associations between social capital and hiv stigma in ...

AIDS Education and Prevention, 21(3), 233–250, 2009 © 2009 The Guilford Press SIVARAM ET AL. SOCIAL CAPITAL AND STIGMA IN CHENNAI

Associations between Social capital and HIV stigma in Chennai, India: Considerations for prevention intervention design Sudha Sivaram, Carla Zelaya, A.K. Srikrishnan, Carl Latkin, V.F. Go, Suniti Solomon and David Celentano

Stigma against persons living with HIV/AIDS (PLHA) is a barrier to seeking prevention education, HIV testing, and care. Social capital has been reported as an important factor influencing HIV prevention and social support upon infection. In the study, we explored the associations between social capital and stigma among men and women who are patrons of wine shops or community-based alcohol outlets in Chennai. We found that reports of social capital indicators were associated with reduced fear of transmission of HIV/AIDS, lower levels of feelings of shame, blame and judgment, lower levels of personal support and perceived community support for discriminatory actions against PLHA. Specifically, when participants reported membership in formal groups, perception of high levels of collective action toward community goals, high norms of reciprocity between neighbors and residents in daily life, and presence of trusted sexually transmitted disease care providers, all levels of measures of stigma were lower. Although we defined social capital rather narrowly in this study, our findings suggest that seeking partnerships with existing organizations and involving health care providers in future interventions may be explored as a strategy in community-based prevention interventions.

Worldwide there are over 25 million adults infected with HIV, the virus that causes AIDS (UNAIDS, 2008). Of these, 2.5 million live in India (National AIDS Control Organization, 2007). Although concerted prevention education programs have increased awareness of prevention and transmission in India, there remain several challenges (Steinbrook, 2007). A key challenge lies in motivating individuals at risk Sudha Sivaram S, Carla Zelaya, V.F. Go, and David Celentano are with the Infectious Diseases Program, Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. A.K. Srikrishnan and Suniti Solomon are with the YRG Center for AIDS Research and Education (YRG CARE), Voluntary Health Services, Taramani, Chennai, India. Carl Latkin is with the Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD. The study was funded by U.S. National Institute of Mental Health Grant U10MH681543-01. Address correspondence to Sudha Sivaram, Infectious Diseases Program, Department of Epidemiology, The Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Rm E6547, Baltimore, MD 21205; e-mail: [email protected]

233

234

SIVARAM ET AL.

to get tested and in managing HIV and treating HIV among those who are infected (Celentano, 2008). Awareness of testing remains low; counseling and testing services at antenatal clinics, key points of prevention, based on a report in rural India was only reported by 3% of women (Celentano, 2008; Singh et al., 2008). Low rates of HIV prevention and care delivery are further supported by studies of health care providers that suggest poor clinical management of persons living with HIV/AIDS (PLHA) and inadequate adherence to guidelines of universal precautions (Datye et al., 2006). Low awareness of services coupled with poor quality of these services might explain why individuals get tested very late in infection and typically when they are sick. Another explanation outside of the health care delivery system might lie in the role of stigma in HIV/AIDS in India (Mawar, Saha, Pandit, & Mahajan, 2005). Stigma is experienced as a result of social norms that render an attribute or a condition to be inferior or inappropriate (Link & Phelan, 2001). It has also been described as a reaction to fear or perceived threat (Ogden & Nyblade, 2005). Studies have outlined that stigma may be a social process related to power, control, or morality (Alonzo, 1995). Although diseases such as leprosy and tuberculosis have been stigmatized as a result of a combination of these processes, the role of perceived morality is prominent in HIV stigma. In India, knowledge of a PLHA has resulted in refusal of care by physician (Kielmann et al., 2005), discriminatory treatment by health providers (Sheikh et al., 2005), and reports of physical violence (Rogers et al., 2006). Further reports of suicide of entire families upon receiving an HIV-positive diagnosis of one member (Kulkarni SS), high-profile law suits arising from marriages arranged without disclosing HIV status of the prospective groom, and instances of withholding disclosure of a son’s HIV status until a grandchild is conceived by the daughter-in-law suggest complex social and cultural dimensions of stigma in India (Taraphdar, 2007). Perhaps anticipating discriminatory treatment in various walks of life, individuals hesitate to adopt prevention and care-seeking behaviors. This is evidenced from studies that show that stigma influences communicating about prevention, negotiating condom use and seeking an HIV test (Madru, 2003; Roth, Krishnan, & Bunch, 2001). The mechanisms of how these prevention and care behaviors are affected by stigma are poorly understood, although there is evidence that the type of stigma may influence these behaviors. The literature discusses several sources and forms of stigma. Fear of transmission by a PLHA is a primary source of stigma. Forms of stigma include enacted stigma, community stigma, and internalized stigma (Berger, Ferrans & Lashley, 2001; Steward et al., 2008). Enacted stigma is one that measures how respondents would act toward PLHA (Swendeman, Rotheram-Borus, Comulada, Weiss, & Ramos, 2006); community stigma refers to perceived community norms about and behaviors toward PLHA (de Bruyn, 2002); internalized stigma occurs when an uninfected individual either believes in stigmatizing PLHA, or when a PLHA believes that s/he deserves to be stigmatized (Thomas, 2005). The fear of infection by PLHA, of unsolicited disclosure to family or community members, and of a sexual partner’s reaction (which includes physical and sexual violence) upon disclosing HIV-positive status have been found by many studies worldwide to be barriers to seeking HIV counseling-and-testing services (Herek, Capitanio, & Widaman, 2003; Lawyers’ Collective, 2004; Keusch, Willentz, & Klienman 2006). Other barriers include unsupportive community norms and fear of stigma and discrimination by health providers (Chandrasekaran, Dallabetta, Loo, Rao, Gayle, & Alexander, 2006).

SOCIAL CAPITAL AND STIGMA IN CHENNAI

235

From these studies it is clear that any intervention to reduce stigma needs to consider factors that operate beyond the individual’s control. A possible intervention strategy may lie in developing supportive social norms about PLHA, mobilizing community support, and strengthening health care systems for HIV prevention and care delivery (Gilmore & Somerville, 1994; Parker & Aggleton, 2003). We posit that this strategy would build social capital. Social capital, in a very broad sense, refers to the systems within a community that increase the ability of community residents to work together for mutual benefit (Kawachi, 2006). First postulated by Durkheim (1951) as the strength of a group over individual members of the group, this concept was later shaped by Bourdieu, Coleman, and Putnam (2000) to suggest that individual health and development outcomes are often influenced by factors operating outside his or her realm of influence; and it is by community participation and neighborhood-based action that several of these goals might be achieved (Lomas, 1998; Welshman, 2006). Some elements of social capital are the strength of formal and informal organizations and social networks within a community, collective action and social support toward common goals, and norms of interaction and reciprocity, which refers to the relationships between members of a community that can work to mutual benefit and growth (Chavez, Kemp, & Harris, 2004; Yamaoka, 2008). Herein, the role of neighborhood organization and community participation are key (Muntaner, Lynch, & Smith, 2001). Social development researchers have also discussed the role of trust in government and other civic leadership and empowerment as essential components of social capital (Mohseni & Lindstrom, 2008). However, although there is general agreement in the literature about the importance of building social capital, there is absent a consensus in the literature about the manner of its application in public health. As a latent variable, its interpretation and measurement are also debated. HIV research papers have either measured social capital as an aggregate variable at the macro level (Holtgrave & Crosby, 2003), or used few measures such as volunteerism, community group participation or social networks to measure it at the individual level (Campbell, Williams, & Gilgen, 2002). Although we recognize this debate, we also in our research seek to explore new approaches for HIV prevention in contexts where control efforts are most needed such as in India. To realize better prevention and care outcomes for HIV, particularly to reduce stigma in India, social capital may be a relevant strategy for many reasons. First, the source of stigma is often community or health systems based (Mawar et al., 2005). Second, there is evidence in the literature that when the social network and social support aspects of social capital are strengthened, desirable HIV related outcomes are achieved (Campbell et al., 2002; Gregson, Terceira, Mushati, Nyamukapa, & Campbell, 2004). Studies in South Africa and Tanzania have shown that participation in voluntary activities and membership in community groups were factors associated with lower HIV prevalence (Campbell et al., 2002). Macro analysis of data from U.S. youth has suggested that social capital measures are associated with higher rates of protective sexual behaviors (Crosby, Holtgrave, DiClemente, Wingood, & Gayle 2003). There is indirect evidence from HIV research in India that suggests a possible role for social capital in realizing HIV prevention goals. In the Sonagachi project targeting female sex workers in eastern India, the data show that community organization and social support generated by this project has resulted in female sex workers gaining information about HIV prevention and advocating for health care. Their formal organization allow for dialogue and discussion between women and

236

SIVARAM ET AL.

their influencers (brokers, brothel madams and clients) and has added more value and acceptability to HIV prevention efforts (Jana, Basu, Rotheram-Borus, & Newman, 2004). In addition to community organization for HIV prevention, there is also evidence of the role of social networks in promoting HIV prevention knowledge and care. Our earlier work has shown that communication about sex and sexual health among men occurs among members of close personal networks that not only inform but also positively influence sexual decisions about care seeking (Sivaram et al, 2005). However, this evidence of strength in organization and peer networks around HIV prevention is more the exception than the norm in India. Among persons and families living with HIV/AIDS studied here however, a lack of social support remains a predominant finding. Lower levels of social support, higher feelings of isolation, and loss of control are expressed by PLHA. Female PLHA experience stigma at much higher levels and are more likely than men to be blamed for their infection (Alert, 2002; Solomon, Chakraborty, & Yepthomi, 2004). Another source for lack of social support is in the health service sector. In some studies physicians themselves fear touching PLHA, and often blame them for their illness (Kielmann et al., 2005). Advocates for HIV-positive individuals and their families emphasize the need for social support not only from physicians but also from community and families in order to better manage disease in India (Indian Network of Positive Living with HIV/AIDS, 2003). This article aims to identify measures of social capital based on ethnography and to explore the statistical association between these social capital measures and HIV-related stigma. We describe domains of social capital that are both positively and negatively associated with stigma. To our knowledge such an analysis has not been reported in the literature from India. However, as public health scientists and practitioners move toward developing new approaches and interventions to address stigma in the community, we anticipate that our findings might help highlight areas of focus for future interventions to reduce HIV stigma.

Methods The study was conducted in Chennai city in the south India state of Tamil Nadu. The data was collected as part of the NIMH HIV/STD Prevention Trial, a community-based cluster randomized trial to test the efficacy of HIV prevention messages disseminated through community popular opinion leaders, or CPOLs (National Institute of Mental Health [NIMH, 2007). The study was implemented in wine shops or bars in Chennai and CPOLs were selected among men and women who patronize these venues. The trial began with ethnographic in-depth interviews of 41 men and women who partronize wine shops. These interview helped develop the survey questionnaire and intervention content. The trial assessments consisted of a baseline survey of behavioral and biological risk followed by CPOL training in intervention venues (control venues received intervention after a 2-year lag). Follow-up assessments of the baseline cohort were conducted at 18 and 34-months after the baseline. At the 34 month assessment in 2006, we conducted an additional assessment of HIV/AIDS stigma and social capital. Men were recruited using systematic random sampling in the venue and women associated with the wine shop were also recruited. To be eligible, participants had to be 18-40 years of age, patronize bars at least thrice weekly, anticipate living in Chennai in the next year, and be lucid and capable


237

of providing voluntary informed consent at the time of the interview. Recruitment was conducted in the wine shops, and informed consent procedures followed by assessment was conducted in the trial offices. Where needed, participants were provided transportation to the trial office for assessment. This study was initiated after ethical review and approval from the institutional review boards of YRG Center for AIDS Research and Education in Chennai, India and the Johns Hopkins University Bloomberg School of Public Health in Baltimore, MD.

Measures Stigma Stigma was measured by a scale that had been previously piloted and validated in a similar population, with four domains (Zelaya et al., 2008). The first domain, fear of transmission, measured causes of stigma by asking questions on individual’s fears of contracting HIV by their interaction with PLHA. The second domain, association with shame blame and judgment, measured participants’ attitudes toward PLHA. Although these two domains measured the causes of stigma, the third domain and fourth domain measured enacted and perceived stigma. The third domain, personal support of discriminatory actions or policies against PLHA, sought responses on how participants’ would themselves treat PLHA or how they perceive PLHA should be treated. The fourth and final domain, perceived community support of discriminatory actions or policies against PLHA, assessed participants, perception of how the community treats and perceives PLHA. All stigma domains were the main outcomes (latent variables) in this study.

Social Capital Social capital measures were developed considering two sources of information. The first was our literature review and second was review of existing instruments (World Bank, 2009). Following this, within the protocol of the NIMH trial, we developed ethnographic guides to gather information on (a) social networks, (b) sources of social support for HIV prevention and care, (c) health-care seeking behaviors, and (d) community life and interaction. We conducted 41 ethnographic interviews. All ethnographic interviews were tape-recorded in the local language, translated and transcribed in English. Development of Social Capital Variables. In the ethnographic analysis, participation in community groups and the role of friends emerged as valuable in providing and discussing information about HIV/AIDS, shaping decisions to drink and to have sex. Participants reported being part of several formal and informal community groups. Among men, these included youth groups, movie star fan clubs, and trade groups such as auto-rickshaw driver associations. Among women, respondents reported belonging to community-based women’s groups that discussed health and nutrition issues. Friends encouraged each other to drink in order to gain weight, in order to get the courage to have sex, to relive minor aches and pains, or simply to be “jolly,” a term that reflects a stress-free state of mind. In addition to knowledge, friends also supported each other by providing money to have sex and negotiating rates with a sex worker as this quote suggests:

238

SIVARAM ET AL. When we want to have sex, four of us friends go together to the sex worker. Some of us may not have enough money but still want to have sex. So we negotiate from 500 rupees and at last settle down for 300 rupees and have sex (Unmarried male, aged 28)

Participants also reported getting support from friends and neighbors in several ways: money loaned when needed, assistance with getting a job, support talking about concerns and problems at home. In the domain of health care seeking, we found several instances of HIV prevention and care information coming from health care providers. One male respondent reported learning from a doctor that the primary sources of sexually transmitted diseases (STDs) are women. Another doctor provided information the following on sexual behavior: After drinking, I will have the sexual urge and want to masturbate. But the doctor told me that masturbation will damage the penis. So, in order to fulfill my urge, I visit a sex worker--Unmarried male, age 24.

Based on this analysis, our earlier work on community norms and HIV communication among social networks and by referring to questions on social capital from the literature, we measured two domains of social capital--groups and networks and collective action. Groups and networks were measured by assessing (a) participants’ membership in formal and informal groups in the community, (b) reported number of close friends and (c) availability of financial assistance in times of need, and (d) trustworthiness of community members. Collective action was measured using three indicators: norms of reciprocity, likelihood of collaboration for mutual benefit, HIV-related support and action. Norms of reciprocity were measured by a series of questions assessing how participants assist their community and friends and how in turn they are assisted similarly by community and friends. For instance, we asked if they received assistance in seeking health care and, conversely, if they got assistance in seeking health care. Collective action was determined by whether community members donate time to projects that further common goals in the community. We developed questions to assess available HIV/AIDS support by assessing the availability of a trusted health care provider and by assessing if they have discussed HIV with friends. All social capital domains served as independent variables in the analysis.

Data Analysis Ethnographic transcripts were analyzed using Atlas.ti (Muhr, 1998), a textual analysis software program. The data were reviewed for three main themes or codes as they were called in the software program: composition and characteristics of social networks, the content of communication in these networks and the association of communication with sexual behavior. Text that matched these codes were retrieved and reviewed. Matrices were developed for each code to enable organization of the data and to understand similarities and contrasts across related themes. In the quantitative analysis, our main outcome variables were the four domains of stigma. Predictor variables were the four domains of social capital. Domains of social capital were dichotomous or continuous variables. Some questions in collective action and available HIV support were measured using a Likert scale of items. We first conducted a descriptive analysis of the variables. Following this, we used structural equation modeling (SEM) to investigate the relationship between social


239

capital and HIV/AIDS stigma. SEM is a system of simultaneous equations that estimate associations between observed predictor variables and outcome variables through intervening continuous latent variables. This study uses a multiple cause and multiple indicators (MMIC) model, a type of SEM in which one or more latent variables intervene between a set of multiple observed predictor and dependent variables. All analyses were conducted using Mplus, Version 4.2 (Muthen, 2007). The relationships between social capital variables (predictors) and stigma (latent variables) while controlling for demographic characteristics are described by multivariate linear regression equations within the model.

Results At the 34-month survey, 2,422 participants were interviewed. Of this number, 53 were removed from the analysis as they had previously tested positive for HIV resulting in a final sample of 2,369. Eighty-four percent were male. Median age of the population was 30 years with women being slightly older than men in this sample. Overall, participants had an average of 7 years of formal education. Sixty percent of participants were married or living with a partner and 31.9% were never married; relatively more men were married and single in this sample as compared with women. Among women, fewer than 5% reported no children with over 80% of the women reporting two or more children. Thirty-three percent of men reported no children and 50% reported two or more children. Our ethnographic data showed that most resided in either nuclear families or had a older relative (in-laws, parents) living with them. Occupations such as auto-rickshaw drivers, day laborers and those in private sector and government service were represented among men. All women in the sample were female sex workers. Among women, there were reports of abusive spouses, separation or abandonment by spouses. All participants patronized wine shops. We have reported detailed descriptions of wine shops earlier (Sivaram et al., 2007). Men visited wine shops at least thrice weekly and represented individuals from all walks of life. Typically, men patronized wine shop with friends--65% of our sample reported visiting wine shops with friends and saw wine shops as a primary venue for socialization. Women visited wine shops less frequently but through mediators had male patrons as their clients. We also explored social network and capital measures reported by the participants (Table 1). Twenty-seven percent reported membership in a formal group in the community such as youth group or women’s clubs. Informal group membership was reported by less than 2%. A majority (53%) of participants reported between one and four friends, and 31% reported five or more friends. Overall, 55% of participants reported that they cannot trust people in the community. We also assessed norms of reciprocity between friends and neighbors--69% reported loaning money, 85% reported listening to problems, 42% reported helping neighbors and friends with child care, and 46% reported assisting with seeking health care. Conversely, 58% reported having receiving money from friends and neighbors in times of need, 82% reported that they had a listening ear to share personal concerns, 33% they received help with seeking health care, and 29% reported that they receive help with child care. Frequency analysis of community participants showed that 64% reported willingness to contribute time to a project to benefit the community and 40% said that they will contribute money to a community project. Finally, we examined two variables that indicated HIV related support and

240

SIVARAM ET AL.

TABLE 1. Frequency Distribution of Social Network and Social Capital Measures Reported by Participants Measure

Frequency Percentage

Groups and networks Membership in a formal group Membership in an informal group

27 1.30

Number of Close Friends 0

16

1-4 friends

53

5 or more friends

31

Trust Cannot trust people in the community

55

Collective action Norms of reciprocity Loaned money to friends/neighbors

69

Listening to concerns of friends/neighbors

85

Helped friends/neighbors with childcare

42

Helped friends/neighbors seek health care

46

Was loaned money by friends/neighbors

58

Friends/neighbors listened to my concerns

82

Friends/neighbors help me with child care

33

Friends/neighbors helped me seek care

29

Collaboration for community’s benefit Will contribute time to work on a community project

64

Will contribute money to help a community project

40

HIV-related support and action Availability of a trusted health provider

25

Discussion about HIV with friends

43

action. Twenty-five percent reported that a trusted health provider to discuss HIV/ STD was available in their community, and 43% reported that they discussed HIV prevention with friends. Table 2 presents the results of the analysis of the association between the domain of fear and transmission and various covariates measuring social capital. Among measures of groups and networks, we found that fear of transmission significantly decreased as membership in formal groups increased. Further, the lesser the likelihood of perceived financial support, the higher reported fear of transmission and disease among men and women in the multivariate analyses, and the lesser reports of trust, the higher the likelihood of reports of fear of transmission and disease. We assessed norms of reciprocity to estimate how individuals help and rely on each other and the extent of cooperation in the community. We found that when reciprocity was higher, fear was lower among both men and women. Similarly, higher likelihood of collective action was associated with lower fear among men and women in the adjusted analysis. Where there was a trusted STD doctor available, this availability was significantly associated with lower fear of transmission and disease

(0.182, 0.426)

(0.018, 0.140)

(0.108, 0.296)

(0.345, 0.905)

(0.097, 0.359)

REF

-0.808

REF

REF 0.068

0.183

0.121

-0.472

-0.979

0.617

REF

0.178

-0.011

-0.301

0.114

(-1.102, -0.514)

(-0.212, 0.348)

(0.056, 0.310)

(0.001, 0.241)

(-0.854, -0.090)

(-1.649, -0.309)

(0.882, 0.882)

(0.033, 0.323)

(-0.027, 0.005)

(-0.585, -0.017)

(-0.139, 0.367)

(LCI, UCI)

MULTIVARIATE - FEMALES* Estimate

* Controling for age (in years); education (years of school completed); marital status (married, never married, widowed, and separated/divorced); income (do you regularly earn money-yes/no); when you visit the wine shop, do you come with friends (yes/no); religion (hindu, christian, muslim, other)

-0.792 (-1.041, -0.543)

REF -0.419 (-0.566, -0.272)

(0.060, 0.334)

(0.010, 0.242)

REF

0.197

0.126

-0.593 (-1.071, -0.115)

-0.924 (-1.665, -0.183)

0.625

REF

0.228

-0.013 (-0.027, 0.001)

-0.46

0.104 (-0.004, 0.212)

0.202

-0.261 (-0.324, -0.198)

-0.488 (-0.596, -0.380)

0.304

REF

0.079

-0.002 (-0.012, 0.008)

(-0.160, 0.260)

-0.326 (-0.583, -0.069)

0.05

REF 0.028 (-0.231, 0.287)

(-0.597, -0.323)

(-0.008, 0.188)

-0.117 (-0.186, -0.048)

0.09

(LCI, UCI)

UNIVARIATE FEMALES Estimate

REF -0.426 (-0.691, -0.161)

(-0.713, -0.195)

(0.034, 0.234)

(0.113, 0.297)

(-0.338, -0.212)

(-0.646, -0.430)

(0.198, 0.452)

(0.059, 0.177)

(-0.016, 0.000)

(-0.180, -0.042)

(-0.024, 0.122)

REF -3.437

0.134

Others helping you (Continuous Latent Variable, higher value higher reciprocity)

Perception of safety at home (1=very safe to 5=very unsafe)

-0.275

Helping others (Continuous Latent Variable, higher value higher reciprocity)

0.205

-0.538

You have to be careful (2)

Likelihood that people will cooperate to solve water supply problem (1=Very likely to 5=very unlikely)

REF 0.325

People can be trusted (1)

(Definitely=1, Probably=2, Unsure=3, Probably not=4)

0.118

-0.008

# of close friends

People available to help if you need money urgently

-0.111

# formal groups where participant is a member

Trusted STD doctor available No Yes Collective Action (HIV related) Have you discussed HIV with friends No Yes

Collective Action

Groups and Networks

0.049

(LCI, UCI)

MULTIVARIATE MALES* Estimate

Estimate

(LCI, UCI)

UNIVARIATE MALES

# informal groups where participant is a member

OUTCOME: FEAR OF TRANSMISSION AND DISEASE

Table 2: Linear regression coefficients and 95% confidence intervals of social capitol domains as predictors of fear of transmission and disease (domain of HIV/AIDS stigma) among high risk men and women in Chennai, India

SOCIAL CAPITAL AND STIGMA IN CHENNAI 241

242

SIVARAM ET AL.

among men. However, among women the presence of a trusted doctor was associated with more fear of HIV transmission. Among both men and women, discussing HIV with friends was significantly associated with lower fear. Following fear of transmission, we explored social capital variables associated with feelings of shame blame and judgment (Table 3). Here we found that among men, as membership in informal groups increased, there was more association with shame, blame and judgment. The less likely there were people available to help in financial need, the more the association with shame, blame, and judgment among men and women. Among women, the higher the number of close friends, the lower the association of shame, blame, and judgment. There was no significant association between close friends and the outcome among men. Among men and women, higher norms of reciprocity were associated with lower associations with shame, blame and judgment. When women reported less likelihood of collective action, there was more association with shame, blame, and judgment. When we analyzed the role of availability of a trusted STD physician, we found that among men who reported having availability, there was more association with shame, blame and judgment. Among both men and women, discussing about HIV with friends predicted less association with shame, blame, and judgment. We next examined the associations between social capital and personal support for discriminatory actions and policies against individuals affected by HIV/ AIDS (Table 4). Membership of men in a higher number of formal groups; higher norms of reciprocity, availability of a trusted doctor, and discussing HIV with friends were associated with lower personal support for discriminatory actions and policies. Among women, higher number of close friends, high levels of norms of reciprocity, availability of a trusted STD doctor, and discussing HIV with friends (among men) were associated with less personal support for discriminatory actions and policies. More personal support of discriminatory actions were associated among men and women with unsafe neighborhoods. Finally, we examined the associations between social capital variables and perceived community support for discriminatory actions or policies toward PLHA (Table 5). Here, we found that more individuals perceived community support for PLHA discrimination when they (men) also reported lesser availability of financial help, more close friends (women), lower reciprocity and unsafe neighborhoods. Individuals perceived lesser community support for discrimination when there was a trusted STD doctor and when men reported discussing HIV with friends.

Discussion In India, stigma is an important barrier faced by PLHA to seek care and maintain a desired quality of life. In this study, we explored the role of social capital as a possible strategy to reduce HIV stigma and our findings suggest that this may be a viable approach. The two domains of social capital that we measured were groups and networks and collective action. We discuss the findings under each social capital domain and outline suggestions of how these findings might translate to intervention design.

Groups and Networks Membership in groups and networks are integral to community life in the study area. Informal meetings in the neighborhood to discuss a range of issues, formal

-0.234 -0.113 0.073 -0.168




Perception of safety at home (1=very safe to 5=very unsafe) (-0.264, -0.072)

(-0.017, 0.163)

(-0.201, -0.025)

(-0.369, -0.099)

(-0.111, 0.065)

(0.018, 0.148)

(0.092, 0.252)

REF -0.286 (-0.400, -0.172)

REF -0.243 (-0.380, -0.106)

-0.198 (-0.294, -0.102)

0.057 (-0.039, 0.153)

-0.086 (-0.176, 0.004)

-0.180 (-0.303, -0.057)

REF -0.034 (-0.116, 0.048)

0.172

-0.001 (-0.011, 0.009)

-0.014 (-0.041, 0.013)

0.083

(0.490, 1.106)

(0.055, 0.301)

(0.198, 0.460)

(0.002, 0.252)

REF -0.298 (-0.580, -0.016)

REF -0.109 (-0.297, 0.079)

0.329

0.127

-0.838 (-1.402, -0.274)

-1.257 (-2.233, -0.281)

REF 0.798

0.178

-0.023 (-0.035, -0.011)

-0.127 (-0.280, 0.026)

-0.083 (-0.336, 0.170)

(LCI, UCI)


REF -0.290

REF -0.093

0.323

0.137

-0.692

-1.387

REF 0.817

0.132

-0.024

-0.094

-0.100

(-0.608, 0.028)

(-0.277, 0.091)

(0.194, 0.452)

(0.006, 0.268)

(-1.135, -0.249)

(-2.398, -0.376)

(0.523, 1.111)

(0.010, 0.254)

(-0.038, -0.010)

(-0.304, 0.116)

(-0.398, 0.198)

(LCI, UCI)

MULTIVARIATE - FEMALES* Estimate


(-0.438, -0.222)

REF -0.023

People can be trusted (1) You have to be careful (2)

(0.123, 0.269)

REF -0.330

0.196

People available to help if you need money urgently (Definitely=1, Probably=2, Unsure=3, Probably not=4)

(-0.018, 0.002)

(-0.417, -0.127)

-0.008

# of close friends

(-0.046, 0.012)

(0.001, 0.127)

REF -0.272

-0.017


Trusted STD doctor available No Yes Collective Action (HIV related) Have you discussed HIV with friends No Yes

Collective Action

Groups and Networks

0.064

(LCI, UCI)

MULTIVARIATE MALES* Estimate

Estimate

(LCI, UCI)

UNIVARIATE MALES


OUTCOME:ASSOCIATIONS WITH SHAME BLAME AND JUDGEMENT

Table 3: Linear regression coefficients and 95% confidence intervals of social capitol domains as predictors of 'associations with shame, blame and judgment (domain of HIV/AIDS stigma) among high risk men and women in Chennai, India


-0.411 -0.222



REF -0.271 REF -0.271

Trusted STD doctor available No Yes

Have you discussed HIV with friends No Yes

0.234

REF 0.064



0.094


0.146

0.001

# of close friends


-0.032


(-0.347, -0.195)

(-0.414, -0.128)

(0.177, 0.291)

(0.095, 0.197)

(-0.265, -0.179)

(-0.491, -0.331)

(-0.020, 0.148)

(0.053, 0.135)

(-0.005, 0.007)

(-0.050, -0.014)

(-0.029, 0.061)

(0.027, 0.117)

(0.002, 0.010)

(0.152, 0.274)

(0.086, 0.188)

REF -0.232 (-0.310, -0.154)

REF -0.246 (-0.393, -0.099)

0.213

0.137

-0.204 (-0.249, -0.159)

-0.364 (-0.444, -0.284)

REF 0.044 (-0.038, 0.126)

0.072

0.006

-0.036 (-0.056, -0.016)

0.033 (-0.016, 0.082)

(0.145, 0.611)

(0.104, 0.280)

(-0.03, -0.006)

(0.112, 0.312)

(0.145, 0.321)

REF -0.411 (-0.627, -0.195)

REF -0.435 (-0.658, -0.212)

0.212

0.233

-0.799 (-1.367, -0.231)

-1.229 (-2.256, -0.202)

REF 0.378

0.192

-0.018

-0.189 (-0.452, 0.074)

-0.035 (-0.258, 0.188)

(LCI, UCI)


REF -0.416

REF -0.427

0.203

0.234

-0.696

-1.324

REF 0.376

0.173

-0.016

-0.152

-0.034

(-0.671, -0.161)

(-0.654, -0.200)

(0.099, 0.307)

(0.142, 0.326)

(-1.127, -0.265)

(-2.255, -0.393)

(0.155, 0.597)

(0.093, 0.253)

(-0.028, -0.004)

(-0.417, 0.113)

(-0.277, 0.209)

UCI

MULTIVARIATE - FEMALES* Estimate LCI


Collective Action (HIV related)

Collective Action

Groups and Networks

0.016


Estimate

(LCI, UCI)

MULTIVARIATE MALES*

Estimate

(LCI, UCI)

UNIVARIATE MALES

OUTCOME:PERSONAL SUPPORT FOR DISCRIMINATORY ACTIONS OR POLICIES TOWARDS PLHA

Table 4: Linear regression coefficients and 95% confidence intervals of social capitol domains as predictors of 'personal support for discriminatory actions and policies towards PLHA' (domain of HIV/AIDS stigma) among high risk men and women in Chennai, India

244 SIVARAM ET AL.

-0.226



REF -0.350 (-0.495, -0.205)

(-0.488, -0.158)

(0.166, 0.346)

(-0.033, 0.097)

(-0.304, -0.148)

(-0.479, -0.267)

(-0.011, 0.239)

(0.087, 0.201)

(-0.012, 0.004)

(LCI, UCI)

(0.074, 0.196)

(0.147, 0.339)

REF -0.334 (-0.479, -0.189)

REF -0.307 (-0.472, -0.142)

0.243

0.028 (-0.035, 0.091)

-0.211 (-0.287, -0.135)

-0.344 (-0.450, -0.238)

REF 0.102 (-0.027, 0.231)

0.135

-0.001 (-0.009, 0.007)

0.034 (-0.001, 0.069)

0.018 (-0.049, 0.085)

(LCI, UCI)

(0.014, 0.112)

REF 0.050 (-0.023, 0.123)

REF -0.099 (-0.154, -0.044)

0.063

-0.025 (-0.052, 0.002)

-0.397 (-0.666, -0.128)

-0.340 (-0.607, -0.073)

REF 0.084 (-0.020, 0.188)

0.004 (-0.023, 0.031)

-0.008 (-0.012, -0.004)

0.009 (-0.020, 0.038)

0.051 (-0.022, 0.124)

Estimate

UNIVARIATE FEMALES

REF 0.036

REF -0.090

0.051

-0.020

-0.294

-0.310

REF 0.059

-0.001

-0.008

0.023

0.018

Estimate

(-0.029, 0.101)

(-0.139, -0.041)

(0.008, 0.094)

(-0.047, 0.007)

(-0.504, -0.084)

(-0.543, -0.077)

(-0.029, 0.147)

(-0.026, 0.024)

(-0.012, -0.004)

(-0.016, 0.062)

(-0.056, 0.092)

(LCI, UCI)

MULTIVARIATE - FEMALES*


No Yes

REF -0.323

0.256

-0.373



REF 0.114


0.032

0.144

# of close friends


-0.004


Trusted STD doctor available No Yes Collective Action (HIV related) Have you discussed HIV with friends

Collective Action

Groups and Networks

0.024

# informal groups where participant is a member (-0.013, 0.061)

0.028

Estimate

(LCI, UCI) (-0.039) 0.095)

Estimate

MULTIVARIATE MALES*

UNIVARIATE MALES

OUTCOME: PERCEIVED COMMUNITY SUPPORT FOR DISCRIMINATORY ACTIONS OR POLICIES TOWARDS PLHA

Table 5: Linear regression coefficients and 95% confidence intervals of social capitol domains as predictors of 'percieved community support of discriminatory actions and policies towards PLHA' (domain of HIV/AIDS stigma) among high risk men and women in Chennai, India


246

SIVARAM ET AL.

membership in youth groups or women’s groups have been reported by us earlier (Sivaram et al., 2005). In this analysis, we found that among men and women, membership in formal community groups is associated with reduced fear of transmission; reduced shame, blame, and judgment, and reduced personal support for discriminatory actions against PLHA. This finding merits consideration as HIV education implemented by governmental and nongovernmental organizations is often targeted at these formal groups (Godbole & Mehendale, 2005; Pallikadavath, Garda, Apte, Freedman, & Stones, 2005). This is particularly relevant in the case of female sex workers in Chennai who receive several targeted HIV prevention interventions (Panchanadeswaran et al., 2008; Uma et al., 2005). A formal group might allow for structure in presenting and processing information and it is plausible that members in these formal groups receive relatively more accurate information than informal groups. This is further supported by our finding of a significant increase of association with shame, blame, and judgment as membership in informal groups increased among men. Although the number of close friends among men was not associated with any stigma domain except personal support of discriminatory actions where there was a negative association, among women, higher number of close friends may be an important point for intervention. Finally, key measures of network support-the ability to rely on others for financial help and trustworthiness--were strongly associated (among men and women) with low levels of stigma. These social support measures have been reported to facilitate disclosure (Chandra, Deepthivarma, Jairam, & Thomas, 2003), and access to and adherence to HIV medication (Kumarasamy, Safren, Raminani, Pickard, James, Krishnan et al., 2005) in India and elsewhere (Wolitski, Pals, Kidder, Courtenay-Quirk, & Holtgrave, 2008). In the Indian context, assessing these factors while planning an intervention for PLHA may suggest areas of focus and individuals of focus in order to build social capital and reduce stigma. The factors of community support, trust worthy individuals have been also reported as key facilitators in the effectiveness of several public health and development initiatives (Van Rompay et al., 2008). PolioPlus campaigns in India rely on community effort to motivate and support mothers to get their children vaccinated; the trust enjoyed by government health workers for this effort is perhaps a key factor in the large turnout in national drives to eradicate polio (Balraj, Mukundan, Samuel, & John, 1993). A similar initiatives, the AIDS Support Organization in Uganda, began as a community-based peer support campaign that is currently a dominant force against HIV/AIDS stigma in the country’s national campaigns (Rwemisisi, Wolff, Coutinho, Grosskurth, & Whitworth, 2008). Based on our findings, future programs that seek to reduce stigma may consider exploring the feasibility of stable community institutions that meet formally and seek the participation of individuals who work to better their communities as a first step in developing the intervention. Further, programs can understand the composition and number of close social networks of PLHA. This can serve as a catalyst to help disseminate communication messages that can reduce HIV stigma.

Collective Action The norms of reciprocity--the practice of give-and-take and assisting each other-that are the hallmark of an ideal community have been applied to several development related initiatives. Community-based bed- netting programs for malaria control in Africa rely on collective action. Studies in the United States and elsewhere suggest that social isolation and lack of cohesiveness in a community are associated with poverty, which in turn predicts poor mental health outcomes and unsafe


247

communities (Chavez et al., 2004; Msisha, Kapiga, Earls, & Subramanian, 2008; Rothenberg, Muth, Malone, Potterat, & Woodhouse, 2005). Our findings that high norms of reciprocity, higher level of collective action and higher perception of safety are associated with lowered HIV stigma suggests a more holistic approach to HIV prevention efforts. We measured collective action by asking individuals about their views on community cooperation to solve water supply problem, a chronic and prominent concern for citizens of Chennai. Prevention programs may be limited in effect if they focus only on individuals without addressing some of the larger community-level needs. Particularly for outcomes such as HIV stigma that are reliant on community perceptions and action, interventions that address these factors may be more relevant to individuals have higher public health significance. Our findings on the role of HIV specific collective action further illustrate the sources of stigma in the community and consequently the role of community involvement in reduction of HIV stigma. Among men who informed the study that there was a trusted doctor in the community, there were lower levels of stigma reported, although the associations were stronger in men than women. This finding may reflect on the content of doctor-client communication and suggest involvement of physicians in disseminating HIV prevention messages and promoting positive attitudes toward PLHA. Given the significant evidence that suggests a negative role of physicians--refusal to provide care to PLHA, referrals of PLHA, and misinformation about HIV--these data show the positive role that physicians can play in prevention education (Datye et al., 2006).

Limitations Our study has limitations that we would like to outline. First, as it was nested in a larger trial we measured stigma and social capital as it was relevant to the Chennai context. This trial sought participation from alcohol users. These participants’ behavior and attitudes may not apply to nonalcohol users or other sociodemographic groups in Chennai. As such, we are unable to make any statements about generalizability of study findings. However, we believe that the perspectives of the respondents with regard to social capital measures may not be biased. This is because these measures were relatively less sensitive than the other items such as sexual and substance use behavior that were measured during the survey. Second, we would like to acknowledge that we measured only a few domains of social capital. Others reported in the literature include volunteerism, homicide rates, community participation, to name a few--these were not measured and as a result we may be presenting a narrow operational of definition of social capital (Gregson et al., 2004). A more rigorous approach to measuring social capital is to conduct formative research to learn about the relevance of indicators in the Indian context followed by development and quantitative assessment of these measures. As we conducted this research as part of an ongoing trial whose primary outcome was not HIV stigma, we were limited in our scope. Third, we have limitations in our analytical approach. By modeling social capital covariates with domains of stigma, we were able to observe only the direction of association and significance of the associations but not the magnitude or relative strength of these associations. As an illustration of this limitation, in Table 2, although we are able to note that having more close friends is associated with less fear and having less access financial support leads to more fear, we are unable to say which element of groups and networks--friends or financial support is more important. Further, we did not standardize our coefficients. This does not allow us to compare the values or width of the confidence intervals directly. We will

248

SIVARAM ET AL.

need more sophisticated analysis approaches to assess effects of each element. As our intent was largely to explore what domains of social capital were associated with stigma, we did not conduct higher levels of analysis. Finally, we acknowledge that not all social capital is health promotive and there may be environmental and individual cognitive factors that influence behaviors. (Pronyk et al., 2008). Despite the directions of our associations suggesting the positive role of social capital in reducing HIV stigma, social capital can also be harmful. For instance, we have reported earlier in this article that men are assisted by friends financially to pay for sex worker services which can result in unsafe sex. This might suggest an entry point for interventions that can train peers to educate and motivate others to have safe sex. Another illustration from our data about the potential of negative social capital is when a physician provides unscientific advice about masturbation. Interventions seeking to build social trust should be cognizant of ensuring quality and scientific accuracy in working with community groups and health providers in education about HIV stigma. This is critical as without this accuracy, individuals may be led to risk behaviors (such as visiting sex workers) instead of averting them. In conclusion, as HIV prevention is a key national priority in India building social capital merits further consideration and exploration as a viable strategy to reduce HIV stigma.

References. Alert, A. (2002). AIDS stigma forms an insidious barrier to prevention/care. HIV experts describe problem in India. AIDS Alert, 17 (9), 111-113. Alonzo, A. A. a. N. R. R. (1995). Stigma, HIV and AIDS: an exploration and elaboration of a stigma trajectory. . Soc Sci Med, 41 (3), 303-315. Balraj, V., Mukundan, S., Samuel, R., & John, T. J. (1993). Factors affecting immunization coverage levels in a district of India. Int J Epidemiol, 22 (6), 1146-1153. Berger, B. E., C.E. Ferrans, and F.R. Lashley. (2001). Measuring stigma in people with HIV: psychometric assessment of the HIV stigma scale. Res Nursing Health, 24 (6), 518-529. Campbell, C., Williams, B., & Gilgen, D. (2002). Is social capital a useful conceptual tool for exploring community level influences on HIV infection? An exploratory case study from South Africa. AIDS Care, 14 (1), 41-54. Celentano, D. D. (2008). Is HIV Screening in the Labor and Delivery Unit Feasible and Acceptable in Low-Income Settings. PLoS Medicine, 5 (5), e107. Chandra, P. S., Deepthivarma, S., Jairam, K. R., & Thomas, T. (2003). Relationship of psychological morbidity and quality of life to illness-related disclosure among HIVinfected persons. J Psychosom Res, 54 (3),

199-203. Chandrasekaran, P., Dallabetta, G., Loo, V., Rao, S., Gayle, H., & Alexander, A. (2006). Containing HIV/AIDS in India: the unfinished agenda. Lancet Infect Dis, 6 (8), 508-521. Chavez, R., Kemp, L., & Harris, E. (2004). The social capital:health relationship in two disadvantaged neighbourhoods. J Health Serv Res Policy, 9 Suppl 2, 29-34. Collective, L. (2004). Indian Judgments. Crosby, R.A., Holtgrave, D.R., DiClemente, R.J., Wingood, G.M., & Gayle J. (2003). Social Capital as a predictor of Adolescent Sexual Risk Behavior: A state level exploratory analysis. AIDS and Behavior, 7, 245-252. Datye, V., Kielmann, K., Sheikh, K., Deshmukh, D., Deshpande, S., Porter, J., et al. (2006). Private practitioners’ communications with patients around HIV testing in Pune, India. Health Policy Plan, 21 (5), 343-352. de Bruyn, T. (2002). HIV-related stigma and discrimination--the epidemic continues. . Can HIV AIDS Policy Law Rev, 7 (1), 8-14. Durkheim, E. (1951). Suicide: A Study in Sociology. Spaulding J, Simpson G, trans. Glencoe, Ill: The Free Press. Gilmore, N. a. M. A. S. (1994). Stigmatization, scapegoating and discrimination in sexually transmitted diseases: overcoming ‘them’ and ‘us’. Soc Sci Med, 39 (9), 1339-1358. Godbole, S., & Mehendale, S. (2005). HIV/AIDS epidemic in India: risk factors, risk behav-

SOCIAL CAPITAL AND STIGMA IN CHENNAI iour & strategies for prevention & control. Indian J Med Res, 121 (4), 356-368. Gregson, S., Terceira, N., Mushati, P., Nyamukapa, C., & Campbell, C. (2004). Community group participation: can it help young women to avoid HIV? An exploratory study of social capital and school education in rural Zimbabwe. Soc Sci Med, 58 (11), 2119-2132. Herek, G. M., J.P. Capitanio, and K.F. Widaman. (2003). Stigma, social risk, and health policy: public attitudes toward HIV surveillance policies and the social construction of illness. Health Psychology, 22 (5), 533-540. Holtgrave D.R., and Crosby, R. (2003). Social capital, poverty, and income in- equality as predictors of gonorrhoea, syphilis, chlamydia and AIDS case rates in the United States. Sex Transm Infect, 79, 62-64. Indian Network for People with HIV/AIDS. (2009). http://www.inpplus.net/projects.html Accessed on Jan 19, 2009. Jana, S., Basu, I., Rotheram-Borus, M. J., & Newman, P. A. (2004). The Sonagachi Project: a sustainable community intervention program. AIDS Educ Prev, 16 (5), 405-414. Kawachi, I. (2006). Commentary: social capital and health: making the connections one step at a time. Int J Epidemiol, 35 (4), 989-993. Keusch, G. T., J. Wilentz, and A. Kleinman, (2006). Stigma and global health: developing a research agenda. . Lancet, 367 (9509), 525-527. Kielmann, K., Deshmukh, D., Deshpande, S., Datye, V., Porter, J., & Rangan, S. (2005). Managing uncertainty around HIV/AIDS in an urban setting: private medical providers and their patients in Pune, India. Soc Sci Med, 61 (7), 1540-1550. Kulkarni S.S., & Kulkarni, A.S. (2002). How HIV/ AIDS patient dare to suicide. International Conference on AIDS. Barcelona Jul 7-12; 14: abstract no. ThPeE7906. Kumarasamy, N., Safren, S. A., Raminani, S. R., Pickard, R., James, R., Krishnan, A. K., et al. (2005). Barriers and facilitators to antiretroviral medication adherence among patients with HIV in Chennai, India: a qualitative study. AIDS Patient Care STDS, 19 (8), 526-537. Lawyers’ Collective. (1998). Indian JudgmentsSupreme Court of India (Right to Marry) http://www.lawyerscollective.org/hiv-aids/ activities/legal-services-sc-right-to-marry. Accessed on April 20, 2009 Link, B.G. and J.C. Phelan. (2001). Conceptualizing stigma. Annual Review of Sociology 27, 363-385. Lomas, J. (1998). Social capital and health: implications for public health and epidemiology.

249

Soc Sci Med, 47 (9), 1181-1188. Madru, N. (2003). Stigma and HIV: does the social response affect the natural course of the epidemic? Assoc Nurses AIDS Care., 14 (5), 39-48. Mawar N, S. S., Pandit, A, Mahajan U (2005). The third phase of HIV pandemic: Social consequences of HIV/AIDS stigma & discrimination & future needs. Indian J Med Res, 122, 471-484. Mohseni, M., & Lindstrom, M. (2008). Social capital, political trust and self rated-health: a population-based study in southern Sweden. Scand J Public Health, 36 (1), 28-34. Msisha, W. M., Kapiga, S. H., Earls, F. J., & Subramanian, S. V. (2008). Place matters: multilevel investigation of HIV distribution in Tanzania. Aids, 22 (6), 741-748. Muntaner, C., Lynch, J., & Smith, G. D. (2001). Social capital, disorganized communities, and the third way: understanding the retreat from structural inequalities in epidemiology and public health. Int J Health Serv, 31 (2), 213-237. Muhr T. Atlas.ti: Knowledge Workbench., 1998. Muthen, B. (2007). Mplus. www.statmodel.com Accessed November 14, 2007. National AIDS Control Organization, N. (2008). HIV Sentinel Surveillance and HIV Estimation in India 2007: A Technical Brief. Government of India, Ministry of Health and Family Welfare. Ogden, J., & Nyblade, Laura, C. (2005). Common at its core: HIV-related stigma across contexts. . In I. C. f. R. o. Women. (Ed.). Washington, DC: International Center for Research on Women. . Pallikadavath, S., Garda, L., Apte, H., Freedman, J., & Stones, R. W. (2005). HIV/AIDS in rural India: context and health care needs. J Biosoc Sci, 37 (5), 641-655. Panchanadeswaran, S., Johnson, S. C., Sivaram, S., Srikrishnan, A. K., Latkin, C., Bentley, M. E., et al. (2008). Intimate partner violence is as important as client violence in increasing street-based female sex workers’ vulnerability to HIV in India. Int J Drug Policy, 19 (2), 106-112. Parker, R. a. P. A. (2003). HIV and AIDS-related stigma and discrimination: a conceptual framework and implications for action. . Soc Sci Med, 57 (1), 13-24. Pronyk, P. M., Harpham, T., Morison, L. A., Hargreaves, J. R., Kim, J. C., Phetla, G., et al. (2008). Is social capital associated with HIV risk in rural South Africa? Soc Sci Med, 66 (9), 1999-2010. Putnam R. Bowling Alone: The Collapse and Revival of American Community. New York,

250 NY: Simon & Schuster; 2000. Rogers,A., Meundi, A., Ambikadevi, A., Rao, A., Shetty, P., Antony, J. et al. (2006). AIDS Patient Care and STDs, 20(11), 803-811. Roth, J., Krishnan, S. P., & Bunch, E. (2001). Barriers to condom use: results from a study in Mumbai (Bombay), India. AIDS Educ Prev, 13 (1), 65-77. Rothenberg, R., Muth, S. Q., Malone, S., Potterat, J. J., & Woodhouse, D. E. (2005). Social and geographic distance in HIV risk. Sex Transm Dis, 32 (8), 506-512. Rwemisisi, J., Wolff, B., Coutinho, A., Grosskurth, H., & Whitworth, J. (2008). ‘What if they ask how I got it?’ Dilemmas of disclosing parental HIV status and testing children for HIV in Uganda. Health Policy Plan, 23 (1), 36-42. Sheikh, K., Rangan, S., Kielmann, K., Deshpande, S., Datye, V., & Porter, J. (2005). Private providers and HIV testing in Pune, India: challenges and opportunities. AIDS Care, 17 (6), 757-766. Singh G, D. A., Khale M, Kulkarni G, Vasudevan S, et al. (2008). Low utilization of HIV testing during pregnancy. What are the barriers to HIV testing for women in rural India. . J Acquir Immune Defic Syndr, 47, 248-252. Sivaram S, Johnson S, Bentley ME, Srikrishnan AK, Latkin CA, Go VF, Solomon S, Celentano DD. (2007). Exploring “wine shops” as a venue for HIV prevention interventions in urban India. J Urban Health, 84 (4):563-76. Sivaram, S., Johnson, S., Bentley, M. E., Go, V. F., Latkin, C., Srikrishnan, A. K., et al. (2005). Sexual health promotion in Chennai, India: key role of communication among social networks. Health Promot Int, 20 (4), 327-333. Solomon, S., Chakraborty, A., & Yepthomi, R. D. (2004). A review of the HIV epidemic in India. AIDS Educ Prev, 16 (3 Suppl A), 155-169. Steinbrook, R. (2007). HIV/AIDS in India: A complex epidemic. New England Journal of Medicine, 356, 1089-1093. Steward, W. T., Herek, G. M., Ramakrishna, J., Bharat, S., Chandy, S., Wrubel, J., et al. (2008). HIV-related stigma: Adapting a theoretical framework for use in India. Soc Sci Med, 67 (8), 1225-1235. Swendeman, D., Rotheram-Borus, M., Comulada, S., Weiss, R., & Ramos M.E. (2006). Pre-

SIVARAM ET AL. dictors of HIV-related stigma among young people living with HIV. Health Psychology, 25(4), 502-509. Taraphdar, P. D. A. S., B (2007). Disclosure among people living with HIV/AIDS. Indian Journal of Community Medicine, 32 (4), 280-282. Thomas, B. E., et al. (2005). How stigmatizing is Stigma in the life of people living with HIV: A study on HIV positive individuals from Chennai, South India. AIDS Care, 17 (7), 795-801 Uma, S., Balakrishnan, P., Murugavel, K. G., Srikrishnan, A. K., Kumarasamy, N., Cecelia, J. A., et al. (2005). Bacterial vaginosis in female sex workers in Chennai, India. Sex Health, 2 (4), 261-262. UNAIDS. (2008). Global Report on HIV/AIDS, 2008. In UNAIDS (Ed.). Van Rompay, K. K., Madhivanan, P., Rafiq, M., Krupp, K., Chakrapani, V., & Selvam, D. (2008). Empowering the people: Development of an HIV peer education model for low literacy rural communities in India. Hum Resour Health, 6, 6. Welshman, J. (2006). Searching for social capital: historical perspectives on health, poverty and culture. J R Soc Health, 126 (6), 268-274. Wolitski, R. J., Pals, S. L., Kidder, D. P., Courtenay-Quirk, C., & Holtgrave, D. R. (2008). The Effects of HIV Stigma on Health, Disclosure of HIV Status, and Risk Behavior of Homeless and Unstably Housed Persons Living with HIV. AIDS Behav. World Bank (2009). Social Capital Assessment Tool. Household Questionnaire. http:// siteresources.worldbank.org/INTSOCIALCAPITAL/Resources/Social-Capital-Assessment-Tool--SOCAT-/annex1C.pdf Accessed on April 21, 2009. Yamaoka, K. (2008). Social capital and health and well-being in East Asia: a population-based study. Soc Sci Med, 66 (4), 885-899. Zelaya, C. E., Sivaram, S., Johnson, S. C., Srikrishnan, A. K., Solomon, S., & Celentano, D. D. (2008). HIV/AIDS Stigma: Reliability and Validity of a New Measurement Instrument in Chennai, India. AIDS Behav, 12 (5), 781-788.