`I`m less at risk than most guys`: gay men`s unrealistic optimism about becoming infected with HIV

Among the self-justifications that gay men use when engaging in high-risk sex is the thought that they are less at risk than most gay men. Two explanatory models of such 'unrealistic optimism' (UO) have been proposed: while the motivational account holds that UO arises because it serves the function of bringing comfort, the cognitive account holds that UO serves no particular function, being simply a by-product of normal cognitive strategies. This study investigated predictions derived from the motivational account. Gay men uninfected with HIV (n = 88) answered two test questions, requiring them to estimate, respectively, their own risk of becoming infected and that of the average gay man. The questions were presented in the two possible orders, and were either separated or not separated by unrelated filler material. The great majority of the men (89%) exhibited UO. Neither question order nor the interpolation of filler material affected responses to either test question. The results were inconsistent with the motivational account, but explicable in terms of the cognitive account. It seems that the cognitive account provides the better explanation of at least that form of UO measured in this study. Implications for AIDS educators are discussed.

Explaining gay men's unrealistic optimism about becoming infected with HIV

Among the self-justifications that gay men use when deciding to have unprotected intercourse is the thought that they are at less risk than most gay men. Two explanatory models of such 'unrealistic optimism' (UO) have been proposed: while the motivational account holds that UO serves the function of bringing comfort, the cognitive account holds that UO serves no particular function, being simply a by-product of normal cognitive strategies. This study tested the prediction, derived from the motivational account, that highlighting the salience of the self-other comparison should increase UO. Gay men uninfected with HIV (n = 122) estimated both their own risk of contracting various health problems - among them, becoming infected with HIV - and that of the average gay man. The purported aim of collecting the data was varied, so as to either make the self-other comparison central to the aim or render one of the two types of estimate irrelevant to the aim. No effect on UO was found. It seems that the cognitive account provides a better explanation than does the motivational account of at least that form of UO measured in this study. Implications for AIDS education are discussed.

Methodological considerations in the measurement of institutional and structural forms of HIV discrimination

The systematic measurement of HIV/AIDS-related discrimination is imperative within the current rhetoric that holds discrimination as one of the two ‘biggest' barriers to HIV/AIDS pandemic intervention. This paper provides a methodological critique of the UNAIDS (2000b) Protocol for the Identification of Discrimination against People Living with HIV (the Protocol) . Specifically, the paper focuses on the Protocol's capacity to accurately identify and measure institutional levels of HIV-related discrimination that allows data that are reliable and comparable across time and contexts. Conceptual issues including the Protocol's objective as an indicator versus a direct measure of discrimination and the role of the Protocol as a tool of research versus a tool of advocacy are explored. Design issues such as the operationalization of discrimination, appropriateness of indicator content, sampling and data collection strategies and issues of scoring are also evaluated. It is hoped that the matters outlined will provide readers with ways of critically reflecting and evaluating the findings of the research papers presented in this Special Issue, as well as pointing to ways of improving research design.

Unrealistic optimism about becoming infected with HIV: different causes in different populations

People tend to believe that their chance of experiencing undesirable events is lower and their chance of experiencing desirable events is higher than that of the average person like them. Two explanatory models of such 'unrealistic optimism' (UO) have been proposed: While the motivational account holds that UO serves the function of bringing comfort, the cognitive account holds that UO serves no particular function, being simply a by-product of normal cognitive strategies. UO for HIV infection was studied in samples of uninfected students (Study 1, n = 68) and gay men (Study 2, n = 63). In each case, participants rated either their relative likelihood of becoming infected (negative valence condition) or their relative likelihood of remaining uninfected (positive valence condition). As predicted, in Study 1 UO was greater where valence was negative and in Study 2 valence had no effect. The findings suggest that the students' UO is better explained by the motivational account, while the gay men's UO is better explained by the cognitive account. Implications for AIDS education are discussed.

Medication compliance and satisfaction with treatment for HIV disease in a sample of African-American crack cocaine smokers

The development of treatment regimes for African-American HIV-infected crack cocaine users has often been based on assumptions about compliance with medication regimes rather than evidence. This study sought to obtain baseline information on the adherence to antiretroviral medications by members of this important risk population in Houston, Texas. It was found that for only 5 of a range of 16 antiviral medications was there a significant correlation between levels of compliance reported by respondents and their beliefs as to how effective these medications are. Medication compliance was also found not to be associated with frequency of crack cocaine use in the month prior to interview. Furthermore, irrespective of both gender and their reported extent of medication compliance, the respondents tended to report positive relationships with their treating physician, with higher levels of satisfaction reported by women. These results suggest that the majority of African-American crack cocaine users are able to comply with HIV treatment regimes, with more than half (53%) claiming full compliance for one or more medications, and a further one third (31%) claiming compliance more than half the time. Moreover, these findings suggest that they will continue to take antiretroviral medications even if they have doubts about the effectiveness of these medications.

Achieving behaviour change: three generations of HIV/AIDS programming and jargon in Thailand

NGOs have played an important role worldwide in the fight to prevent the spread of HIV/AIDS through achieving behaviour change. NGOs have often been at the forefront of innovative changes, influencing government and international programming activities. This paper identifies and analyses the evolution of the HIV/AIDS programmes of one NGO in Thailand over a period of ten years. Three generations of programming are identified both through distinct approaches to this area of work and through the changing jargon used to describe the people the programmes are aimed at.

Spontaneous comparisons with others in gay men´s judgements of HIV risk

In studies on ‘unrealistic optimism’ (UO), when people are asked questions designed to make them compare their risk of experiencing an undesirable event with that of the average person, they tend to respond that their risk is lower. This study investigated whether comparisons of own and others’ risk also occur spontaneously, unprovoked by such questions. Gay men uninfected with HIV (n¼50) were asked to think aloud about their risk of becoming infected; their comments were audiotaped and analysed. Over half the men added comments relating to others’ risk. The phrasing of these comments and the reported basis for them are described. The men represented others’ risk as relatively high, own risk as relatively low. In the case of onethird of the men, it seemed possible to be confident that a comparison was being made. The findings suggest that comparisons of own and others’ risk do occur spontaneously and that, while the judgements made in UO studies do not capture all the characteristics of those made spontaneously, they resemble them in important ways.

Stigmatization of patients with AIDS : understanding the interrelationships between Thai nurses' attitudes towards HIV/AIDS, drug use and commercial sex

There is currently a scarcity of research on the nature of HIV/AIDS stigma within the Thai health context. This is problematic given the negative role of stigma in hindering the provision of patient care and treatment. This study used a mixed-method approach to investigate the interrelationships between the stigma of HIV/AIDS and the stigmas relating to its various modes of disease transmission including injection drug use (IDU). Twenty interviews were conducted with trainees and qualified nurses from a Bangkok college. Participants were presented with vignettes describing a hypothetical person varying in disease diagnoses (AIDS, leukemia, no disease) and co-characteristics (IDU,  commercial sex (CS), blood transfusion, no co-characteristic). Using a Q-sort task, participants arranged the vignettes along a bipolar scale according to their willingness to interact with the persons, and were asked to explain their decisions. Univariate and multivariate regression analyses showed that IDU, AIDS, and CS were all individually stigmatizing. Strong interactions were found between the stigmas of HIV/AIDS, IDU, and CS. Interview data also showed clear biases toward patients according to their IDU and CS habits. The findings  suggest that addressing these co-stigmas could be vital to the success of efforts aimed at reducing the disease stigma of HIV/AIDS.

Disentangling the stigma of HIV/AIDS from the stigmas of drugs use, commercial sex and commercial blood donation - a factorial survey of medical students in China

Background
HIV/AIDS related stigma interferes with the provision of appropriate care and support for people living with HIV/AIDS. Currently, programs to address the stigma approach it as if it occurs in isolation, separate from the co-stigmas related to the various modes of disease transmission including injection drug use (IDU) and commercial sex (CS). In order to develop better programs to address HIV/AIDS related stigma, the inter-relationship (or 'layering') between HIV/AIDS stigma and the co-stigmas needs to be better understood. This paper describes an experimental study for disentangling the layering of HIV/AIDS related stigmas.

Methods
The study used a factorial survey design. 352 medical students from Guangzhou were presented with four random vignettes each describing a hypothetical male. The vignettes were identical except for the presence of a disease diagnosis (AIDS, leukaemia, or no disease) and a co-characteristic (IDU, CS, commercial blood donation (CBD), blood transfusion or no co-characteristic). After reading each vignette, participants completed a measure of social distance that assessed the level of stigmatising attitudes.

Results
Bivariate and multivariable analyses revealed statistically significant levels of stigma associated with AIDS, IDU, CS and CBD. The layering of stigma was explored using a recently developed technique. Strong interactions between the stigmas of AIDS and the co-characteristics were also found. AIDS was significantly less stigmatising than IDU or CS. Critically, the stigma of AIDS in combination with either the stigmas of IDU or CS was significantly less than the stigma of IDU alone or CS alone.

Conclusion
The findings pose several surprising challenges to conventional beliefs about HIV/AIDS related stigma and stigma interventions that have focused exclusively on the disease stigma. Contrary to the belief that having a co-stigma would add to the intensity of stigma attached to people with HIV/AIDS, the findings indicate the presence of an illness might have a moderating effect on the stigma of certain co-characteristics like IDU. The strong interdependence between the stigmas of HIV/AIDS and the co-stigmas of IDU and CS suggest that reducing the co-stigmas should be an integral part of HIV/AIDS stigma intervention within this context.

Stigmatization of AIDS patients : disentangling Thai nursing students' attitudes towards HIV/AIDS, drug use and commercial sex

This paper analyzes the interrelationships between the stigma of HIV/AIDS stigma and the co-stigmas of commercial sex (CS) and injecting drug use (IDU). Students of a Bangkok nursing college (N = 144) were presented with vignettes describing a person varying in the disease diagnoses (AIDS, leukemia, no disease) and co-characteristics (IDU, CS, blood transfusion, no co-characteristic). For each vignette, participants completed a social distance measure assessing their attitudes towards the hypothetical person portrayed. Multivariate analyses showed strong interactions between the stigmas of AIDS and IDU but not between AIDS and CS. Although AIDS was shown to be stigmatizing in and of itself, it was significantly less stigmatizing than IDU. The findings highlight the need to consider the non-disease-related stigmas associated with HIV as well as the actual stigma of HIV/AIDS in treatment and care settings. Methodological strengths and limitations were evaluated and implications for future research discussed.

Risk factors for HIV/AIDS and hepatitis C among the chronic mentally ill

The objective of this study was to document the prevalence of risk factors for HIV/AIDS and hepatitis C among people with chronic mental illness treated in a community setting.

A method for the quantitative analysis of the layering of HIV-related stigma

HIV-related stigma is regarded as one of the major barriers in the development of effective prevention and care programs; but the stigma associated with HIV stigma is not a singular entity. The stigma of the infection is layered with other stigmas, such as those associated with the routes of transmission (e.g., sex work and injecting drug use) and personal characteristics (e.g., race, religion, ethnicity and gender). In developing programs and policies to overcome HIV-related stigma, cognisance needs to be taken of all the sources of stigma, and how they may interact. A novel method is described for examining the layers of HIV/AIDS-related stigma, and secondary data are adapted to illustrate this. The importance of understanding the layering of stigma for the development of effective interventions is also discussed.

HIV discrimination : integrating the results from a six-country situational anaylsis in the Asia Pacific

The findings of the six independent studies on institutional forms of HIV discrimination in the Asia Pacific presented in this Special Issue of AIDS Care are integrated. At first glance, the general pattern of the results across the study sites suggests that discrimination is most pertinent in the domain of 'practice' rather than in the domains of law or institutional policy. On closer analysis, however, utilising the qualitative data, this conclusion does not take sufficient account of the cultural context within which the interpersonal interaction (practice) between the health carers and people living with HIV/AIDS occurs. Limitations on the use of anti-discrimination legislations and protective written policies for reducing discrimination in these contexts are discussed. The need for alternative approaches to thinking about discrimination intervention is raised and this is done through a consideration of the strategy of universal precautions.

Institutional and structural forms of HIV-related discrimination in health care : a study set in Beijing

This paper presents key findings of a situational analysis of institutional and structural levels of HIV/AIDS-related discrimination in Beijing, China, with a focus on the area of health care. Initially slow to respond to the presence of HIV, China has altered its approach and enacted strict legislative protection for people living with HIV/AIDS (PLWHA). In order to determine whether this has altered discrimination against PLWHA, this study examined existing legislation and policy, and interviewed key informants working in health care and PLWHA. The overall findings revealed that discrimination in its many forms continued to occur in practice despite China's generally strong legislative protection, and it is the actual practice that is hindering PLWHAs' access to health services. A number of legislative and policy gaps that allow discrimination to occur in practice were also identified and discussed. The paper concludes with a call to rectify specific gaps between legislation, policy and practice. An understanding of the underlying factors that drive discrimination will also be necessary for effective strategic interventions to be developed and implemented.