Visualizing stigma and HIV service engagement: a participatory approach using causal loop diagrams

Area of Science:

• Public Health
• Systems Science
• Social Epidemiology

Background:

• HIV stigma undermines prevention and care, especially in disproportionately affected communities.
• Understanding stigma's complex role across the HIV care continuum is challenging.
• This study uses participatory systems science to map HIV stigma dynamics.

Purpose of the Study:

• To map the complex dynamics of HIV stigma across the HIV care continuum.
• To identify feedback loops and leverage points for stigma mitigation.
• To inform multi-level interventions for the Ending the HIV Epidemic (EHE) initiative.

Main Methods:

• Employed participatory systems science with stakeholders from health departments and community organizations.
• Conducted virtual group model building sessions to create causal loop diagrams (CLDs).
• Iteratively developed and validated CLDs representing HIV prevention, testing, and treatment.

Main Results:

• CLDs revealed feedback loops in personal health attitudes, service quality, and community influences.
• Internalized and enacted stigma weaken social support, resilience, and care quality.
• Community stigma is context-dependent, influenced by social isolation or inclusive norms.

Conclusions:

• Participatory systems methods effectively visualize how HIV stigma impacts care engagement.
• CLDs provide a framework for identifying intervention leverage points.
• Findings can guide multi-level interventions to reduce HIV stigma and advance EHE goals.