HIV/AIDS Stigma Construction:
A Comparative Analysis Between San Antonio and Azerbaijan
My name is Jullian James Valadez and I am a Azeri Mexican from Houston, Texas majoring in Neuroscience at Trinity University in San Antonio, Texas. Research has always been a source of interest for me, and my greater ambition is to apply my research to the medical field in an effort bridge the gap between the academic and medical field as an MD/PhD.
Using the case studies of San Antonio, Texas and the Baku area of Azerbaijan, this paper analyzes the HIV/AIDS epidemics through the lens of stigma’s existence, impacts, and future in these regions. Individually, Baku and San Antonio provide great points of analysis due to their uniqueness and aberrations from international norms regarding HIV/AIDS epidemiology. While internationally HIV/AIDS affects more women than men and is contracted primarily through heterosexual sex, in both Azerbaijan and San Antonio a distinct majority of current and new infections are male and the predominant forms of transmissions are Injecting Drug Users [IDU] and Men who have Sex with Men [MSM] respectively (United Nations, 2017; Kurian, 2017). Due to aberrations from international epidemiological norms, these regions present unique patterns of stigma and barriers that must be noted when analyzing the epidemics.
The processes of understanding how stigma is created and exists in areas that differ from international norms can result in more understanding as to how stigma operates on a foundational level since it is functionally the same form of oppression despite the difference in environments. However, both San Antonio and Azerbaijan also serve as interesting points of comparative analysis in their unique differences and oppressive environments surrounding HIV/AIDS. Underscoring each of the respective epidemics are molds that are structurally the same: forms of conservatism rooted in religion and/or tradition that drive much of the stigma and narrative creation around the virus. Despite both San Antonio and the Baku Area of Azerbaijan differing in many distinct manners due to their existence on entirely different parts of the globe, their respective HIV/AIDS epidemics are linked in the nature of stigma’s construction and existence in the regions through conservatism permeated through mediums of tradition, religion, and social hierarchy.
Human immunodeficiency virus (HIV) and the syndrome it can progress to, acquired immunodeficiency syndrome (AIDS), is one of the most prominent chronic illnesses around the world. Affecting an estimated 35 million individuals worldwide, HIV/AIDS is categorized in many countries as either a nationwide or concentrated epidemic among certain populations. HIV/AIDS is a chronic illness without a viral cure, but treatments can extend lifespans to relatively normal lengths if medication is taken regularly and if viral load is suppressed. Treatment helps fight the attacks on an individual’s immune system, but it cannot address the rampant stigma and stigmatization of the people who are HIV + or at risk to be. The stigma that results from an HIV + status, or being “at-risk”, can result in oppression comparable to the medical prognosis of the disease. Yet, stigma is often overlooked as another symptom of diagnosis and must be accounted for in any epidemiological analysis. Here stigma can be defined as the feelings of disqualification, inadequacy, or shame present as the result of an attribute an individual possesses that is deemed an aberration from normalcy, whereas stigmatization is defined as the actual act disqualification and shunning towards the individuals from outside populations on account of the trait (Goffman, 1963).
HIV/AIDS results in stigma construction via cultural dynamics, like religious, conservative, and patriarchal institutions, that shun the discussion and define the disease as shameful. But, it also results in the stigmatization of those living with HIV/AIDS in the form of discrimination and prejudice, often without a medical warrant, towards those infected or merely at risk. This paper will focus on the stigmatic effects of HIV/AIDS, as it is at the core of both the problem of and the solution to ongoing epidemics around the world. It operates as the barrier to prevention activities (in the form of denial of sexual health education and discussion), the gatekeeper to care and support (in the form of poor state agencies and campaigns and family shunning of those infected or at risk), and the direction of the future of the disease (in the form of how HIV/AIDS will be discussed in the community and how people will be educated about the disease).
San Antonio has approximately 6,500 individuals who currently live with HIV, with 3,878 individuals having a suppressed viral load (San Antonio Metro Health Data Sheet). With 6,500 individuals who are HIV + in a city with 1.5 million citizens, HIV/AIDS is not considered an overall epidemic. However, with some counties having an 89% risk factor diagnosis and 100% transmission risk among MSM populations, like Bexar County, the disease can be categorized as a concentrated epidemic (Kurian, 2017). Other transmission avenues exist but are far less likely, with transmission routes like IDU only accounting for 6% of diagnoses. Though in San Antonio, the rates for a high-population city in a developed country are alarming, the epidemic in many ways is becoming increasingly managed. With initiatives and organizations dedicated to combatting HIV/AIDS and promoting education, rates are likely to decrease and the number of viral suppressions to increase.
The Baku area mirrors San Antonio in many ways epidemiologically. Overall, there is a low national HIV prevalence rate – less than 1% with a high-end estimate of 9,200 individuals living with HIV in a nation of near ten million people. But there are certain populations with very high prevalence rates – primarily IDU. While both regions have seen a higher than average increase of new infections, Azerbaijan has seen an above-average 358% increase of new diagnoses in the past decade (Gottfreðsson, 2014). Unlike San Antonio, though, Azerbaijan lacks efficient centers and programs dedicated to treatment and information about HIV/AIDS. Azerbaijan also exacerbates the epidemic with policies that aim to legally punish at-risk groups like IDU, MSM, and sex workers through jailing instead of rehab, and which subsequently increase HIV risk-taking behavior (Ávila, 2018; Gottfreðsson, 2014; Polonsky et al. 2016). Other policy items like instituting voluntary instead of mandatory HIV testing, an omission of sexual rights from the country’s constitution, and lack of outreach to rural areas also increase transmissions (Magerramov, Ismayilova, & Faradov, 2005).
Qualitative Data Presentation
In addition to a literature review, this essay incorporates two data sets regarding HIV/AIDS stigma conducted from interviews (thirty-four interviews in San Antonio by Dr. Huesca and fifteen questionnaire responses from Azeri individuals by undergraduate researcher Jullian Valadez). The qualitative data was used to both add to, and inform, the literature review. The San Antonio dataset was procured and later coded for trends and patterns of stigma by Dr. Huesca, from various individuals who either were or are at risk to be HIV +. Data was also compiled from the audience interaction in the various theatrical performances from the End Stigma End HIV/AIDS Forum Theatre Project (San Antonio Aids Foundation, Beat AIDS, Trinity University, Alamo Area Resource Center, Esperanza center, and Syphilis and AIDS task force).
Following Boal’s Theater for Social Change model, these performances were designed to display an oppression, unsolved, with the intent that audience interaction in the forms of suggestion and/or role play would solve the oppression while simultaneously preparing individuals for future scenarios where they might observe stigma. Two scenes were presented (one within a clinic depicting a tester giving an HIV + diagnosis and the other within a house where a family faces their estranged HIV + daughter), and data was procured through the commentary between the director and audience during and after scenes, following performances with written responses on brief questionnaires, and through the interventions and suggestions provided by audience members. Abstract ideas were pulled from the performances and analyzed alongside the interviews and literature to extrapolate larger ideas.
For Azerbaijan, qualitative data came from questionnaire responses sent out to both previous and current citizens of Azerbaijan. The questionnaire was confidential, translated, and included sixteen open-ended questions designed to gauge both stigma and knowledge about HIV/AIDS in the Baku area. It was distributed via email through an Azerbaijani cultural center in the region, through a physician specializing in HIV/AIDS, through social media networks populated by Azeri individuals, and through local businesses in the region.
Data Analysis: San Antonio
The San Antonio data set’s coding revealed distinct patterns of stigma based on the perception of self and the fear of perception by others – often seen through concealment of status from co-workers and family. Other prominent trends identified were forms of self-blame for contraction, criticism of clinical practices, fear that contraction would burden others, and feeling like contraction is equivalent to a death sentence.
The coding of the data corroborates previously published data analysis on HIV/AIDS stigmatization, and divides the stigma into four main factors: personalized stigma, disclosure concerns, negative self-image, and concern with public attitudes about people with HIV/AIDS (Beyrer & Baral, 2011). Among the interviews, there was a constant discussion of the role ignorance and/or miseducation played in stigma construction, an idea which was also present in both post-performance written responses and candid audience interactions. Overall, the data revealed an understanding of the dynamic nature of stigma (e.g., an audience member commenting on how an interaction could easily change among families or how an individual can both advocate openness about serostatus but continue to hide his own), but also the existence of identifiable points of origin: a common item discussed with the audience was the presence of distinct and clear points of oppression, such as homophobia, fear of contraction, and miseducation.
This increased socio-spatial awareness of HIV/AIDS stigma and the presentation of solutions from the audience in the context of the forum theatre projects corroborates previous literature claims that more qualitative data and community-based mobilization efforts would be an essential component to mapping out the relationship of HIV/AIDS’ complex nature and its simple solutions (Parker & Aggleton, 2003). More abstract trends found in the data were the receptiveness and interaction differences found between different audience types. Communities in which HIV/AIDS was more prominent (in terms of serostatus) resulted in more candidness and discussion during the forum theatre presentations; people were quicker to speak, quicker to engage, and more open to providing uncensored opinions. This trend supported previous academic literature that found that in environments where an individual’s status was already known or where HIV/AIDS was common, discussion would be increased (Du, Chi, & Li, 2018; Marks et al., 1992).
Data Analysis: Azerbaijan
The questionnaire data set was coded for trends. Among the most popular trends was the feeling of confidence in one’s knowledge of HIV/AIDS (twelve individuals). Yet this claim was contrasted with only a couple of individuals who were aware of current data on HIV/AIDS or aware of current Azerbaijan policy and campaigning for HIV/AIDS (six and three respectively). Despite homophobia within the country at all levels, only seven individuals associated HIV/AIDS with homosexuality; rather, most correlated it with an IDU disease (twelve) or a sex worker disease (seven). A notable point of contrast in the data set was the frequent denial of HIV/AIDS being taboo (only five claimed it was a taboo topic), which differed from the twelve individuals, some being the same respondent, who claimed it brought shame to the culture and/or family.
While the data sample did skew towards females (comprising ten out of the fifteen respondents), the trends of homophobia, hyper-masculinity, and traditionalism were embedded in most of the responses. It is important to take into account the altruistic and nationalistic nature of some of the responses; Azerbaijan’s relatively recent independence and embedded traditionalism likely influenced some respondents to paint either the country, or themselves, in a better light. This was most apparent in some respondents claiming the efficiency of Azerbaijan healthcare, but being unable to name a clinic, campaign, or any recent data on HIV/AIDS. More critical responses of Azerbaijan medical systems came from those more distanced from the nationalism or the country, especially those who fled the country at a young age.
The Role of religion in stigma construction
Religion comprises the foundation of many social interactions in several regions across the world, serving as a pillar of values from which communities derive much of their mores and customs. The role of religion is distinct in both San Antonio, where Catholicism is the predominant religion of the communities affected by HIV/AIDS (with Baptists comprising a present, but smaller, proportion of both the data set and city of San Antonio), and the Baku area of Azerbaijan, where Islam is the religion most common throughout the country (Grammich et al., 2012; Magerramov et al., 2005). However, the ideas and values of Catholicism and Islam were especially present within the dataset, and facilitate the creation of communities with more pronounced stigma. Catholic teachings are often rooted in ideas of abstinence, anti-homosexuality, and general sexual conservatism with one’s identity (American Life League). Many facets of Catholic teachings of sexuality are mirrored in Islamic teachings; Islam also places great emphasis on female virginity until marriage, and as result, sexual education within the religious communities fails to inform women, or men, about STDs (Parvaneh).
The sexual values embedded within each of the religious teachings subsequently permeate the communities, creating mores and ideas that are often at odds with those living with HIV/AIDS. This can be seen clearly in the questionnaire responses from Baku area residents, living in a greater community that is ninety-five percent Muslim, which often critiqued the moral makeup of those living with HIV/AIDS who were infected through IDU – a critique that is prevalent throughout the Quran (“Azerbaijan Population,” 2018; Sattari, Mashayekhi, & Mashayekhi, 2012). In San Antonio, this trend is much less pronounced, but still evident in some interviews/interactions that commented on religion aiding in their contraction (ignorance because of a religious community that never spoke of sexuality) or concealment of status (fear of judgment by religious family or peers). Concealment among African Americans and Hispanics was also a trend noted in previous literature, which has found that the anti-gay nature of their respective communities (natures that are very apparent in both the Catholic and Baptists faiths) resulted in the increased secrecy of serostatus (Marks et al., 1992). Religion, operating as a pillar of values and ideas that many communities see as primary sources of “truths,” operates as a main factor in stigma construction – especially in regions like Baku in Azerbaijan, where religion permeates social and political spheres (Magerramov et al., 2005).
Tradition: A Medium for Conservatism and stigma construction
Tradition is a broad term that can describe sets of customs, values, and general norms that are evident within a community. In the Baku data set, tradition was seen not only as “how things are done,” but to many, it was also “how things should be done.” In addition to the influence of Islam on the stigma towards HIV positive individuals due to violations of Quran, general tradition in Baku perpetuates stigma as well. Many of the Baku area respondents noted general negative attitudes towards HIV positive people for moral reasons unrelated to Islam: some commented on sexual promiscuity being at odds with a very conservative and family-oriented Azeri identity, while others noted that IDU aberrated from norms of hard-working individuals who care for their life and family. The family identity of a hard-working man and a loyal housewife is shared by Baku and San Antonio, and in both, HIV/AIDS breaks this mold. In San Antonio, the notion of “machismo cultures” in Hispanic culture or “Hotep culture” in African Americans serves as a second pillar of values and customs in the region. Both cultures center on a heterosexual, masculine man who can lead both a house and a community, and MSM, seen both in interviews and audience responses, do not fit the archetype and thus are ontologically denied in their respective communities. A comparable culture is present in the Baku area of Azerbaijan; women are expected to be subservient in many regards, sexually conservative until marriage, and ready to dedicate their lives to caring for children and a “strong and moral man” (Buckley). Homosexuality is also a lifestyle that is opposed in the Baku area, arguably more staunchly and aggressively than in San Antonio, with reported human rights violations for the treatment of gays in the region and HIV/AIDS agencies drastically underreporting the number of MSM in the region due to shame (Ávila, 2018; Beyrer & Baral, 2011).
However, the differences in the severity of the stigma embedded within the tradition can also explain the differences in the epidemiology between Baku and San Antonio, such as the predominant forms of transmission and the future of the disease. In the U.S, while drug use is still criminalized and stigmatized, many needle exchange programs across the country are funded by the government or non-profit agencies and have contributed to IDU reduction (Bassler, 2007). The increased campaigning and public dialogue via ads about substance abuse reduced overall stigma and lack of treatment for IDU, and thus may explain the lower rates of transmission via needles in San Antonio. However, these efforts and campaigning have not been made for MSM, many of whom commented in interviews (both from the S.A and Baku data set) that sexuality is rarely discussed in the U.S., and that poor sexual education for MSM increases stigma and transmission in San Antonio. In Azerbaijan, stigma plays a scaled-up role: MSM are erased from existence and IDU are incarcerated or assaulted. The extensive stigma in Azerbaijan towards MSM decreases transmission rates via erasure statistically or physically, with condemnations of Azerbaijan for underreporting and assaulting MSM by UNAIDS (Ávila, 2018; Beyrer & Baral, 2011). Similarly, the aggressive incarcerations of the perceived “immoral and reckless” IDU, again also based on stigma, result in empirical increases of IDU transmissions (Polonsky et al., 2016).
Patriarchy: an intersection of hypermasculinity and
heteronormativity that creates stigma
The role of tradition and its effects on women is also an interesting point of analysis. While both regions’ epidemic is male based, Azerbaijan’s structural difference in its epidemiology puts women at a unique risk. Among the questionnaire responses, near half of all respondents viewed sex workers as one of the most at-risks groups in the region – a perception which is empirically supported by research that found that commercial sex workers were the second most common carrier of HIV/AIDS, and were just as criminalized and stigmatized by the general public for non-traditional values (Magerramov et al., 2005). The patriarchal attitudes prevalent in Baku are far more severe and encompassing of values than in San Antonio, and thus produce distinct risks for women in the country, despite having structurally the same form of stigma based on heteronormative values (Cheemeh, Montoya, Essien, & Ogungbade, 2006). The future for the respective epidemics differs as a result of the level of patriarchal traditions and perceptions (e.g., in Baku, women are inherently expected to quit working once pregnant, as seen in the case of one interviewee who had been a physician). Though females are biologically and socially more likely to contract HIV, both regions’ epidemiology and traditions have resulted in an epidemic with male-centered narratives (Türmen, 2003).
However, a distinction between Baku and San Antonio can be made in regards to future susceptibility for women. While San Antonio still has clear heteronormative and hypermasculine value systems in some communities, it has a concentrated epidemic among MSM – a population less likely to transmit to women. Baku, however, has an epidemic concentrated to IDU – a group non-exclusively male – with neighboring regions seeing increased infections among sex workers (Magerramov et al., 2005). Baku’s intersection of patriarchal and conservative value systems results in women receiving less sexual education and protection, while also increasing the risk of transmission with no legal protection and campaigning for sex workers. Though stigma against sex workers and sexism against women are prevalent in San Antonio, the level at which the stigma exists in Baku, as well as the mediums in which it is expressed (at the governmental and community leader levels), results in increased risk of infection for women in the region.
Middle Eastern countries have been involved in political and sociological turmoil for the past decade due to factors such as war, national disaster, and political turnover; this instability, combined with existing patriarchal institutions and heteronormative values, has resulted in unique epidemiology and stigma not only between countries but within them as well (Cheemeh et al., 2006). Azerbaijan’s epidemic differs on the rural side of the region, where sex worker transmission is more common than in Baku, where IDU is the predominant manner in which new infections occur (Magerramov et al., 2005). The approach of culturally competent care, in which approaches and programs are tailored specifically to areas with certain needs and unique cultures, applies to both the Baku and San Antonio areas, where different identities are more receptive, and in need of, targeted approaches (Cheemeh et al., 2006). The lack of any dedicated MSM HIV/AIDS prevention programs in the Bakku region has drawn international critique, and possibly exasperated stigma and harm towards sexual minorities in the area (Ávila). However, a culturally competent model that deals within the socio-cultural environment within Azerbaijan is key to countering stigma (like using a religious leader as a campaign leader); otherwise, it has been empirically shown that such efforts will fail due to public rejection (Bozicevic, Voncina, Zigrovic, Munz, & Lazarus, 2009; Magerramov et al., 2005).
Future research should explore the significance of the underscoring motif of heteronormative value based stigma that links San Antonio and Baku. Understanding how this mold of oppression exists within two distinct regions of the globe, one being a first-world, predominately Hispanic region and the other being a predominately Muslim developing country, can shed light on how stigma is constructed and the factors that drive its existence. Continued research comparing Muslim conservatism to Catholic conservatism should be conducted in order to understand the stigma constructions within these cultures.
The existence of non-homophobic Azeri individuals from the data set is not an exception to the theoretical framework, but rather a key extension of the roles cultural pillars play in stigma creation. Those who were exposed to a more accepting climate in the United States tended to respond differently about HIV/AIDS, with many claiming it to be a “disease of the poor and uneducated” rather than one “they deserved.” The shift is important to note; the stigma did not dissipate but rather changed to a different form that is more present in United States culture. Shared points of stigmatization between Baku and San Antonio, like that of the IDU or MSM, differed in the ultimate stigmatized narrative that existed as the popular truth within a community. The complexity of the role that cultural hubs and value pillars is put on display in these case studies, which show similar mechanisms of stigma creation for similarly stigmatized behaviors resulting in drastically different narrative constructions for those who reside within the ostracized spheres (e.g., the opinion that they deserved it or the opinion that it unfortunately was an affliction tied to their very existence). Narrative formation is thus seen to be an intricate process tied intimately with the specific society in which it is created and the value systems and norms which comprise it. The imprinting from new cultural hubs, like a more friendly and unregulated LGBTQIA social media presence and more access to sexual health programs, is empirically present in the data set where Azeri individuals who lived in the U.S were more likely to be critical of Baku’s healthcare system and expect more campaigning for HIV/AIDS.
However, similar trends of ignorance and lack of sexual healthcare access were present in the San Antonio dataset, with some interviewees admitting STDs were not something they were ever taught (and several not knowing much about HIV/AIDS at all, despite being at risk). This too, however, is not an exception to the theoretical framework presented about stigma construction. The presence of stigma and ignorance around HIV/AIDS in San Antonio, a city with more access to sexual healthcare and a distinctly smaller degree of homophobia than Baku, can be explained by the same justifications. While to a lesser extent than the Baku data set, the San Antonio dataset does indicate similar trends of homophobia, feelings that HIV + individuals deserved the disease for their actions, and feelings of general societal stigma around ones’ HIV + existence. Each facet of stigma existed in both, but depending on the prominence of the cultural pillars that propagate such attitudes (i.e. in San Antonio Catholicism is common, but not predominant and controlling like Islam is in Baku), the resulting stigma took on a structurally similar, but differently scaled form. Targeting the cultural pillars that influence individuals’ value constructions – similar to how Azeri youth who spent years in the U.S changed their perceptions about HIV/AIDS – while working solely within a region, should be a future theoretical model to analyze and counter stigma.
The implications of this brief comparative analysis show stigma construction as a process correlated with certain cultural belief systems, such as religion or patriarchal traditions, but not necessarily with a region. Because of their unique epidemiology, both Baku and San Antonio are interesting cases in regards to their aberrations from international norms; however, it is their related socio-cultural institutional values, despite apparent cultural differences, which holds particular value for stigma research. These institutions and the social attitudes they produce in the form of stigma are not broad entities with vague correlation between the regions; they are identifiable centers of religious, traditional, and patriarchal identity within the cultures, with stigma construction evident in the coding of the responses. These seemingly unrelated regions with drastically different histories are linked by the manner in which their stigma toward HIV/AIDS continues to shape public perception, attitude, and policy.
Stigma is defined in each of the regions by certain cultural pillars in the society, but it also continues to influence the interpretation of, and application of cultural values onto, new items and conditions, resulting in new value constructions that evolve into what can now be defined as cultural narratives at odds with a society – or simply “Stigma.” This comparison elaborates the stigma’s existence as a dynamic entity that both defines, and is defined by, public attitude, but it also sheds light on its confines within a sphere. Understanding the sphere within which it operates (e.g., the certain traditions or cultural identities which lend themselves to stigma constructions), as well as the scale of stigma within that sphere (e.g., how latent homophobia in San Antonio compared to rampant homophobia in Baku might result in a structurally similar shame an epidemic, but a distinctly lesser form of stigmatization
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