Sexual orientation and differences in HIV cognitions

Abstract

Health-related cognitions associated with approach and avoidance motivations can impact individuals' decisions to engage in positive health behaviors, such as testing for HIV. Although HIV has historically primarily impacted sexual minorities, heterosexuals are at increasing risk for the disease in the U.S. Due to this shift in the epidemic, it is important to understand the cognitions that are differentially relevant for sexual minority and heterosexual individuals. We examined differences between sexual minority individuals and heterosexuals in anticipated HIV stigma, HIV infection-control beliefs and HIV status avoidance, in a sample of 232 at-risk Washington D.C. residents. When controlling for race, gender, and HIV risk level, sexual minorities had lower HIV status avoidance, lower anticipated HIV stigma, and higher HIV infection-control beliefs. This research informs our understanding of differences in HIV-related cognitions among sexual minority and heterosexual people who are equally at-risk for HIV. Targeted interventions aimed at improving HIV-related cognitions among heterosexuals are necessary as these cognitions may influence testing behavior.

Introduction

Engaging individuals in health screening behavior is a well-established challenge that can cost lives as treatable diseases go undiagnosed. For example, despite consistent advice from medical professionals to engage in cancer screenings as early as possible to improve treatment outcomes (Smith et al., 2018; Smith, Mettlin, Davis, & Eyre, 2000), 39% of a nationally representative sample of U.S. adults agreed with the statement, “I would rather not know my risk for cancer” (Emanuel et al., 2015), and 34% of a sample of cancer survivors reported actively avoiding information about cancer at some point (McCloud, Jung, Gray, & Viswanath, 2013). Similarly, although over three-quarters of women in one study (Howell & Shepperd, 2014) and 90% of women in another study (Chaliki et al., 1995) reported that they would undergo a free test for the genetic mutations associated with breast cancer, less than a third of women who received a free testing opportunity underwent testing. Thus, despite the undeniable advantages provided by health screening (i.e., early detection), a sizable portion of individuals will purposely avoid learning their risk for disease, preferring to live in “blissful ignorance”.

One approach to understanding this phenomenon is to examine the underlying psychological processes that drive information approach or avoidance. When people contend with threatening information, such as an unwanted medical diagnoses, they have two choices for how to handle the potential information (Roth & Cohen, 1986; Sweeny, Melnyk, Miller, & Shepperd, 2010; Witte, 1992). First, they can attempt to reduce the threat by seeking, or by gathering more information, such as looking up current treatments for a disease or what risk factors are associated with it. This feeling of taking control of a piece of information can decrease the perceived danger of the threat (Witte, 1992). The second strategy is attempting to evade the negative emotions evoked by the threatening piece of information by avoiding information related to the threat in an attempt to dampen the uncomfortable feeling of fear (Roth & Cohen, 1986; Sweeny et al., 2010; Witte, 1992).

Research on health-specific information avoidance has found that people display measurable individual differences in their tendency to avoid relevant medical screening (Emanuel et al., 2015; Howell, Crosier, & Shepperd, 2014). Researchers have applied the approach-avoidance framework to predict screening acceptance for multiple diseases such as cancer (Emanuel et al., 2015; Howell & Shepperd, 2012; Shepperd & Howell, 2015), diabetes (Jennifer L Howell & Shepperd, 2013; van Koningsbruggen & Das, 2009), UV-related skin damage (Dwyer, Shepperd, & Stock, 2015), STD testing (Ganguly & Tasoff, 2014) and recently, HIV testing (Price et al., 2019). However, not all diseases are avoided equally. The extent to which a piece of information evokes a negative affective response, requires a behavioral change, or changes a worldview can increase the likelihood that the piece of information will be avoided (Sweeny et al., 2010). Therefore, the degree to which various diseases are socially stigmatized can impact the extent to which they are avoided, as stigma evokes fear (i.e., a negative affective response), may require behavioral changes (e.g., forecasting experiences of discrimination, changing one's social behaviors to avoid judgment or physical harm), and may change one's worldview (e.g., a view of oneself as a healthy, a view of one's future as long and unimpeded by medical adherence) (Arnold, Rebchook, & Kegeles, 2014; Barbour, Rintamaki, Ramsey, & Brashers, 2012; Crocker & Major, 1989; Herek, 2009; Howell, Lipsey, & Shepperd, 2016). The more stigmatized the condition, the less likely people will engage in testing behavior for said condition (McGinty, Goldman, Pescosolido, & Barry, 2015). Additionally, several studies have examined affective and cognitive factors in relation to sexual risk behavior to determine strategies for HIV prevention. Researchers have examined the role of state and trait affect (e.g., Mustanski, 2007), risk appraisals (e.g., Newcomb & Mustanski, 2014), and sexual control self-efficacy (e.g., Pachankis, Rendina, Ventuneac, Grov, & Parsons, 2014) in sexual risk behavior. However, this body of research is limited in its scope in that it has focused predominantly on the behavior of gay and bisexual men and demonstrates the differential attention paid to the HIV-related cognitions in this population compared to heterosexual individuals.

Conversely, certain characteristics of diseases can encourage proactive, information-seeking behavior as well. A factor that is commonly associated with health information-seeking and testing behavior is the extent to which the disease in question is perceived as controllable (Ajzen, 1985; Howell, Lipsey, & Shepperd, 2016; Sweeny et al., 2010). Many studies have provided evidence that people are more likely to avoid diagnostic testing if the disease or illness is described as being untreatable (i.e., uncontrollable) than if it is described as more treatable, and with high treatment success rates (Dawson et al., 2006; Melnyk & Shepperd, 2012; Yaniv et al., 2004). Thus, while people are more likely to avoid health information if it comes with the burden of stigma, infection-control beliefs—the belief that a specific disease or illness is controllable—is positively associated with information seeking.

Although the information approach-avoidance framework has been applied to many diseases in order to increase motivation for diagnostic testing, to our knowledge, only one study has investigated this framework in association with HIV (Price et al., 2019). The United States HIV epidemic has changed considerably, in both treatment and prevention strategies, as well as demographics, since its peak epidemic in the 1980s. In the treatment domain, modern antiretroviral therapy (ART) has allowed a person living with HIV to maintain such a high quality of life that the disease that was once considered a “death sentence” is now considered a treatable chronic illness, much like diabetes (Centers for Disease Control and Prevention (CDC, 2017). Contemporary HIV treatments have not only allowed a person living with HIV to lead a healthy life but they have also enabled unprecedented control over a once uncontrollable disease. If taken daily, ART can reduce an HIV positive person's viral load to an undetectable amount, making it virtually impossible to transmit the disease to another person, ushering in a new era of control over the disease (Cohen et al., 2011; NIH, 2018).

Despite considerable advances in HIV treatment and prevention efforts, new HIV infections in the United States have remained remarkably stable, hovering around 40,000 new infections annually (Centers for Disease Control and Prevention, 2018). A substantial proportion of new HIV infections are transmitted via sexual contact between men (68%), with 23% of new infections attributed to sexual contact between cisgender men and women (23%) (CDC, 2017).

There is evidence that there may be sub-group level differences in how the controllability of HIV is conceptualized. A combination of gay/bisexual male identity development (Crawford, Allison, Zamboni, & Soto, 2002) and targeted prevention campaign resources (Centers for Disease Control and Prevention (CDC, 2006) toward sexual minority men has created a discrepancy in the dissemination of information about the treatability and controllability of HIV between sexual minority people and heterosexual people. This difference in information sharing about a critical component of HIV could differentially impact the ways in which heterosexual and sexual minority people think about the ability to control their health while living with HIV and may in turn destigmatize their views of living with HIV. Because the cognitions surrounding control over a particular health outcome can have such an impact on one's decision to prevent and test for the disease, heterosexual people may be less likely to engage in preventative behavior or HIV testing compared to sexual minority people who have historically had more of this information geared toward them.

Drawing from the past literature demonstrating the influence of illness-related cognitions and the differential amount of attention paid to the cognitions of gay and bisexual men, we aim to examine differences in HIV-related cognitions between sexual minority and heterosexual individuals. In particular, we sought to understand these differences in a diverse sample of at-risk Washington D.C. residents. We sought to test three main hypotheses. We predict significant differences in anticipated HIV stigma, HIV infection-control beliefs, and HIV status avoidance by sexual orientation/sexuality. Specifically, we predict that compared to sexual minority individuals, heterosexual people will score higher on HIV status avoidance and score lower on anticipated HIV stigma and HIV infection-control beliefs.