as positive, negative, unknown, or "rather not say." Since this study aimed to understand the personal experiences of people living with HIV/ AIDS, study participants were invited to complete the online survey if they met the following eligibility criteria: (1) were HIV/ AIDS positive and (2) resided in Maricopa County.
Survey. This patient survey of people living with HIV/AIDS focused on attitudes, experiences, and impacts of multiple stigmas. The patient survey was administered using both paper and online versions in the beginning months of 2019. The survey included demographic questions specific to income, race/ethnicity, educational level, current health rating, marital status, and sexual orientation. As the HSDF framework had been identified as necessary to understanding intersecting stigmas, several validated scales were used to measure stigma from different viewpoints; other life experiences and U = U questions were also added to provide a robust depiction. Three members of the Zero Stigma committee led the compilation of survey questions from numerous sources. Survey questions were decided through an iterative process with the entire City of Phoenix Fast Track Cities subcommittee via email and finalized by consensus during the Zero Stigma subcommittee's monthly meetings.
Multiple sources were utilized to generate the survey, including an amalgamation of demographic screening tools used by public health agencies that assisted in crafting questions about forced labor, bonded labor, trafficking, and involuntary servitude related to sexual activities. Among the validated measures utilized was the Berger HIV Stigma Scale (Berger et al., 2001), a 40-item measure consisting of four subscales that assess personalized stigma, disclosure concerns, negative self-image, and concern for public attitudes. Using a 4-point Likert scale (strongly disagree, disagree, agree, strongly agree), an index score was created. A total score and each subscale score were calculated by dividing the total possible score for each domain. The National Alliance of State and Territorial AIDS Directors Stigma & Discrimination Survey contains eight questions answered using a four-point Likert scale (never, rarely, sometimes, often). The U = U portion of the study includes four items created by the committee regarding the participant's knowledge about U = U, how the U = U concept impacts them, how confident they feel about the concept of U = U, and with whom they have discussed U = U. A $15.00 gift card was provided to participants for their participation in the study. A total of 296 respondents completed the survey for this study.
Gathering experiences of HIV-related stigma was the primary focus of this study. In recognizing that compounding factors such as disease diagnosis (e.g., HIV/AIDS and adiction) and demographic data (e.g., race, gender, sexuality) intersect and make it challenging to isolate the root causes of discriminatory practices, questions were chosen to take into account junctures in social locations and circumstances.
Measures. For each question, descriptive statistics were utilized and presented to show frequencies and percentages. Since the large majority of respondents (n = 247, 83.4%) identified as LGBTQ, sexual orientation was not used as an independent variable for the analysis. Instead, six participant characteristics were used as independent variables: age, race, income, education, residence, and health rating. Race and ethnicity were asked as separate questions but overlapped in the response choice of Hispanic, making it more reliable to recode these responses into one variable: White, non-Hispanic = 0 and Non-White = 1. The question on residence, where participants were living, was recoded as living alone = 0, not living alone = 1, as the not living alone choices were similar, and the issue of study was the factor of social isolation related to living alone. Three of the characteristic items (age n = 11, residence n = 22, health rating n = 23) had missing data as participants were allowed to skip items; ARTICLE HUMANITIES AND SOCIAL SCIENCES COMMUNICATIONS | https://doi.org/10.1057/s41599-022-01086-8 respondents were excluded only from the items on which the characteristic was missing.
Two-dependent questions concerned the topic of U = U. The first item was the level of confidence in U = U (ranging from not at all confident = 0, to very confident = 4); the second item was a series of responses about with whom the participant had discussed U = U, such as their doctor, family, friend or romantic partner, with each coded as having talked with this person (No = 0 and Yes = 1).
The six dependent stigma variables were calculated as mean scores for the Everyday Stigma Scale and for the Berger HIV Stigma Scale total and its four subscales. The slightly modified Everyday Discrimination Scale asked eight questions that were framed in the negative (e.g., You are called names or harassed). Responses were coded with lower values for positive responses (0 = never, 1 = rarely, 2 = sometimes; and 3 = often) with a total score range from a low of zero to a high of 24; Cronbach's alpha was rated high (0.901). The Berger HIV Stigma Scale has 40 questions with four subscales, several of which used the same questions: personalized stigma (18 questions), disclosure concerns (10 questions), negative self-image (13 questions), and concern with public attitudes about people with HIV (20 questions). Each of the subscales showed a high-reliability factor rating using Cronbach's alpha: personalized stigma (0.957), disclosure concerns (0.870), negative self-image (0.925), and concern with public attitudes about people with HIV (0.942). To create the index score, the total score and each subscale score was calculated by dividing the overall possible score for each domain. The higher mean scores represented more participants who agreed with the multiple questions on each scale, questions which are posed in the negative (lower scores mean less HIV-related stigma).
Data analysis. Linear regression analyses examined the association between the personal characteristics and HIV-related stigma, with binary logistic regression used to examine personal characteristics and U = U. All analyses were conducted in SPSS (IBM SPSS Statistics 27).

Results
Personal characteristics. Characteristics for the sample of 296 respondents are presented in Table 1. The survey screener asked respondents to identify their HIV/AIDS status as positive, negative, unknown, or "would rather not say." Since this study's focus was on the personal experiences of people living with HIV, only respondents who were HIV/AIDS positive and who resided in the County of interest were invited to complete the online survey.
The majority of respondents identified as LGBTQ 4 (n = 247, 83.4%) as their sexual orientation, while 49 respondents (16.6%) identified as straight/heterosexual; gender identity was not asked. Respondents' ages ranged between 18 and 77 years old (M = 43.6 years, SD = 13.7; median age = 45 years). As to race/ethnicity, about half of respondents identified as White, non-Hispanic (51%) and half as non-White (49%). Household income skewed somewhat low for this sample, with 20.5% earning less than $10,000 annually, 24.3% between $10,999 and $24,999, and another 14.9% between $25,000 and $34,999. In contrast to lowincome levels, education levels were somewhat high: a total of 22% had only attended middle school, some high school, had a high school diploma, or had a GED; another 39.9% had attended trade school or had some college; and 38.1% had some form of a college degree. Almost half of the respondents reported living alone in a house or apartment (n = 135; 49.3%). While only a small percentage (2.6%) stated that their health was very poor (n = 1) or poor (n = 6), others reported their health as fair (n = 77, 28.6%), about half reported their health as good (n = 138, 50.5%), and less than one-quarter viewed their health as excellent (n = 50, 18.3%). This survey also asked about the U = U health concept. Seven of ten respondents (n = 211, 71.3%) had heard about U = U before the survey. That also meant that there were still many people unfamiliar with this health treatment as a prevention strategy. When asked with whom respondents had spoken about U = U, a friend was the most likely to have been part of a discussion (51.0%), followed by a doctor, romantic partner, or family member.
HIV-related stigma outcomes. The majority of responses to the Everyday Discrimination Scale were positive, with an overall low summed mean score of less than 10 based on a range of 0 to 24 (M = 8.89, SD = 5.57), and with 60 to 70% of respondents stating that never or rarely did they encounter some of the negative situations; that also showed that 30 to 40% of the time, respondents sometimes or often faced negative HIV-related stigma interactions.
For the Berger total and subscales, each index score was calculated by dividing the overall possible score for each domain; higher stigma scores are more negative while lower scores are more positive. For the total stigma score, the mean score was 0.6226 (SD = 0.14412). The highest mean score was for the subscale of disclosure, indicating that more respondents agreed with negative statements that they needed to be careful about how and to whom they disclosed their HIV/AIDS status because they worried they would be discriminated against and judged. Interestingly, when the other individual questions were examined, approximately half of the respondents strongly agreed with the statement, and about half disagreed or strongly disagreed.
The standardized coefficients from linear regression analyses showing the study outcomes are presented in Table 2. A respondent's age was associated with five of the seven outcomes. The pattern for each of these is an inverse relationship in that a higher age had a lower level of everyday discrimination, total stigma, personalized stigma, negative self-image stigma, and public attitudes stigma. Thus, the older an individual, the lower their reported discrimination and HIV-related stigma.
Level of income was associated with four outcomes all showing that higher income was associated with higher total stigma. An increase in income was also associated with less confidence in U = U, higher negative self-image stigma, and higher public attitudes stigma. The factor of living alone was associated with only one outcome, such that if you lived alone you had less personalized stigma. Race and education were unrelated to all the measures of HIV-related stigma and to level of confidence in U = U.
Health rating emerged as the most salient factor, associated with six of the seven outcomes. Increases in health rating were associated with decreases in everyday discrimination, and with four of five stigma outcomes, the exception being the disclosure subscale stigma. Conversely higher health ratings were associated with higher levels of confidence in U = U, such that higher health ratings showed less HIV-related stigma.
In managing one's health, especially for this population who indicated they were HIV positive, speaking to a doctor, family, friend, or romantic partner about the relatively new U = U prevention strategy might be seen as necessary. However, in examining how the six personal characteristics might have an impact on those discussions, the only associated outcome was between race and communication with the participant's doctor. In this instance, White non-Hispanic participants were less likely to have told their doctor, while non-White respondents were 2.3 times more likely to have talked to their doctor than Whites.

Discussion
The purpose of this study was to understand the impact of HIVrelated stigma among a geographic population of people living with HIV/AIDS. This survey was performed by the City of Phoenix Fast Track Cities Zero Stigma subcommittee, some but not of whom are HIV/AIDS and/or health experts. The analysis was performed by a diverse team of seasoned and novice university researchers. The subcommittee's objective was to gain a broader understanding of how people living with HIV/AIDS experience HIV-related stigma in the Phoenix Metro Area and how stigma interplays with aspects of their quality of life and health management, including their perception of U = U. Members of the committee expected to see exacerbated stigma scores among the more socioeconomically distressed respondents and among racial, ethnic, or sexual minorities.
In contrast, these results showed that the statistically significant variable occurring most often in the experience and perception of HIV-related stigma and confidence in U = U was the degree to which respondents felt healthy. The results suggested that recognition of participants' rating of their own health has untapped potential for future research and HIVrelated stigma interventions. The significant relationships between feeling healthy and perceiving less HIV-related stigma calls for an examination of self-health rating as an independent variable. It is crucial to understand how the respondents in this study achieved a good or excellent health rating since those participants had lower stigma scores. Drivers of intersecting stigmas related to HIV/AIDS often center around fear (e.g., fear of contagion, fear of loss of income, and mortality) (Stangl et al., 2019). Stangl et al. (2019) sought to deemphasize psychological models and "instead emphasize, the broader social, cultural, political and economic forces that structure stigma" (pp. 3-4). For people living with HIV/AIDS, any examination of intersecting HIV-related stigma must also consider tenants of queering public health approaches to examine categories of demarcation and aspects of gender and sexuality (Nagington, 2015). Accounting for these many aspects necessitated using a theoretical framework, such as the HSDF, that considered intersectional and multiply marginalized populations living with HIV-related stigma in the Phoenix metropolitan area.

Implications/policy recommendations
The application of HSDF foregrounds HIV-related stigma reduction, which can lead to potential policy changes, improved population health outcomes, and additional stigma-reducing initiatives. Based on related qualitative and quantitative studies by Arizona Department of Health Services (2018a, 2018b), the public relations firm, it is evident that HIV-related stigma persists as a challenge in Maricopa County and other parts of Arizona. Therefore, stigma mitigation activities must be given attention in relation to how stigma interplays with individual health ratings.
Individual level implications. HIV-related conversations focused on stigma remain a difficult but necessary topicto grapple with for providers and people living with HIV/AIDS. For people living with HIV/AIDS, discussions with health care providers on emotionally difficult topics like the impact of stigma can be-and often are-a matter of life and death. Yet, too often, these conversations are not initiated by either the individual or the provider. For example, less than half of the survey respondents had discussed U = U with their doctor. Since knowing the science behind U = U and PrEP can be both de-stigmatizing and lifesaving, these conversations need to take place.
Optimistically, the data indicated that people living with HIV/ AIDS who have a high self-health rating also have a lower experience and perception of HIV-related stigma according to their responses to both stigma scales. These ratings offer providers the potential to use the existing power dynamic with their patients to help people living with HIV/AIDS move toward a stronger perception of self-health and engage in conversations about life-saving preventative measures, such as condom use, medication adherence, and U = U. Providers should include conversations about self-perception and a sense of healthiness as a routine part of the conversation.
Program planning implications. Prior research and this study have substantiated that lower levels of internalized HIV-related stigma are associated with a higher sense of well-being and physical health indicators (Earnshaw et al., 2013(Earnshaw et al., , p. 1791. This study suggests that the importance of maintaining a positive concept of one's health is more influential than merely having a happy outlook. Since the existence of stigma has harmful and unhealthy effects on people living with HIV/AIDS, procedures, policies within various health departments, communities, governmental agencies, and provider organizations should encourage discussions around the existence of stigma, HIV/AIDS prevention, and treatment, and living healthy and stigma-free lifestyles among whole bodies of people, not just among patient/ provider dyads. Moreover, identifying as belonging to cultural, ethnic, and social groups often impacts identity and reactions to adverse events. Thus, any strategies, policies, and messages should be tailored with cultural, social, and ethnic sensitivities in mind. To address these threats, policies must be created that reduce the impact of HIV-related stigma within various systems, including but not limited to the public health sector. Centering the community in these efforts may improve the likelihood of success as community capacity increases when there is broad input on program planning (Ford et al., 2019, p. 335).
Marketing campaigns can help push forward discussions at all levels and raise awareness about HIV-related stigma and its correlation to individual healthiness perceptions. These campaigns can be both general and for targeted populations and groups to provide specific messages.
Further research is needed to determine if respondents with higher health ratings live in protective spaces where they may experience less prejudice, if they have sought social circles that create a buffer of support, or if they embody this confidence within themselves.

Conclusions
Self-reported health outcomes differ by class, race, and ethnicity due to the various cultural interpretations of the definition of health (Bombak, 2013). Therefore, researchers and health care providers must be attentive to these variations and intersecting HIV-related stigma when providing services across diverse populations, especially when working with groups that often experience stigma, such as people living with HIV/AIDS. Providers can take a more active role in discussing with people living with HIV/AIDS how their perceptions and experience of stigma may be taking a toll on their perceptions of their health and refer them to support groups or individual counseling. Conversely, individual providers and clinical workgroups should be cognizant that they have a valuable opportunity to improve the perception of healthiness among people living with HIV/AIDS to help them combat the effects of HIV-related stigma.
Limitations. This project has several limitations. It lacks generalizability due to two factors: first, it focuses only on Maricopa County, Arizona, and second, 83% of respondents identified as LGTBQ. Therefore, it is not representative of heterosexual people living with HIV/AIDS. Moreover, owing to the fact that recruitment was primarily through AIDS service organizations, the majority of respondents were connected to organizations that are holistically supportive of participants' physical and psychosocial well-being. Lastly, the survey did not ask people to identify their age or gender. Age was estimated by year of high school graduation and could be imprecise.

Notes
1 Per the UNAIDS 2015 Terminology Guidelines, the preferred term is people living with HIV as this reflects the fact that persons with HIV may continue to live well and productively for many years. 2 Formally known as the Patient Protection and ACA, and colloquially known as Obamacare. 3 In scientific terms, an undetectable HIV viral load only prevents HIV transmission to sexual partners. Condoms also help prevent HIV transmission and other sexually transmitted infections (STIs) and pregnancy. The choice of an HIV/AIDS prevention method may differ depending upon a person's sexual practices, circumstances, and relationships. For instance, if someone is having sex with multiple partners or in a non-monogamous relationship, they may consider using condoms to prevent other STIs. "Negligible" is so small or unimportant not worth considering; insignificant. 4 Transgender (T) is a gender identity, not a sexual orientation.