The Issues of HIV Stigma Facing HIV Positive Gay Men & How They Cope Through the Mechanisms of Resilience: A Qualitative Phenomenological Transcendental Study

Gigliello J^* and Ackerman ML
^*Correspondence: Gigliello J, Department of Psychology, Northcentral University, San Diego, California, USA, Tel: +9542359256, Email:

Keywords

HIV; HIV stigma; Gay men; Resilience; Coping

Introduction

Men who have sex with men (MSM) are at a heightened risk for HIV infection [1-3]. The clear majority of gay men who are HIV positive, experience stigma, not only for sexual orientation (homophobia), but for having acquired HIV disease [4]. As a significant consequence, the result is multiple stigmas [5-8]. Since the start of the epidemic in the early 1980’s, HIV has been associated with stigma [9]. The highest concentrations for new HIV diagnoses is focused on the southern section of the United States [1].

The seminal works of Goffman view stigma as a “Spoiled identity” arising from the perception the individual has of himself in regard to others he views as “normal” and how others view him [10]. The research focused on the meaning of stigma and what the perceptions were toward a group seen as being stigmatized. This original conceptual framework of perceptions focused toward specified groups with criminals and homosexuals being placed in the same category having “Undesirable behaviors.” HIV stigma is associated with a wide range of psycho-social negative and harmful outcomes for the person living with HIV disease [11,12]. As a result of the disease being transmitted mainly through sex or drugs, there is stigma automatically attached to it, regardless of how it was acquired [13]. HIV stigma directly contributes to a lower overall quality of both mental and physical health [14]. Furthermore, the advent of less complicated medications, such as the one per day pill, which should have lessened stigma, have not done so. Stigma remains pervasive for a plethora of reasons [15]. A significant obstacle in dealing with HIV stigma stems from the fact that stigma does not work in isolation unto itself. The challenges are substantial and numerous [16]. As much as one study focused on depression or self-isolation in conjunction with numerous co-factors, these challenges do not work independently but always function in tandem with other negative conditions directly related to HIV stigma [14].

There are significant, harmful outcomes as a direct consequence of HIV stigma in gay men who have the disease which has been well documented in the literature [17]. Some very critical and dangerous consequences of HIV stigma for gay HIV positive men include severe alcohol and drug abuse, increased and sustained suicide attempts continue despite numerous effective treatments to suppress HIV and lack of medication adherence which can lead to rapid disease progression [18-20]. HIV stigma is one of the main causes for individuals not seeking healthcare of any kind for fear of discovering they are HIV positive or fear of disclosure by anyone [13,21-23]. Consequently, in the effort to not disclose sero-status and appear to be HIV negative, thus not be stigmatized, this can lead to high risk unprotected sex and transmission of HIV to others [24,25]. One of the most common negative effects of HIV stigma is anxiety and depression, which often leads to self-isolation and PTSD [26].

While the literature on the negative outcomes of HIV stigma is prolific, the information on how to mitigate these negative effects is scarce. Available research argues for the theoretical framework of resilience, referring to it as one of the main ways for those living with HIV can successfully cope with the disease [27]. Even more significant, is the belief that resilience can be taught to assist those who live with HIV can have more fulfilling lives [28]. HIV positive gay men who associate and feel a connection to resilient social groups/ communities, demonstrated an improved mental health effect. It is central to understand the potential role of individual resiliency which, when braided with community organizations, social groups, and organizations, can often support the mental health and well-being of this vulnerable and growing population [27].

Early works of Bandura and Rutter focused on examining Resilience Theory (RT) as a set of factors that protected the individual from any stressor they encountered, noting the differences between those who adapted to any circumstance that was traumatic or negative (adaptation to circumstance) and those individuals who fell apart or yielded to those stressors in negative manners. In other words, why some individuals withstood, conquered, and thrived on the pressure and stress that they withstood, while others experiencing the same stressors and pressures fell apart [29]. With over a dozen explanations for resilience theory, the preponderance of recent research points to RT defined as a multi-faceted construct which includes the adult individuals’ determination and ability to endure, adapt, and recover from adversity [30]. Since resiliency is a learned trait the attributes of what supports these men to cope with and manage HIV stigma can be uncovered and explored [29,31].

Resilience theory focuses on the perspective that the framework is a mechanism that supports a positive response to any adversity, chronic or acute and is a significant factor in lesbian, gay, bisexual, and transgender individuals (LGBT) who experience minority stress [32,33]. It is a multidimensional framework which encompasses environmental, community, and individual factors and is viewed as protective for those who experience health related trauma such as chronic illness as in HIV disease [34]. These health life experiences serve as an inducement for resilience [35]. Although the definitions of resilience are viewed as either a process as one move through life, while others view it as a psychological characteristic or attribute [36,37]. There is a host of well-known definitions within the multidimensional framework of resilience that are agreed upon in the literature; both as a process of dealing with a stressor, and the outcome of those efforts to navigate or negotiate the use of relevant resources toward psychological well-being [38].

One aspect of this multidimensional framework is stress inoculation which posits that any exposure to chronic stress can promote resilience, which is similar of the resilience one has to a pathology upon receiving an inoculation to protect one from said pathology [39]. This bouncing back is usually reminiscent of a pattern of positive adaptation in any context of a present (ongoing) or past trauma or stress. This resilience or mastery (self-efficacy) is indicative of psychological well-being [36].

The problem addressed by this study was the issues HIV positive gay men face with HIV stigma and how they cope with stigma through resilience [14,40]. It is imperative to identify aspects of resilience to alleviate stigma and its negative consequences while more needs to be known about the mechanisms of resiliency within HIV positive gay men who manage despite stigma [27]. Resilience is a process by which individuals overcome detrimental properties of continued exposure to traumatic events [11]. Coping mechanisms are aspects of resilience theory necessary for dealing with HIV stigma [30].

This investigation had two essential questions:

• The first examined how gay HIV positive men use resilient coping mechanisms to manage HIV stigma.

• The second investigated the impact of these coping mechanisms of resiliency have on HIV positive gay men’s ability to manage HIV stigma. Although HIV stigma has been researched for several decades, few studies, if any, focus on the first-person evaluations of the lived experiences of the phenomenon of these effects, and more importantly, how and if these men are resilient and able to cope with and manage long term (chronic) HIV stigma [20].

Research Methodology

The purpose of this qualitative, phenomenological, transcendental study was to develop a deeper understanding of the lived experiences of gay men regarding mechanisms they use to cope with HIV stigma and which mechanisms are used to manage HIV stigma. The study was conducted in the Broward County section of South Florida utilizing a cross section of 12 gay male participants who have been HIV positive for 5 years or longer. Interviews of 30-60 minutes were conducted using open ended semi-structured questions asked by the researcher to elicit rich responses yielding insights and themes on coping mechanisms to contend with HIV stigma [41,42]. Interviews were conducted in the local Gay Community Center in South Florida where counseling was available if the participants became distressed due to the nature of the topic. Recruitment of participants included ads placed in local Facebook groups and at the testing site which caters to a gay clientele. Data analysis was twofold; manual sorting and a computer assisted software, NVIVO, which analyzed transcribed interviews into developed themes and patterns of responses.

The qualitative design utilized was a phenomenological, transcendental method. This specific strategy endeavored to comprehend insights, understandings, and subjectivities of a given phenomenon and the synthesis of these subjective insights braided into their identities [43]. A fundamental element of all phenomenological exploration is the researcher analyzing the lived experiences pertaining to a phenomenon as described by a small group of participants having common experiences. This utilizes the analysis of significant statements which generate meaningful themes and patterns in the development of essence description [41,42].

There are 1.2 million people living with HIV in the United States. Over 137,000 HIV positive people live in the state of Florida, which accounts for the third highest rate of HIV positive individuals, with the majority having chronic HIV disease an average of 17.3 years. Rates of HIV infection are the highest in the south, at 16.8 per 100,000 compared to 11.2 in the northeast, 10.2 in the West, and 7.5 in the Midwest. Further, those 50 years and older make for the largest age group living with chronic HIV [44]. African American men are particularly disproportionately affected. While they account for 12% of the population, they account for 44% of all HIV diagnoses while Hispanic/Latinos who represent 18% of the population account for 25% of all diagnoses [45]. The population in Southern Florida is appropriate for the study due to several factors. First, the study investigated how and if resilience plays a role in mitigating the devastating effects of HIV stigma. Second, the population studied were HIV gay positive men. Third, as has been stated in earlier portions of this paper, gay men make up the clear majority of HIV positive individuals in the United States, accounting for approximately 70% of all HIV infections [46]. Fourth, the south has the highest rates of HIV infection in the United States [44].

Criteria for inclusion was an HIV positive diagnosis of five (5) years or longer and who are biologically born males and who selfidentify as having sex with men, or as gay regardless of age, race, ethnic background, or religious affiliation. Notices were placed in two public local city-wide periodicals and newspapers recruiting participants for a period of 4-12 weeks, encompassing Fort Lauderdale, and surrounding areas within Broward County Florida.

The demographic information collected included the following. There was a total of 12 participants, all self-identified as gay men who have had HIV infection for five (5) years or longer. Of the 12 men, 10 were self-identified as white and 2 were self-identified as Hispanic. There were no African American men included in the study because during recruitment because none responded. All participants resided in Broward County Florida. Their ages ranged from 33 to 61, and years with HIV infection ranged from 6 years to 31 years. Over 137,000 HIV positive people live in the state of Florida, which accounts for the third highest rate of HIV positive individuals, with the majority having chronic HIV disease an average of 17.3 years. Rates of HIV infection are the highest in the south, at 16.8 per 100,000 compared to 11.2 in the northeast, 10.2 in the West, and 7.5 in the Midwest. Further, those 50 years and older make for the largest age group living with chronic HIV [44]. Ethnic diversity was somewhat supported along with a varied range of ages although there were no African American men who volunteered. As mentioned, previous, the south has the highest rates of HIV infection in the United States [44]. Further, gay men make up the clear majority of HIV positive individuals in the United States, accounting for approximately 70% of all HIV infections [46] (Table 1).

The instruments that were used for this qualitative phenomenological investigation was semi-structured open-ended interview questions utilized as the primary data collection process that elicited rich verbal responses on HIV stigma and what the participant experienced, how stigma touched the participant, the reaction to it and how the participant can deal with it or if there is any ability to deal with it [47-49]. This final product was then used as the interview questions for the gay male participants with HIV who deal with stigma, and was a reflection of the research [50].

IRB approval was secured before any data collection. All identifying information was removed and pseudonyms in lieu of their real first names were employed. The only information that was viewed is their age, race, and length of time having HIV. Participants received both verbal and written information regarding the purpose of the study. All participants were required to sign an informed consent with the knowledge that they can withdraw at any time before or during the interview. Compensation for a completed participation was in the form of a $25 Visa gift card.

Results

Strategies to code and analyze the information were two-fold: first, responses from interview questions were inserted in the NVIVO software for analysis of patterns and themes, and second, in conjunction to this, the researcher performed manual analysis seeking codes, patterns, and themes for extra rigor and to verify the findings of the NVIVO software. This will provide quality in content analysis through trustworthiness and credibility [51]. By associating the data within the study to the experience of others who share similar experiences in the phenomenon, transferability can occur [48]. This process also enhanced credibility [48,51]. This complimentary dual analyses of NVIVO and manual assisted in providing an extra layer of rigor and thus, credibility to the findings in the data [48,51].

Research Question 1:

How do HIV positive gay men use resilient coping mechanisms in response to HIV stigma?

RQ 1 Theme 1: Support System

The main response given by all 12 men, unequivocally was a good stable support system. Family, friends, and a caring medical provider. In the early days, those who have HIV for 20+ years, which accounted for half (6) of the participants, again the answers were quite similar. The family was not at all supportive, but their friends were, and those who had neither went out to find a support system to help them deal with HIV. Both Carl, Ian, and Lawrence, (HIV positive for 30, 31, 29 years respectively) said that they sought out a support system which is very important. Lawrence went on further to state, “The more empowered I became as I realized I was OK, my support system developed as I did.” The most emphatic of the benefits of a good support system was from Gil, who declared that, “The reason why I am still alive today is because of my support system.” Kyle says that, “A good support system is critical to my well-being.” Three of the men expressed their support system to be of mostly other HIV positive gay men who understand what they are going through because they are like me. Henry said, “It gives me the ability to manage and cope with my HIV.” Amadeus feels that, “Support is an enormous help in me managing and dealing with my HIV and stigma.” Ben stipulated that, “I can get support from others out there like me,” but on the opposite end was David who claimed that, “The HIV support groups were very negative and diseasefocused, so I stopped going to them. I get my support from my friends both HIV positive and negative.”

RQ1 Theme 2: Education

Seven of the men said that education for themselves and others is a large coping factor in managing HIV stigma. Amadeus states that, “I had to educate myself and others. This helped me cope and coping is acceptance. Education stops stigma toward guys like me.” Ben smiled and said, “I advocate for educating others. It makes me feel empowered. It’s not a death sentence. Being open and honest reduced shame. I also talk to myself in the mirror.” Julian declared that, “Education is the most important to cope with stigma. People still don’t understand. I also don’t worry about the future which reduces my stress. I live for now.”

RQ1 Theme 3: Chronic illness not death

Three of the men said that HIV was not a death sentence any longer. It was a chronic illness like diabetes. Amadeus said, “I accept my condition. It’s not a death sentence. When I accepted this, it was the biggest part of coping and managing. David basically said the same thing. “It’s not a death sentence. It’s like having diabetes. It’s not a big deal. HIV doesn’t control my life, I do. I’m so much more than HIV and when you understand that, you’ll be fine and I am. I stay away from negativity and negative people. Upbeat positive people only.” Henry suggests, “be active in your health to remain healthy.

Subtheme 1: Self-care: Two of the participants mention self-care. “Self-care is very important to manage and cope with HIV.” Lawrence states, “If I can survive with HIV back then when there was nothing, I can now.” Amadeus said, “You have to take care of yourself; the whole body and as you take care of yourself it becomes less of an issue.”

Research Question 2:

What impact do these coping mechanisms of resiliency have on HIV positive gay men’s ability to manage HIV stigma?

RQ2 Theme 1: Self care

Amadeus said that, “Through my support system, I can manage stigma and live a good long life through a whole-body health approach.” Henry said, “HIV doesn’t define me. That’s my management.” Carl said, “You face it, deal with it head on, and manage it by taking care of yourself, advocating, and educating yourself and others.” David stated, “I always knew inside that I would be ok no matter what.” Ben decided he would become an activist. “I created a support group for both HIV positive and negative men which made me feel empowered.” In the same venue, Ben said, “I came out of the HIV closet. This empowered me to be genuine and true.” Ian declared that, “I wasn’t dying. I decided to get off disability and go back to work because I could.”

Sub theme 1: Sense of self: Three of the men spoke of their sense of strength within self. Ben simply said, “You develop a thick skin from dealing with HIV over time. It’s their problem not mine. I’m fine thank you.” A similar point was made by Lawrence who stated, “You just keep going because you have to. Sink or swim. I’m swimming.” Gil echoed a similar statement in saying, “I have a strong opinion of myself. I refuse to give power to anyone to allow their words to bother me. That’s how I deal with HIV stigma, how my life is and that’s my inner strength.”

RQ2 theme 2: Where you live

There were 4 participants who stated that living in Broward County was an important aspect of managing their lives with HIV. Gil, Henry, Kyle and Lawrence all made similar statements that the area is very supportive to those living with HIV. Kyle and Lawrence specifically stated that they were “Living in a bubble and were very lucky because it’s not like this elsewhere.” Gil stated that, “I’m happy to be in South Florida. Its accepting and easy-not so in other areas,” while Henry said, I can’t tell anyone up north where my family is. It’s so easy here [Broward County, South Florida] to be [HIV] positive.”

RQ2 theme 3: Keeping Occupied/Busy

According to Gil, Ian, and Julian, they manage their lives with HIV stigma by keeping busy. “I manage and deal with stigma in my life by keeping busy, volunteering to help others. I keep my mind occupied” stated Julian, while Gil said, “I do what I like to do to fulfill my life and staying busy is key.” Ian resonates a similar response. “I keep busy and move forward with what I like to do.”

RQ2 theme 4: Struggles brought strength

Four participants, Gil, Ian, Kyle, and Lawrence felt that the struggles made them stronger. These participants have had HIV for 30, 31, 31, and 29 years respectively. They all stated that their long-term struggles and adversity made them stronger and able to survive.

RQ2 theme 5: Spirituality and Prayer

This was mentioned by two participants. David declares “I believe in the power of prayer and my belief in God,” while Lawrence states, “Helping others like myself feel better and finding my spiritual side, spiritual books and reading good self-help books have managed my HIV coping ability. I’ve learned by spiritual men over the centuries.”

The following responses demonstrated a unique perspective.

Kyle says, “My inner strength comes from reaching out to others. Not isolating myself. I don’t want to feel like I am on an island by myself. I meditate, breathe, relax and through this you realize you come to a point where you can conquer anything.

Lawrence in a different take on the current situation with HIV stigma says, “I’m free to disclose more now than ever. It’s the HIV negative guys that are being stigmatized for NOT having HIV.”

Discussion

Research Question 1 themes

Resilience as a multi-faceted construct includes the adult individuals’ determination and ability to endure, adapt, and recover from adversity [30]. Since resiliency is a learned trait the attributes of which specific traits assist these men in coping with and managing HIV stigma can be uncovered, explored and taught through education [29,31]. The responses and resulting themes were clustered into three main themes. Theme 1, the main pattern of coping mechanisms in response to HIV stigma was the HIV positive gay man having a strong, stable, and consistent support system. This confirms prior research demonstrating that HIV positive gay men who associate and feel a connection to resilient social groups/communities, demonstrated an improved mental health effect [27]. It is central to understand the potential role of individual resiliency which, when braided with community organizations, social groups, and organizations can often support the mental health and well-being of this vulnerable and growing population [27,28,33,52-55].

The next significant theme was theme 2; the aspect of education and educating themselves and others as a coping mechanism to manage HIV stigma. This theme was demonstrated, most notably, in a metaanalysis on educating others toward factual information on HIV which results in a stigma decrease. The 42 studies analyzed were of various investigations whereby different types of anti-HIV stigma interventions were utilized thorough educating the participants on HIV. Data indicated across the board that those individuals who received these various educational materials throughout those 42 studies, showed small to significantly lower levels of HIV stigma directed at people who are living with HIV/AIDS [56]. This coincides with the current study that demonstrated that self -education and that of others is a coping factor in the management of HIV stigma.

Theme 3 demonstrated, albeit noted in only two participants that the struggle and adversity made them stronger, supporting stress inoculation resilience which posits that the very stress presents resistance to a negative pervasive influence to affect a positive manipulation on one’s health and creates a strong positive response [31,57,58]. In a meta-analysis of 54 studies conducted, on the topic of stress inoculation, indicated that in various situations such as corporate issues, campus parking, social issues, politics, equality issues, among others, the introduction of a threat and stress inoculated the person with the ability to deal with the stressor provided the stressor was consistently the same stressor [59]. However, there were highly varied results on the length of time the inoculation against the stress remained.

Research Question 2 themes

Theme 1 was the aspect of self-care, making good choices, taking care of your physical and mental health helps positively impacts the ability to manage stigma. This also supports previous research which states that sustained long term self-care, coupled with good choices over the course of a lifetime living with HIV will successfully assist the individual [36,60,61].

Subtheme 1: Sense of self, also connected to self-care, was indicated in two of the men where they stated that their struggle over the years in dealing with the various experiences of HIV stigma, positively impacted their strength and gave them “An inner strength” and the ability to manage HIV stigma. This is compared to recent research on stress inoculated resilience stating that being exposed to a threat, that very exposure to the threat (stressor) inoculates the individual to withstand the stressor over time [31,57-59].

Theme 2, the impact of the participants choice of where they live, and 4 of the men mentioned how living in Broward County (South Florida) was a place where they feel accepted by their community of friends because there are many men like them who have HIV. The community and environmental support were shown as an integral part of positively impacting a successful managing of stigma [33,55].

Subtheme 2 was indicated in 2 of the men regarding spirituality and prayer. This is seen as an important factor in resilience is the positive impact one’s spirituality is in coping with aversive and challenging conditions [62-65]. The findings of the data regarding these two research questions demonstrate a contribution and addition to previous research, and to the theory of the complex processes of resilience as a powerful positive force in coping with the management of HIV diseases in HIV positive gay men.

Several significant themes evolved from the data which confirmed previous investigations on the theoretical framework of resilience [27,29]. To cope with and manage HIV stigma, the clear majority of men required a strong support system with self-education and the education of others to mitigate the negative factors of HIV stigma. The impact of these mechanisms was shown in self-care and a strong self-identity which included living in a supportive environment. Many of the negative impacts and challenges established in prior research were also demonstrated in the themes, such as self-isolation, drug and alcohol abuse, suicide ideation and depression that emerged from the responses of the participants [18,19,26,66,67]. The implications of this, verify prior work stating that the negative impacts of HIV stigma are multiple and far reaching and are associated with a surge of negative and harmful outcomes for the person living with HIV disease and do not work in isolation of other negative impacts such as sexual identity, gender, drug use, ethnicity, race, and culture [12,16].

A review of each research question is offered below including an analysis of the findings. In addressing the first research question, the gay HIV positive men who participated in the study used specific themes that were discovered in the results to manage and cope with stigma. The first of these themes indicated that 11 out of the 12 participants mentioned the importance of a strong support system. The implications of this were significant. Regardless of whether the participant was HIV positive for 6 years or 30 years, whether they were 33 years old or 61, the responses for research question 1 were all indicative of a need for a strong support system as a coping mechanism for HIV stigma in the lives of the participants. Education was another major theme the men used to cope and manage stigma. There was a strong sense to educate themselves and others to mitigate HIV stigma. Both of these strong significant patterns of responses were used by most of these men as an effective means for dealing with stigma and living a relatively normal life despite them having to deal with it. Most notable was the fact that half of the men have had HIV for 18 years or longer and bore the brunt of the most severe HIV stigma prior to the advent of or very early beginnings of medications [15,68]. However, as was stated by one participant, the stigma was still there just more covert rather than in your face. These coping mechanisms were used to circumvent the negative effects of HIV stigma. These factors contributed to resilience in several ways. Since there were a host of definitions and viewpoints on resilience, there was no consensus on definitions, and different interpretations arose on the operationalization of the term [61,69]. Resilience is commonly described as the capability and capacity to “Bounce back” decidedly and quickly from traumatic and challenging events which resulted in better mental health functioning and wellbeing [27,32]. Based on the above, the study contributed to theory based on the definitions offered here even though resilience is multifaceted and complex [30].

In addressing the second research question, the impact of the use of coping mechanisms to manage HIV stigma was observed. The impact of coping on HIV stigma management provided for a strong sense of self and the ability to self-care. There was a consensus in responses noting to the direct ability of the men to have a good self-identity of their sexual orientation in managing HIV stigma. In addition, self-care, and strong sense of self-awareness, helped them deal with the myriad of challenges regarding HIV. This included the management of and side effects of medications, in addition to HIV stigma, 11 of the 12 men from researcher observation and observational field notes, appeared to have successfully coped with HIV stigma. Further, the management of all aspects of the disease due to their support system, and more importantly, the perception of that support system in relation to them. This directly contributed to theory which posits that social support and the appraisal process shared a critical role impacting the mechanisms of resilience [29,70]. Numerous psychological factors relating to personality, motivation, confidence in one’s abilities, focus, and one’s perception of social support, protected those suffering from stressors. These processors had protective factors which lead to a bouncing back and resilience [29]. A strong self-identity of their sexual orientation and positive community support assisted gay men in either preventing HIV or supported those who already had it [62,70].

Further, one of the main mitigating factors in lessening the effects of the chronic stress from having HIV disease was the community aspect of resilience which embraced the connections of others in similar situations. Specifically, in that case, other gay men suffering from HIV disease which was known as community resilience within this population of gay HIV positive men [33,52-55,71]. Community level factors within the sub-population were powerful protective factors for mental health and well-being [33]. This confirmed another theme demonstrated in the results which was the impact of choosing to live in an accepting area where HIV positive gay men had the ability to commune with each other.

Adapted from “Resilience Processes Demonstrated by Young Gay and Bisexual Men Living with HIV: Implications for Intervention” [72] (Figure 1).

There were no unexpected results related to the men’s experiences of the negative impacts of HIV stigma. The research on that topic was abundant and supported previous research [5,7]. For the research questions there was actually only one unexpected result. That was demonstrated in the area of spirituality. Only two participants (out of the 12 men) mentioned their connection and belief to God and spirituality as a mechanism of coping with and managing HIV stigma. Previous research, however, demonstrated that spirituality was an important factor in the management of HIV stigma and coping with the disease and stigma [73-75]. Another main theme that was observed from the data was education. The clear majority of the men felt that educating themselves on the virus, self-care, and then educating others was a mitigating circumstance in HIV stigma. By learning how to care for themselves and others through education on how HIV is transmitted, they felt a positive change was made for themselves and others around them. This was demonstrated as a coping factor in managing HIV stigma and by taking an active role, they were doing something positive and keeping busy. As much as there was no direct research on this topic to refer to, it did however look at the theory of resilience from a strength based rather than a shortage-based perspective [70,76]. This corroborated recent research which had shifted the theoretical concept of resiliency from a pathogenic response and life’s adversities to a successful adaptation to those adversities [77-79]. These men have adapted by looking at their lives through selfcare, and the education of self and others rather than being focused on the myriad of challenges of the disease itself, thus it created a positive adaptation to the disease. Education was a practical application of the results and was reported as a theme in the data. A recent metaanalysis was performed on the issue of HIV stigma interventions by educating people on factual aspects of HIV stigma and various educational intervention programs [56]. The 42 studies analyzed were of various investigations whereby different types of anti-HIV stigma interventions were utilized. The data had suggested across the board that those who received these various interventions throughout those 42 studies by educating people, showed small to significant lower levels of HIV stigma directed and people who are living with HIV/AIDS [56]. This was supported by other, earlier studies that found significant reductions in HIV stigma through curriculum educations [80,81]. One of these studies which involved nursing students in India saw a 95% effectiveness of the nursing education curriculum in reducing stigma toward HIV positive clients among the nursing students attending that program [80]. Additionally, a third study involved medical students in Puerto Rico demonstrated significant differences between a control group and educational intervention group of 507 medical students in the reduction of external HIV stigma (stigma that was directed toward others) that was sustained over a 12-month period [81]. Based on the results of the study, the next step in better understanding resilience and HIV stigma would be to replicate the current study with a similar but larger sample of gay HIV positive men in varied geographic locations throughout the United States to determine differences or compatibility in findings on HIV stigma and the coping mechanisms of resilience in the management of HIV stigma [24].

The contribution of this study to resilience theory were as follows. The study added to the focus on the perspective that resilience was a mechanism that supported a positive response to any adversity; chronic or acute [32]. Resilience was a significant factor in Lesbian, Gay, Bisexual, and Transgender individuals (LGBT) who experience minority stress [33]. The contributions of the study findings supported for a multidimensional theory which encompassed environmental, community, and individual factors [34]. The data also demonstrated that resilience was protective for those who experience health related trauma such as chronic illness as in HIV disease and contributed to the research [75-81].

Conclusion

The study shed light on how resilience contributed to the coping mechanisms which allowed gay HIV positive men the ability in managing HIV stigma and the impact such coping had on their ability to cope with and manage their experience. The results indicated the importance of a strong social support system from family, friends and the community; along with the environment surrounding those who dealt with the challenges of HIV stigma. The impact of these mechanisms resulted in a strong sense of self for their identity and sexual orientation. Moreover, being in an accepting environment, community support, educating themselves and others, impacted their lives positively. The study contributed to the growing body of knowledge on resiliency demonstrating these mechanisms which supported the bouncing back of the participant from an unhealthy to healthy state, both physically and psychologically.

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