Exploring the Stigma of Sexually Transmitted Infections (STIs) and HIV/AIDS in Arkansas

Background and Purpose: Rural, southern LGBTQIA+ individuals receiving healthcare frequently encounter bias and discrimination by providers, including being blamed for personal health status. The majority of rural Arkansans living with HIV are not engaged in their medical care (Marshall, 2023). Some healthcare providers lack knowledge of diverse lifestyles and sexual practices, which may intentionally or unintentionally exclude people who are most at risk (Bjorkman & Malterud, 2009; Arbeit et al., 2016). There is a need to understand better the perceptions of people at risk and the providers' perceptions of serving them.

Methods: Semi-structured interviews were conducted with individual Arkansans who are disproportionately impacted by STIs and HIV/AIDS (e.g., LGBTQIA+, people of color, and rural residents) and healthcare providers who serve them. Individuals were asked about their experiences accessing healthcare, relationships with providers, and comfort talking about STIs and HIV/AIDS with providers. With providers, we explored their employment experiences, training/education, practices related to STIs and HIV/AIDS, experiences serving individuals with diverse lifestyles and sexual practices, and their perceptions of STIs and HIV/AIDS. Interviews were recorded and transcribed. Two independent coders conducted an inductive thematic analysis to analyze the qualitative data.

Results: Between 2021-2023, interviews with 24 participants occurred: 12 healthcare providers and 12 individuals who sought healthcare in Arkansas. Of providers, 33% reported “very little” or no training in treating individuals from diverse backgrounds. In comparison, 42% said their training came from their general education, such as a class session in their degree program. Providers specifically requested more training on implicit bias, pronouns, and working with transgender clients. Additionally, 25% of providers did not understand what was meant by the term “sexual orientation.”

Individuals' comfort levels (M = 8.60, SD = 1.96) with providers varied, with 25% explicitly noting higher comfort with female providers. Individuals in rural areas were less comfortable talking with providers due to concerns about privacy and stigma. Of individuals, 25% had to educate their providers on topics related to their care.

After having negative experiences with providers, this individual's description of their first experience disclosing sexual orientation captures the value [empowerment] of recentering and democratizing knowledge of STIs and HIV/AIDS in Arkansas:

"It kind of gave me almost a sense of ownership of my health and ownership of my life too finally. I reached a point in my life where I felt comfortable speaking to essentially a stranger about such a taboo subject, but something that had bothered me."

Conclusions and Implications: Individuals described concerns but also resourceful ways they met their healthcare needs in unwelcoming environments. Providers described stigmatizing practices but also ways they provide affirming practices in settings that can be hostile towards people with diverse identities and sexual practices. Social workers should collaborate with primary care providers, possibly using a primary care behavioral health model, to reduce disproportional health outcomes for this population. Improving access to quality, accessible, culturally informed, affirming healthcare is a must, especially in rural communities with already limited options for care.