Introduction

Stigma has been defined as “an enduring condition, status, or attribute that is negatively valued by a society and whose possession consequently discredits and disadvantages an individual” [1, p. 595]. AIDS-related stigma refers to “prejudice, discounting, discrediting, and discrimination directed at people perceived to have AIDS or HIV, as well as the individuals, groups, and communities with which they are associated” [2, p. 2]. It apparently arises from fears of contagion, disease, and death [3]. AIDS-related stigma is ubiquitous [4], but levels vary among racial groups [5] and it is more often found among the least educated members of a society [6, 7].

As the twentieth century came to an end, overt expressions of AIDS-related stigma had declined among the English-speaking population living in the continental United States, but approximately one-third of all Americans continued to express negative sentiments towards persons infected with HIV [8]. AIDS-related stigma and discrimination against people living with HIV/AIDS (PLWHA) continue to hinder efforts to eliminate racial and ethnic disparities in HIV disease and control the HIV/AIDS epidemic in the United States [9]. In 2001, “the serostatus approach to fighting the HIV epidemic” (SAFE) proposed case management and community-level and structural interventions to provide HIV-prevention services and reduce the stigma associated with HIV disease [10]. Levi [11, p. 1015] cautioned, “[I]f SAFE is to be a success, efforts must be undertaken to address stigma,” but little support for community-level and structural interventions to mitigate the effects of AIDS-related stigma has been forthcoming from the Centers for Disease Control and Prevention (CDC) or anyone else [12].

Although national telephone and Internet surveys have been conducted in the continental United States to assess the prevalence and correlates of AIDS-related stigma, few have examined the extent of AIDS-related stigma in Hispanic and other ethnic minority populations [13]. Researchers have not assessed AIDS-related stigma in any major metropolitan area of the United States to determine how stigma impacts personal and community-wide efforts to prevent HIV infection and control the magnitude of the epidemic among those at increased risk. Since racial and ethnic minority young adults are at increased risk for HIV infection [14] and many ethnic minority residents are likely to speak a language other than English, we sought to discover how stigma was affecting the abilities of minority communities to respond effectively to local HIV-prevention efforts.

Our research was based on the work of Herek [4] and his colleagues [7, 15, 16]. They have demonstrated that AIDS is a stigmatized condition, AIDS-related stigma can influence attitudes toward health policies [17], and AIDS-related stigma can inhibit actions (such as HIV-antibody testing and disclosure of results) that could be beneficial for individuals, their sexual and needle-sharing partners, and their communities. We sought to extend this body of work by assessing to what extent AIDS-related stigma existed in various vulnerable populations living in a highly diverse metropolitan area of the southeastern United States and how stigma was limiting the abilities of young people to protect themselves from HIV infection, take ownership of the HIV problem in their communities, and participate in HIV-prevention efforts.

Formative research conducted in the Ft. Lauderdale metropolitan area (Broward County) during 1999–2000 indicated that AIDS cases (≈73%) among Black and Hispanic residents 18–39 year-old were concentrated in 12 (of 53) ZIP-code areas [18]. Discussions with local residents suggested that AIDS-related stigma was inhibiting efforts to eliminate disparities in HIV disease among racial and ethnic minorities. Therefore, major purposes of our study were to assess the prevalence of AIDS-related stigma among young minority adults at increased risk for HIV infection living in Broward County in 2003 and to compare our findings with survey results reported for Black and White adults living in the continental United States in 1991, 1997, and 1999 [8]. In addition, we wanted to know how AIDS-related stigma was related to personal primary and secondary HIV-prevention practices, perceptions of risk, beliefs about who was most responsible for solving the AIDS problem in Broward County, and participation in community-level HIV-prevention efforts. Finally, we wanted to look at other variables that might be related to AIDS-related stigma, prevailing beliefs, and prevention practices.

Our research objectives were to: (1) determine the extent of AIDS-related stigma among Black and Hispanic 18–39 year-old adults living in 12 high AIDS-incidence areas of Broward County, Florida; (2) relate patterns of AIDS-related stigma to gender, marital status, age group, ethnic identification, language preference, educational attainment, religiosity, country of origin, and length of residence in Broward County; and (3) assess how AIDS-related stigma is associated with abstinence, use of condoms, HIV-antibody testing, perceptions of risk, perceived ownership of the AIDS problem, and participation in community-level intervention efforts.

Methods

A cross-sectional computer-assisted telephone interview (CATI) survey was conducted in summer 2003 with representative samples of telephone numbers listed for customers located in the 12 ZIP-code areas of Broward County, Florida, with a high incidence of AIDS [19]. Randomly selected telephone numbers were dialed (cold contacts) by multilingual interviewers employed, trained, and monitored by the Institute for Public Opinion Research (IPOR). Interviewers were required to make up to ten attempts to reach a potential respondent until a disposition could be made.

Participants and Procedures

Eligible respondents had to be residents between the ages of 18 and 39 years and report that they were of African-American, Caribbean, Haitian, or Hispanic descent. If a household contained more than one eligible respondent, the caller asked to speak with an eligible male. If no eligible male was present, the caller asked to speak with an eligible female. If someone answered, the caller identified herself (or himself), briefly introduced the purpose of the survey, established eligibility, and attempted to obtain consent to conduct an interview. Research procedures were reviewed and approved by the Institutional Review Board at Florida International University.

Data Collection Instrument

A semi-structured CATI guide was constructed to address “a major health problem” and “help people living in Broward County.” An incentive was offered, “If you qualify and complete the survey, we will mail to you a $10.00 gift card.” After consent was obtained, the interviewer read each question and recorded each response on a programmed computer screen. The interview was designed to be completed in less than 20 min. At the conclusion of the interview, the interviewer asked the respondent to provide a mailing address where the gift certificate could be sent.

Survey Items

Independent variables included: (1) race/ethnicity (African American, Afro-Caribbean, Haitian, and Hispanic), (2) gender, (3) age, (4) marital status, (5) educational achievement, (6) country of origin, (7) length of residency in Broward County, (8) language of preference (Creole for Haitians and Spanish for Hispanics), and (9) religiosity. Dependent variables included: (1) perceptions of HIV risk, (2) self-reports of sexual experience, (3) condom use, (4) HIV-antibody testing history, (5) beliefs about responsibility for addressing the HIV problem, and (6) actions taken to do something about the local HIV problem.

To assess risk perceptions, the interviewer said, “Now, I want to ask you a few questions about the risk of HIV infection and how people might protect themselves. If you don’t want to answer any of these questions, that’s OK, just let me know as I read them. First, what are your chances of getting HIV, that is the virus that causes AIDS: Would you say high, medium, low, or none?” Self-reports of sexual experiences (virginity and abstinence in the past year), condom use (lifetime and in the past year), and HIV-antibody testing (lifetime and in the past year) were obtained, as described elsewhere [19]. In addition, we assessed beliefs about responsibility for addressing the local AIDS problem and actions taken to do something about it. The former was introduced with the question, “Who is most responsible for taking care of the problem of AIDS?” Multiple response categories included: “the Federal government; the Florida Department of Health; Broward County Health Department; doctors; community members; families; or people just like you.”

Personal engagement in problem-solving activities was introduced with, “Now, I want to ask you about some activities you might be involved in to solve these health problems in your community. In the past year, have you taken part in any activities with a group or on your own to help your community solve any of these health problems?” If the respondent indicated some activity, the interviewer asked, “Which of the problems we’ve talked about did you work to try to solve in your community?” Multiple response categories included diabetes, drug abuse, gonorrhea, AIDS, and other.

AIDS-Related Stigma

AIDS-related stigma items were adopted from national surveys conducted in 1991 [5] and again in 1999 [8]. Three addressed AIDS-related policies: (1) “People with AIDS should be legally separated from others to protect the public health,” (2) “The names of people with AIDS should be made public so that others can avoid them,” and (3) “People who got AIDS through sex or drug use have gotten what they deserve.” A fourth item included in our 2003 CATI survey concerned trust of authorities: “The government is using AIDS as a way of killing off minority groups.” The latter was asked in the 1991 national survey [5], but was not included in the 1999 nine-item stigma index constructed by Herek et al. [8].

The next three items addressed feelings of anger, fear, and disgust towards PLWHA. The last series of questions examined intentions to interact with a young child and a neighborhood grocer, both living with AIDS. The interviewer opened this discussion by saying, “Suppose you had a young child who was attending school where one of the students was known to have AIDS. How would you feel about that? Would you feel comfortable having your child at that school, or would you feel uncomfortable?” Follow-up questions explored two possible reactions: “Would you send your child to another school” and “would you discourage your child from having any contact with him or her?” The other series concerned reactions to knowledge about “the owner of a small neighborhood grocery store where you liked to shop had AIDS.”

Stigma Scales

We set out to construct a simple stigma scale of nine items following the procedure described by Herek et al. Herek et al. [8, p. 375] reported internal consistency was “acceptably high” for their nine-item index in 1991 (α = .77), in 1997 (α = .79) and in 1999 (α = .77). During pretest, we discovered that questions about reactions to information about a man working with you in the same office had developed AIDS did not resonate with inner-city young adults living in Broward County. Thus, the series of questions about working in the same office with a man with AIDS was omitted from our 2003 CATI survey. Our nine-item scale was created with previously used stigma items, but differed from the index used in national surveys.

Data Management and Statistical Analysis

The Statistical Package for the Social Sciences (version 15.0) was used to facilitate data management and statistical analyses. Internal consistency of AIDS-related stigma scales was assessed by Cronbach’s α. Tables were constructed, Pearson Chi-square tests were calculated to examine levels of statistical significance, and unadjusted odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to measure effects for dichotomous variables. Binary logistic regression models were used to assess the effects of independent variables on AIDS-related stigma and on each dependent variable with AIDS-related stigma entered as a covariate [20].

Results

IPOR interviewers called 36,793 telephone numbers in 2003. Interviewers reported that 9,063 numbers (24.6%) were disconnected, 4,213 (11.5%) were telephone answering machines, 945 (2.6%) were facsimile machines, 693 (1.9%) were repeatedly busy, and 655 (1.8%) were businesses, not residences. In addition, 3,494 (9.5%) numbers rang, but no one answered, and 2,355 (6.5%) were privacy directors. Of the remaining 15,375 telephone numbers, 8,230 residents reported that no eligible minority young adult lived in the household, 1,329 requested that the interviewer call back later, 233 reported that someone in the household was eligible, but unavailable for study participation, and 198 respondents could not be screened because they spoke a language other than English, Spanish, or Haitian Creole. Slightly over half (53.0%) of the 5,385 residents who answered the telephone refused to answer any screening questions. In the remaining 2,529 households with an eligible respondent, 2,002 (79.2%) agreed to participate, provided verbal consent, and completed the CATI interview.

About one-third of the 2,002 18–39 year-old residents interviewed in 2003 considered themselves to be Hispanic (34.5%), another one-third considered themselves to be African American (31.2%), and the remainder Afro-Caribbean (18.1%) or Haitian (16.2%). The majority were women (66.2%). The average age of all respondents was 29 years (mean = 28.5; SD = 6.9; median = 29). The average length of residency in Broward County was less than 10 years (mean = 9.4 years; SD = 7.7 years). All 625 Afro-American and 361 (99.4%) of 363 Afro-Caribbean participants were interviewed in English, but 411 (59.6%) of 690 Hispanics were interviewed in Spanish and 74 (22.8%) of 324 Haitians were interviewed in Haitian Creole.

African-American and Afro-Caribbean respondents were more likely than other CATI survey respondents to be women. African-American and Haitian respondents were younger and more likely to be single and never married than Afro-Caribbean and Hispanic respondents. Four-fifths of African Americans were born in the United States; 14.9% in English-speaking Caribbean countries. Less than one-fifth of the three other ethnic populations said their country of origin was the United States. Differences were also found for years of residency in Broward County, educational achievement, and frequency of attendance in religious services (Table 1).

Table 1 Socio-demographic characteristics of 18–39 year-old survey respondents by race/ethnicity
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Prevalence of AIDS-Related Stigma

Of the 13 AIDS-related stigma items included in our 2003 CATI survey, the one regarding reactions to the presence of a child with AIDS in a school caused the most concern. Over half of Haitian (53.9%), 47.2% of Afro-Caribbean, 41.9% of Hispanic, and 33.7% of African-American respondents said they would feel uncomfortable having their child attend a school where a student was known to have AIDS. African-American and Hispanic respondents indicated the least stigmatizing attitudes towards PLWHA for most other items. An obvious exception was the question about the government using AIDS to kill off minority groups (Table 2).

Table 2 AIDS-related stigma among 18–39 year-old ethnic minority residents of Broward County
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Internal consistency for the eight item AIDS-related stigma index was unacceptably low (α = .657). Addition of the item about “the government is using AIDS to kill off minority groups” did not help (α = .618). Substituting “uncomfortable with an AIDS child,” “discontinuing contact with an AIDS child,” and “uncomfortable with an AIDS grocer” for “the government is using AIDS to kill off minority groups,” “PLWHA deserve what they got,” and “I am angry towards PLWHA,” however, produced an acceptable reliability coefficient (α = .745).

Ten survey participants (0.5%) refused to answer any questions about AIDS-related stigma, 233 (11.6%) declined to answer one of the eight questions used to create the national stigma index, and 105 (5.2%) failed to answer two or more. In response to the question about the government “using AIDS as a way of killing off minority groups,” 208 (10.4%) said they did not know or were not sure of the correct answer. For the revised nine-item AIDS-related stigma scale adopted for our 2003 Broward County survey, 1,639 minority young adults (81.9%) answered all nine questions, 228 (11.4%) answered eight, and 135 (6.7) answered seven or fewer.

Of the 1,639 respondents who answered all nine questions, 579 (35.3%) held no stigmatizing attitudes towards PLWHA, 333 (20.3%) held one, 242 (14.8%) held two, and 485 (29.6%) held three or more (mean = 1.81; SE = 0.49). Men (49.1%) were more likely than women (42.0%) to indicate that they held two or more stigmatizing attitudes towards PLWHA (OR = 1.33, 95% CI: 1.08–1.64, P = .01). Being 30 years of age or older (OR = 1.13, 95% CI: 0.93–1.37, P = .23), being single (OR = 1.07, 95% CI: 0.88–1.31, P = .48), and attending a religious service almost every week (OR = .95, 95% CI: 0.78–1.16, P = .63) were not associated with AIDS-related stigma, but failing to study beyond high school (12 years) was (OR = 1.79, 95% CI: 1.47–2.18, P < .001). On all nine items used to create our stigma scale, Haitian respondents were significantly more likely than other minority young adults to receive the highest—most stigmatizing—scores (Table 2).

Country of origin was related to AIDS stigma. Respondents who said that their country of origin was not the United States (50.9%) were more likely to indicate two or more stigmatizing attitudes than respondents who claimed the United States as their country of origin (33.7%) (OR = 2.0, 95% CI: 1.66–2.51, P < .001). The 41 Hispanic respondents from Puerto Rico (29.3%) were least—and the 73 respondents from Mexico (64.4%) were most—likely to indicate two or more stigmatizing attitudes towards PLWHA [χ2 (4, N = 560) = 25.15, P < .001]. Among Black respondents, those born in the United States (33.0%) were significantly less likely than those from English-speaking Caribbean countries (46.5%) and those from Haiti (71.9%) to indicate two or more stigmatizing attitudes towards PLWHA [χ2 (2, N = 848) = 79.30, P < .001].

Language of preference was associated with AIDS stigma (Table 3). Hispanic respondents who chose to be interviewed in Spanish were more likely than Hispanic respondents interviewed in English to indicate two or more stigmatizing attitudes (OR = 1.55, 95% CI: 1.10–2.18, P = .01). Similarly, Haitian respondents who chose to be interviewed in Haitian Creole were more likely to indicate two or more stigmatizing attitudes than Haitian respondents interviewed in English (OR = 3.36, 95% CI: 1.65–6.85, P = .001).

Table 3 Nine-item AIDS-related stigma scores by ethnicity and language preference
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HIV-Prevention Practices

Stigma scores for 116 virgins (7.2%) were not statistically different from those obtained for 1,490 respondents (92.8%) who were sexually active (OR = 1.38, 95% CI: 0.95–2.02, P = .10). They were also similar for sexually experienced respondents who had ever used condoms (84.6%) and those who had not (OR = 0.79, 95% CI: 0.60–1.05, P = .10). HIV-antibody testing in the past year was unrelated to AIDS-related stigma (OR = 1.06, 95% CI: 0.84–1.34, P = .64), but respondents who had never been tested (51.6%) were more likely to hold stigmatizing attitudes than those who had been tested at least once (41.7%) (OR = 0.67, 95% CI: 0.54–0.84, P < .001). Never receiving an HIV-antibody test was the only practice that was associated with AIDS-related stigma when other variables were taken into consideration (Table 4).

Table 4 Primary and secondary prevention practices of minority young adults in Broward County
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Perceptions of Risk, Ownership, and Participation

The 290 respondents (18.0%) who said their chances of becoming infected with the AIDS virus were moderate to high were more likely than others to express stigmatizing attitudes towards PLWHA (OR = 1.46, 95% CI: 1.13–1.88, P = .004), even when other variables were evaluated (Table 5). The 966 respondents (60.1%) who thought that they, their families, or their communities were responsible for addressing the AIDS problem were not less likely to hold stigmatizing attitudes towards PLWHA than the 641 respondents who thought that doctors, health officials, or the government were responsible (OR = 0.92, 95% CI: 0.75–1.13, P = 0.42). The 101 respondents (6.2%) who indicated they had participated in AIDS prevention efforts in the past year were less likely to possess stigmatizing attitudes towards PLWHA than the 1,538 respondents who had done nothing (OR = 0.46, 95% CI: 0.29–0.72, P = .001). The inverse relationship between AIDS-related stigma and steps taken to do something about AIDS remained statistically significant when potentially confounding variables were assessed (Table 5).

Table 5 Perceptions of risk, responsibility for action, and participation in community efforts
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Ethnic minority men and women with a high-school education or less were more likely to express stigmatizing attitudes towards PLWHA; they were also more likely than others to perceive themselves to be at moderate to high risk of becoming infected with HIV (OR = 1.91, CI: 1.51–2.42, P < .001). Only 10.0% of 529 respondents who studied beyond high school and held no or one stigmatizing attitude considered themselves to be at increased risk. Among the 391 respondents who did not study beyond the 12th grade and held two or more stigmatizing attitudes, 22.3% considered themselves to be at increased risk. Similarly, reports of participation in community efforts to prevent HIV in the past year increased from 3.0% among those with lower levels of educational achievement and higher levels of AIDS-related stigma to 9.7% among those with higher levels of educational attainment and lower levels of AIDS-related stigma.

Discussion

AIDS-related stigma was more prevalent among 18–39 year-old racial and ethnic minority adults living in 12 high AIDS-incidence areas of Broward County in 2003 than it was among national samples of older English-speaking adults living in the continental United States in the latter part of the twentieth century. Fear of HIV transmission through incidental contact with an infected child at school was of greatest concern among young minority CATI survey respondents. Furthermore, significant differences were found among the four major minority groups with respect to all nine items used to construct our AIDS-related stigma scale. In general, Haitian respondents were most likely to express negative attitudes toward PLWHA, especially if they chose to be interviewed in Haitian Creole. Our findings suggest that AIDS-related stigma is even more prevalent than previously thought. Promises to mitigate the effects of AIDS-related stigma through mass media campaigns, such as “Know Now” [10], have not been kept.

AIDS-related stigma was not significantly associated with virginity or abstinence in the past year, ever using a condom or using a condom in the past year, or receiving an HIV-antibody test in the past year. AIDS-related stigma was, however, more frequently found among minority residents of Broward County who had never been tested for antibody for HIV. AIDS-related stigma was also associated with an elevated perception of risk of infection with HIV and failure to participate in local community mobilization efforts to control the epidemic. Lower levels of educational attainment combined with higher levels of AIDS-related stigma produced the highest perceptions of risk and the lowest likelihood of participation in AIDS-prevention activities in the past year. Both short-term efforts to curtail the direct effects of AIDS-related stigma and longer term structural and community-level interventions to improve educational opportunities should produce beneficial effects, but are currently underfunded or unavailable.

Eliminating AIDS-related stigma requires government action in at least three areas: (1) protecting the privacy of PLWHA from unauthorized disclosures, (2) preventing discrimination against PLWHA, and (3) promoting health through vigorous AIDS-related risk and stigma reduction [3]. An unprecedented health communications program to modify attitudes towards PLWHA and promote “safer sex” was launched in the United States in 1987. It remains as the U.S. Government’s most comprehensive outreach program on HIV/AIDS. At the core of this effort was CDC’s “America Responds to AIDS.” This 10-year multimedia campaign focused on providing the public with accurate information about HIV infection and emphasized prevention—over anything else—to combat stigma and concentrate public attention on behaviors that could reduce the risk of HIV transmission [21].

Interventions at the community level aim at correcting misinformation and unfounded fears while enhancing empathy for PLWHA [22]. A comprehensive approach to HIV prevention in New York has included legal, regulatory, policy, and programmatic interventions to curtail HIV infections and prevent HIV-related stigma and discrimination. Training in confidentiality and diversity, program monitoring and technical assistance, consumer education and social marketing for communitywide education and awareness have been key components in this multifaceted program. According to Klein et al. [23, p. 49] these services were provided because, “Consumer education and empowerment are proven deterrents to HIV-related stigma and discrimination.”

Strategies and interventions have been proposed, developed, and implemented from the intrapersonal level to the national level, but the effectiveness of health promotion programs in reducing the deleterious effects of AIDS-related stigma have rarely been evaluated [24]. Through December 31, 2001, 22 evaluations of interventions designed to increase tolerance of PLWHA had been published in peer-reviewed journals [25]. Most were conducted with elementary, secondary, and college students. Many showed promising results, but none was able to demonstrate reductions in deep-seated fears and none was conducted with adults at the community level.

UNAIDS implemented a World AIDS Campaign in 2002–2003 that sought to eradicate HIV/AIDS-related stigma and discrimination. The 2-year campaign incorporated several educational strategies, including a poster campaign that advocated fair and equal treatment of PLWHA. While the campaign succeeded in redefining images of HIV/AIDS, a visual studies approach to textual analysis showed that certain aspects of the posters may have unintentionally served to reinforce stigma and discrimination [26].

An AIDS-related stigma intervention “must be multifaceted and multilevel” and “must ultimately address the fundamental cause of stigma—it must either change the deeply held attitudes and beliefs of powerful groups…or it must change circumstances so as to limit the power of such groups” [27, p. 381]. Community mobilization programs are needed to challenge existing inequalities of class, race, gender, and sexualities, alter power relations, and stimulate social change [28], but have not been able to generate support from federal agencies. In 2004, CDC provided $415.5 million (out of $668 million [62.2%]) to state and local health departments to support HIV-prevention programs. Most of this money was used to conduct surveillance and support counseling and testing programs—the least cost-effective method of preventing HIV—leaving little money to support community mobilization programs for high-prevalence populations and mass media campaigns for low-prevalence populations—the most cost effective combination of HIV-prevention interventions [29].

Survey Limitations

Our observations were based on a cross-sectional study of persons who answered a telephone call from IPOR and agreed to be interviewed in summer 2003. We don’t know anything about those who didn’t answer their telephones or those who refused to participate, and we don’t know how honest participants were in their responses to our questions. AIDS-related stigma was assessed using a brief instrument that was adopted from a large inventory of items. Different items may have yielded different results. Findings from our survey of residents of 12 high AIDS incidence ZIP-code areas should not be generalized to other populations or areas of the United States. Conditions regarding the status of “immigrants” and “illegal aliens” have changed since 2003. Our observations may no longer hold true for racial and ethnic minority populations living in high AIDS-incidence areas of Broward County.

Implications and Recommendations

In the last decade, CDC and other federal agencies have recognized AIDS-related stigma as a barrier to HIV risk reduction, but have been unable or unwilling to address the problem directly. The most recent iteration of the national HIV-prevention strategic plan considers stigma and discrimination to be “urgent priorities” [30], yet the only action step mentioned is “to make HIV testing a routine part of medical care” because that “might help reduce the stigma that some associate with an HIV test” [31]. The Black AIDS Institute in Los Angeles recognizes that AIDS in Black America is “a generalized epidemic” that must be addressed by “community mobilization” because, “Where national AIDS responses have succeeded, communities have mobilized to fight stigma, overcome prejudice and promote solidarity” [32, p. 13]. The Institute calls for a renewed commitment from federal health agencies to overcome a “legacy of neglect.”

Existing evidence suggests that community-level and group-level interventions for HIV prevention have more impact on reducing risky behaviors and are more cost-effective than most individual-level interventions favored by CDC [33]. AIDS-related stigma interferes with efforts to introduce and implement comprehensive HIV-prevention programs that require community and group (as well as individual) participation. AIDS-related stigma persists and must be addressed with properly designed, carefully implemented, and rigorously evaluated HIV-prevention programs that aim at the elimination of HIV transmission, AIDS-related stigma, and discrimination against men, women, and children living with HIV/AIDS.