HIV prevention and treatment therapies have had major advancements in the last 20 years; however, HIV remains a highly stigmatized disease worldwide, preventing people with risk or infection from seeking prevention tools, learning their HIV status, accessing support services, or adhering to antiretroviral therapy.1,2 The concept of stigma is complex, and how stigma manifests may vary among different cultures and groups of people, but its impact on HIV-related health outcomes is consistently detrimental.3

Perception of stigma among those with HIV has been correlated with a late presentation for treatment.4 Despite many studies on HIV in blood donors, to date, no studies have evaluated the linkage with health care services after the HIV notification counseling conducted by the blood bank nor how the stigma surrounding this illness affects this specific group of individuals.

Our study aimed to assess whether HIV-positive donors who returned to the blood center for notification later attended HIV counseling referral centers for additional treatment and follow-up and investigate factors associated with HIV-positive donors' perceived levels of social stigma.

The potential study population consisted of 720 confirmed HIV-positive blood donors who had participated in the previous HIV risk factor study. Of these, 268 (37 %) agreed to participate in the current protocol and were included in this study. The median time elapsed between the HIV-positive blood donation date to the completion of the ACASI interview was of 5 years (range, 2‒17). Table 1 provides the donors' demographic variables and donor status.

When asked if participants knew about their HIV infection before donation, 13 out of 263 (5 %) answered that they were aware of their status before donation, and 4 (31 %) said they tried to donate blood again. Among the 249 participants unaware of their HIV infection before donation, 7 (3 %) tried to donate blood after the blood center HIV notification and counseling. Two hundred thirty-three participants (89 %) reported seeking medical care after HIV notification and counseling from the blood center, and 140 (60 %) of these sought medical care within two weeks of blood center notification (Tables 2and3). Two hundred twenty-three (83 %) participants reported taking ARV medications at the time of their study visit.

Two hundred and sixty-two participants (99.6 %) consented to allow access to their HIV disease monitoring data in the Brazilian MoH database. However, Brasilia SI-CTA could only link data for 229 (87 %) of the participants. Of the 229, at some point after the blood center HIV notification, 107 individuals had CD4 data, 121 had CD4 and viral load data, and one participant had only viral load data in the system.

When the ACASI participants were asked to rate the HIV notification and counseling performed by the blood center, 231 (86 %) answered that the counseling skills of the blood center physician during their HIV notification were very satisfactory or satisfactory. When asked to rate their confidence in the blood center physician's approach to notification, 246 (92 %) responded that they were very confident or confident. Almost all participants, 262 (97 %), rated as very important or important the blood center counseling in their decision to seek health care.

Using the calculated stigma index, 105 (39 %) participants were classified as having none to low levels of stigma, and 163 (61 %) participants with moderate stigma. No one reported high levels of stigma. No differences in stigma levels were observed between the groups regarding age group, gender, self-reported race, marital status, and the blood center where participants were notified of their HIV infection.

We conducted a bivariate analysis to examine the association between demographic variables and perceived levels of stigma. Our findings revealed that individuals reporting heterosexual orientation were more likely to self-report moderate stigma compared to those reporting homosexual orientation (OR = 2.19, 95 % CI [1.21‒3.94]). However, no differences in stigma levels were observed between individuals reporting bisexual or homosexual orientation (OR = 0.95, 95 % CI [0.40‒2.24]). Moderate stigma level was more likely for individuals who reported not being employed (OR = 1.69, 95 % CI [1.01‒2.85]), and for those who reported elementary school education level (OR = 3.77, 95 % CI [1.40‒10.16]), compared to those with technical or professional school.

Knowing someone with HIV infection, currently taking antiretroviral therapy, and having heard of or previously tested in a counseling and testing center showed no association with self-reported stigma level. There was a significant difference in the odds of reporting moderate levels of stigma among individuals who sought health care after HIV status notification by the blood center compared to those that did not seek health care (OR = 2.75, 95 % CI [1.04‒4.94]).

Sexual orientation, education level, employment status, and healthcare-seeking behavior were selected for the final model logistic regression. Adjusting for other predictors, we found that seeking health care significantly increased the odds of self-reported moderate stigma level (OR=2.46, 95 % CI [1.10‒5.48]) compared to the reference level. Respondents who reported heterosexual orientation had significantly increased odds of reporting moderate levels of stigma compared to those who reported homosexual orientation (OR = 2.13, 95 % CI [1.08‒4.22]) (Table 4).

The relationship between HIV infection, stigma, and accessing health care services is complex and likely varies between populations. Our study examined the impact of perceived HIV-related stigma on blood donors who were notified about their HIV status through blood donation. Among donors with HIV from four different regions of Brazil, more than half reported experiencing moderate HIV stigma and discrimination. We found that the odds of experiencing perceived levels of moderate stigma and discrimination were over two times higher among respondents who sought health care. Reporting heterosexual orientation was strongly associated with experiencing HIV stigma compared to those reporting homosexual orientation. Based on other research, it has been observed that the magnitude of stigma can vary and appears to be higher for people living with HIV who have not yet disclosed their serostatus.7,8 Although in our study stigma was present, its intensity was not a major barrier in this population of blood donors since the vast majority of the respondents reported having disclosed their serological status to others.

Furthermore, black/mixed race, lower education, residing in a less developed region, and high levels of social vulnerability are all associated with a higher likelihood of presenting to care with more advanced diseases, not using antiretroviral therapy, and not achieving viral suppression in Brazil and in other countries.9-12 Intersectional stigma is the convergence of belonging to multiple stigmatized groups (e.g., HIV status, sexual orientation, race, socio-economic status) and may intensify negative detrimental health effects.13,14 However, contrary to our expectations, we found that stigma was not strongly associated with self-reported black/mixed race or gender in our study population. Even though the group of people with lower educational attainment showed a higher level of stigma, this finding was not significant in multivariable analysis. On the other hand, those who declared heterosexual orientation experienced significantly higher levels of HIV-related stigma previously described as being related to the acceptance of their status, which may be influenced by their negative perception of HIV, conceptions of masculinity, and their fear of experiencing homophobia.15-17

Prior research identified HIV-related stigma and discrimination as associated with lower levels of HIV treatment engagement,18,19 healthcare-seeking behavior,7,20 and access to HIV care.2 In contrast, our data indicate that among Brazilian blood donors, there is a significant positive association between the likelihood of seeking health care services and the presence of moderate self-reported stigma. Most study participants were on antiretroviral therapy. This relationship may have been found because our participants were a convenience sample willing to participate in the study and may have been more likely to engage with health care services. In addition, almost all individuals reported blood bank counseling as important or very important in their decision to seek health care. Most likely, the impact of a good counseling process was more meaningful for those participants who reported a higher level of stigma and experienced more discrimination. Increasing disease awareness among those who feel marginalized due to a specific condition is critical to undoing misconceptions or beliefs regarding HIV/AIDS and can encourage coping strategies, of which the decision to seek care is a key part.

There are limitations in our study. A validated stigma questionnaire to measure HIV-related stigma in the Brazilian setting was not available, and we may have missed important components of measurement of stigma and discrimination in Brazilian culture. The time elapsed between the HIV-positive donation and the return to the blood center to complete the questionnaire was varied, with a median of 5 years. This long interval between blood donation and participation in the study may have partially underestimated the number of individuals who reported stigma since stigma can attenuate over time, especially in those diagnosed more than five years ago.2 We also recognize the size of the group participating in the study may limit the generalizability of the findings, even to all donors with HIV who are notified of their serostatus by blood centers in Brazil. Finally, our findings are not generalizable to all blood donors with infection. Differences are evident among those who did and did not participate. For example, we had less success enrolling those who were younger and had lower educational attainment at the time of the HIV-positive donation. Additionally, the participants in the study are likely the most engaged, as they were drawn from the pool of previous blood donors we successfully contacted, and they voluntarily participated in this study. Those previous donors we couldn't contact or who declined to participate may exhibit differing levels of perceived stigma and access to health services.

Our study provides previously unreported information about stigma and discrimination in the Brazilian blood donor population, highlighting the importance of blood center counseling in facilitating linkage to care and reducing stigma among individuals recently diagnosed with HIV. The findings suggest that heterosexual orientation and healthcare-seeking behavior are associated with higher levels of perceived stigma, emphasizing the need for targeted interventions to address HIV-related stigma in these groups.

All authors contributed to the article and approved the submitted version.