Population Density and AIDS-Related Stigma in Large-Urban,
Small-Urban, and Rural Communities of the Southeastern USA
Published online: 11 February 2017
Society for Prevention Research 2017
Abstract AIDS stigmas delay HIV diagnosis, interfere with
health care, and contribute to mental health problems among
people living with HIV. While there are few studies of the
geographical distribution of AIDS stigma, research suggests
that AIDS stigmas are differentially experienced in rural and
urban areas. We conducted computerized interviews with 696
men and women living with HIV in 113 different zip code
areas that were classified as large-urban, small-urban, and ru-
ral areas in a southeast US state with high-HIV prevalence.
Analyses conducted at the individual level (N =696)account-
ing for clustering at the zip code level showed that internalized
AIDS-related stigma (e.g., the sense of being inferior to others
because of HIV) was experienced with greater magnitude in
less densely populated communities. Multilevel models indi-
cated that after adjusting for potential confounding factors,
rural communities reported greater internalized AIDS-related
stigma compared to large-urban areas and that small-urban
areas indicated greater experiences of enacted stigma (e.g.,
discrimination) than large-urban areas. The associations be-
tween anticipated AIDS-related stigma (e.g., expecting dis-
crimination) and population density at the community-level
were not significant. Results suggest that people living in rural
and small-urban settings experience greater AIDS-related in-
ternalized and enacted stigma than their counterparts living in
large-urban centers. Research is needed to determine whether
low-density population areas contribute to or are sought out
by people who experienced greater AIDS-related stigma.
Regardless of causal directions, interventions are needed to
address AIDS-related stigma, especially among people in
sparsely populated areas with limited resources.
The stigmatization of AIDS is manifested in social distancing,
avoidance, prejudice, discrimination, and self-devaluation.
Negative attitudes toward and discrimination against people
living with HIV remain entrenched across cultures
(Kalichman et al. 2009; Lieber et al. 2006;Tsaietal.2013)
and are not simply the result of misinformation (Wong 2013).
People living with HIV who experience greater AIDS-related
stigma have poorer mental health and poorer medical out-
comes (Rao et al. 2011;Tsaietal.2013; Vanable et al.
2006). AIDS stigmas have been studied in relation to medica-
tion adherence, where the relationship between experiencing
greater stigma and suboptimal antiretroviral therapy (ART)
adherence is clearly established (Katz et al. 2013; Sweeney
and Vanable 2015). There are multiple dimensions to stigma
and each has potential adverse health implications for people
living with HIV. Earnshaw et al. (2013) proposed a model
consisting of three distinct stigma mechanisms, specifically
internalized, anticipated, and enacted stigma, each linked to
different health outcomes. Internalized stigma reflects a sense
of being less worthy or inferior to others due to having HIV
and is directly associated with mental health outcomes includ-
ing a sense of helplessness and denial of one’s diagnosis.
Anticipated stigma, on the other hand, reflects how a person
with HIV may expect to be mistreated and discriminated
against in the future because they are HIV positive.
Anticipated stigma may have its greatest impacts on
* Seth Kalichman
Department of Psychology, University of Connecticut, 406 Babbidge
Road, Storrs, CT 06269, USA
Mercer University Medical School, Macon, GA, USA
Prev Sci (2017) 18:517–525