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AIDS Care
Psychological and Socio-medical Aspects of
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A meta-analysis of disclosure of one's HIV-positive
status, stigma and social support
Rachel Smith
a
; Kelly Rossetto
b
; Brittany L. Peterson
b
a
Department of Communication Arts & Sciences, Pennsylvania State University,
Pennsylvania, US
b
Department of Communication Studies, University of Texas at Austin, Austin, US
First Published on: 17 June 2008
To cite this Article: Smith, Rachel, Rossetto, Kelly and Peterson, Brittany L. (2008)
'A meta-analysis of disclosure of one's HIV-positive status, stigma and social support', AIDS Care,
To link to this article: DOI: 10.1080/09540120801926977
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A meta-analysis of disclosure of one’s HIV-positive status, stigma and social support
Dr. Rachel Smith
a
*, Kelly Rossetto
b
, and Brittany L. Peterson
b
a
Department of Communication Arts & Sciences, Pennsylvania State University, Pennsylvania, US;
b
Department of
Communication Studies, University of Texas at Austin, Austin, US
(Received 17 June 2007; final version received 16 January 2008)
This study provides an analysis of the relationships among perceived stigma, reported disclosure and perceived
social support for those living with HIV. The meta-analytic summary of 21 studies (4104 participants) showed, as
predicted, a positive, heterogeneous correlation between disclosure and social support (r´ .159), a negative,
heterogeneous correlation between stigma and social support (r´ .344) and a negative, homogenous
correlation between stigma and disclosure (r´ .189). The heterogeneity of the first two relationships indicates
the presence of moderators, which may include participants’ age and publications’ year.
Keywords: disclosure; stigma; social support; meta-analysis
Introduction
One may need support to address a given health
condition. When the health concern is HIV or AIDS,
however, people may not receive help from their
families, neighbors, friends and co-workers (UN-
AIDS, 2002). The decision to disclose one’s status
could involve careful consideration of the social
consequences of disclosure (Huber, 1996), such as
stigma, rejection and banishment (Fredriksson &
Kanabus, 2004). Indeed, it is not clear as to whether
disclosing one’s HIV status to more people actually
engenders more social support (Petrak, Doyle, Smith,
Skinner, & Hedge, 2001). It has been 20 years since
the first reported diagnosis of HIV, and during this
time a small literature has grown on the relationship
between disclosure, social support and stigma. When
a literature develops, it can help to look for relation-
ships that may appear across studies in order to better
develop campaigns and interventions. This paper uses
meta-analysis to examine the relationship among
perceptions of an HIV/AIDS stigma, reported dis-
closures of one’s HIV status and perceptions of social
support.
Literature review
Within the past decade, many health agencies have
argued that stigma is the leading impediment to
health promotion, treatment and support (e.g. US
Department of Health and Human Services, 1999;
World Health Organization [WHO], 2001), but it is
also the least understood (e.g. UNAIDS, 2004). HIV/
AIDS presents a relevant example. Since its discov-
ery, HIV has inspired social responses of compassion
for and solidarity with as well as anxiety about, and
prejudice against, those living with HIV (Frediksson
& Kanabus, 2004). For example, those living with
HIV experienced rejection by their loved ones and
banishment from their community, illustrating that
‘‘HIV and AIDS are as much about social phenom-
ena as they are about biological and medical con-
cerns’’ (Frediksson & Kanabus, 2004, p. 1).
HIV/AIDS researchers have paid some attention
to social context, given that it shapes and situates
personal values, beliefs and behaviors that impact
HIV-prevention behaviors, such as increasing use of
condoms or HIV tests. In contrast, few studies have
explored behaviors such as caring for those living
with HIV or adopting AIDS-orphaned children (e.g.
Smith, Ferrara, & Witte, 2007). Garnering assistance
may not be easy, because it may necessitate the
disclosure of one’s HIV-status.
HIV and disclosure
I’ve told my closest sister and we discussed how much
further this should go. We thought that they (sib-
lings) don’t all need to know ... (Interview of HIV-
positive man: Katz, 1997, p. 140)
Self-disclosure is defined as informing others of
someone’s HIV status by the person or a third-party
with or without consent (World Health Organization,
1999). Regardless of the discloser, disclosing HIV-
positive status to others supposedly allows people to
garner social support (Emlet, 2006; Serovich, 2001).
This social support, in turn, would allow them
to cope with health concerns by increasing their
*Corresponding author. Email: ras57@psu.edu
AIDS Care
2008, 110, iFirst article
ISSN 0954-0121 print/ISSN 1360-0451 online
# 2008 Taylor & Francis
DOI: 10.1080/09540120801926977
http://www.informaworld.com
Downloaded By: [Smith, Rachel] At: 15:08 18 June 2008
perceived efficacy to enact healthy behaviors (e.g.
Cohen et al., 1998). Although perceived efficacy
exhibits positive impacts on people’s health and
wellbeing across a variety of health domains, includ-
ing drug use (Hays & Ellickson, 1990), sexual activity
(Jemmott et al., 1991), smoking (Lawrance & Ru-
binson, 1986) and weight loss and diet (Baranowski et
al., 1990). Delineating the first link, between disclo-
sure and social support, remains to be studied more
rigorously.
Disclosure can be good or bad as it both causes
and alleviates tension (Holt et al., 1998; Idowu, 2004;
Landau & York, 2004). Self-disclosure is a way to
receive social support (Emlet, 2006; Serovich, 2001),
but it also allows for the possibility of stigma and
shame (Landau & York, 2004). People living with
HIV can have difficulty maintaining close personal
relationships because of stress associated with the
diseases (Haas, 1999) and rejection from close ties
(Brashers, Neidig, & Goldsmith, 2004).
As such, when people learn that they test posi-
tively for HIV, they may want their HIV-positive
status to remain secret. Brashers, Neidig and Gold-
smith (2004) noted that people living with HIV
through their experience with stigma and rejection
feared disclosing their HIV status and felt less
confidence in their ability to elicit support. Disclo-
sure, however, may result in better mental and
physical health (Pennebaker, Colder, & Sharp,
1990). In fact, it is generally thought that keeping a
secret may stress one’s body (Pennebaker, Hughes, &
O’Heeron, 1987). Concealing one’s HIV-positive
status can wear away at the secret-holder (Imber-
Black, 1998) and this wear may ultimately encourage
the secret-holder to disclose his/her diagnosis to
someone else. Furthermore, disclosing ones’ status
may be the only way to justify their need for support.
HIV and social support
Social support is defined as perceptions of, or experi-
ence with, other people providing emotional support
(Idowu, 2004; Josephson, 1997; Simoni, Demas, Ma-
son, Drossman, & Davis, 2000; Weiss, 2003), material
(Josephson, 1997) or tangible (Simoni et al., 2000)
support and health-related support (Greenberg, 2000;
Simoni et al., 2000). Further, social support comprises
cognitive and behavioral factors, such as perceived
availability of support (Berger, Ferrans, & Lashley,
2001; Greenberg, 2000; Idowu, 2004; Josephson, 1997;
Kalichman, DiMarco, Austin, Webster, & DiFonzo,
2003; Kimberly & Serovich, 1996; Perry et al., 1994;
Vira, 2003). It may also include validation or accep-
tance (Berger et al., 2001; Greenberg, 2000; Josephson,
1997; Kalichman, DiMarco, Austin, Webster, &
DiFonzo, 2003; Kimberly & Serovich, 1996), subjec-
tive social integration or individuals’ perceptions of
involvement in their communities (Berger et al., 2001;
Greenberg, 2000; Josephson, 1997) and objective social
integration or individuals’ actual involvement in com-
munity activity (Greenberg, 2000; Josephson, 1997).
Those living with HIV may feel the need to spare
their networks from the cognitive and emotional
strain associated with providing support. These
concerns may be realistic. Potential supporters some-
times avoid interactions with those needing support
because the situation and the need are too emotion-
ally taxing (Brashers, Neidig, & Goldsmith, 2004)
and complicated by uncertainty about the condition
and how to provide support (Brown & Powell-Cope,
1991). Indeed, one-in-five adults in the US still fears
people living with HIV (Herek, Capitanio, & Wida-
man, 2002). In a study in eastern China, 56% of those
surveyed were unwilling to be friends with someone
living with HIV and 73% felt that people living with
HIV should be isolated (Lee et al., 2005). Thus, while
people living with HIV may need and seek support,
others may not be ready or willing to provide it
because of the uncertainty and stigma surrounding
the condition.
HIV and stigma
Stigma is defined as a simplified, standardized image
of the disgrace of certain people that is held in
common by the community at large (e.g. Goffman,
1963). Stigma communication, then, is the messages
spread through communities to teach its members to
recognize the disgraced (i.e. recognizing stigmata)
and to react to them accordingly (Smith, 2007). Thus,
stigma is a social construction (e.g. Brown, Macin-
tyre, & Trujillo, 2003; Dovidio, Major, & Crocker,
2000) shared among members of a community
seeking to protect itself from threats to its effective
functioning. Consequently, stigma messages rely
largely on communication to learn of offenders’
discrediting marks and to enact devaluation of
offenders (Smith, 2007).
A person marked with a stigma ‘‘is thus reduced
in our minds from a whole and usual person to a
tainted, discounted one ... We believe the person
with a stigma is not quite human. On this assumption
we exercise varieties of discrimination, through which
we effectively, if often unthinkingly, reduce his life
chances’’ (Goffman, 1963, pp. 35). People gain
advantages if they ‘‘selectively avoid, reject or elim-
inate other individuals whose behaviors are disruptive
to group organization’’ (Brewer & Carporael, 1990,
p. 240). Indeed, people stand or sit farther away from
stigmatized persons (e.g. Mooney, Cohn, & Swift,
2 R. Smith et al.
Downloaded By: [Smith, Rachel] At: 15:08 18 June 2008
1992) so as to avoid having the community extend
them a ‘‘courtesy stigma’’ (Goffman, 1963).
With this in mind, AIDS stigma is defined as
‘‘prejudice, discounting, discrediting and discrimina-
tion directed at people perceived to have AIDS or
HIV, their loved ones and associates and the groups
and communities with which they are affiliated’’
(Herek & Capitanio, 1998, p. 232; Herek, 1990;
Herek & Glunt, 1988). Out of a sense of protection,
people living with HIV may be reticent to disclose
their status to others if they risk their own or others’
rejection. Keeping these kinds of secrets is associated
with personal distress and loneliness for those in a
stigmatized group and those associated with them
(Wiener, Battles, & Heilman, 2000). Indeed, expect-
ing and fearing rejection due to stigma is associated
with more constricted social networks (Link et al.,
1989), low self-esteem (Wright, Gonfrein, & Owens,
2000) and strained conversations with potential
stigmatizers (Farina et al., 1968).
The stigmatized often employ similar coping
strategies as those who face any form of psychological
challenges (for a review, see Dovidio et al., 2000) such
as secrecy, denial, deception and social withdrawal in
order to avoid rejection (Markowitz, 1998). They also
compensate, avoid anxiety ridden situations and make
social comparisons (Miller & Major, 2000). They may
avoid admitting or even considering their risk for an
event associated with shame or deviation from a
moral code (Weinstein, 1988). The fear of being found
out by the community, of disgracing one’s self and
family and of mistreatment by healthcare workers are
related indirectly to health seeking intentions (Smith
& Morrison, 2006) and behaviors (Chandra, Deepthi-
varma, & Manjula, 2003; Herek, 2002). Furthermore,
social avoidance or rejection can then, of course,
hinder peoples’ psychological and physical health.
Those anticipating ostracism experience increased
stress and anxiety (Cioffi, 2000).
Interrelationships
Scholars assert that a strong relationship exists
between social support and disclosure of one’s HIV-
positive status. People must disclose their status to
receive support (Hays, McKusick, & Coates, 1993;
Huber, 1996; Kalichman, DiMarco, Austin, Webster,
& DiFonzo, 2003; Kimberly & Serovich, 1996; Leask,
Elford, Bor, Miller, & Johnson, 1997; Marks et al.,
1992). As Huber (1996) notes, people cannot actually
receive support until disclosure occurs. On the other
hand, individuals must perceive that social support
will exist before they make the decision to disclose
(Kimberly, Serovich, & Greene, 1995). Consequently,
people with greater social support will have a greater
intention to disclose their HIV status (Landau &
York, 2004). Regardless of causal order, the literature
suggests a positive relationship between disclosure
and social support, leading to the following hypoth-
esis: Disclosing one’s HIV-positive status will corre-
late positively with social support.
Researchers assert that the relationship between
stigma and self-disclosure presents a dilemma for
individuals living with HIV (Derlega, Winstead, &
Folk-Barron, 1997; Letteney, 1997). If individuals
choose disclosure, then they no longer have to
struggle with concealing a secret but may be exposed
to stigmatized reactions (Alonzo & Reynolds, 1995;
Chesney & Smith, 1999). Serovich’s (2001) conse-
quence theory states that individuals will choose to
share information if the rewards outweigh the costs of
disclosure (Idowu, 2004; Petrak, 2001; Serovich &
Mosack, 2003; Vira, 2003 (study 1), 2003 (study 2);
Weiss, 2003). Stigma may present such a cost. Indeed,
scholars attribute a lack of self-disclosure to such
things as awareness (Clark, Lindner, Armistead, &
Austin, 2003) and expectation of stigma (Landau &
York, 2004; Lee & Rotheram-Borus, 2002). The
following hypothesis is proposed: Greater HIV
stigma will correlate negatively with disclosure of
one’s HIV-positive status.
As stated earlier, because potential supporters
may fear (Herek, Capitanio, & Widaman, 2002) and
encourage the isolation (Lee et al., 2005) of people
living with HIV, they are likely to be less inclined to
provide support. Additionally, the risk of courtesy
stigma (Goffman, 1963) could discourage supporting
people living with HIV. Therefore, people living with
HIV who perceive high levels of stigma are likely also
perceiving less available support (in addition to the
actual decrease in support available). Thus, the
following hypothesis is proposed: HIV stigma will
correlate negatively with social support.
This investigation uses meta-analysis because it
provides several distinct advantages. A meta-analysis
combines the results from many studies to generate
confidence in claims because they replicate across
studies (Hunter, Schmidt, & Jackson, 1982). As such,
it creates a much larger sample from which to test
findings, making results less vulnerable to confound-
ing by sampling error (Hunter & Schmidt, 1990;
Rosenthal, 1991) and Type II error, which is argued
as a concern in other literature reviews (Dindia &
Allen, 1992). A meta-analysis also formally tests if the
relationship between two given variables is homo-
genous or not. Finding a heterogeneous relationship
indicates that mediators exist among studies that alter
the findings and can provide important guidance for
theory and research development (Hunter & Schmidt,
1990). From the previous literature review, we expect
AIDS Care 3
Downloaded By: [Smith, Rachel] At: 15:08 18 June 2008
to find a positive relationship between disclosure and
social support, and negative relationships among
stigma and disclosure and stigma and social support.
Methods
Search procedure
Six databases (Communication & Mass Media Com-
plete, Dissertation Abstracts International, Goo-
gleScholar, MEDLINE, PsycINFO and Social
Sciences Citation Index) were searched from Novem-
ber, 2006 until February, 2007. The following key-
words were included in the search: HIV, AIDS,
stigma, social support, support and disclosure.
Our search yielded 56 manuscripts. All articles
considered for the analysis had to meet the following
inclusion criteria: (1) include measures of at least two
of the three variables and (2) report the association
between these two variables.
Many of the manuscripts were qualitative in
nature and did not provide statistical information
(n9). Other manuscripts were excluded because
they did not measure more than one of the three
variables (n 8) or did not provide the necessary
statistical information from which to yield an effect
size (n15) or if they described non-personal HIV
disclosures, such as a parent disclosing to their child
that the child has HIV or intentions to disclose (n
5). One study (Vira, 2003) had two separate samples
and both were included separately in the meta-
analysis, yielding 21 studies for analysis.
The effect size indicator for this analysis was the
Pearson correlation coefficient (Rosenthal, 1991).
When available, the correlation coefficient was
directly extracted from the manuscript. If the correla-
tion was not reported, other statistics were converted
into correlations (Hunter & Schmidt, 1990).
Study attributes
Within each article, information about the sample
was also extracted. Specifically, gender, age, country
and years since HIV diagnosis were included. The
year of publication was also noted, see Table 1.
Results
Meta-analysis
The effects for each of the three correlations were
estimated using the weighted averaging procedure
(Hunter & Schmidt, 1990) with fixed effects, see
Table 2. The study estimates were not corrected for
attenuation because few publications provided relia-
bility scores. Twenty-one studies met inclusion cri-
teria. They were published in peer-reviewed journals
(n13) and dissertations (n 7) between the years of
1994 and 2007.
1
As can be seen in Table 1, the studies
present some diversity in gender, age and country.
Disclosure and social support. Hypothesis 1 proposed
that disclosing one’s HIV-positive status would
correlate positively with social support. The average,
weighted observed correlation between disclosure and
social support was positive, r .159, k 14, n 2253
(95%CI.044, .283). The correlation is signifi-
cantly different from zero, z (2251)5.67, pB.05.
Hypothesis 1 was consistent with the observed data.
The variance around the weighted correlation (i.e.
heterogeneity) was statistically significant, Q (k 14,
N2253)220.28, pB.05, indicating that mediators
exist among studies.
Stigma and disclosure. Hypothesis 2 proposed that
greater HIV stigma would correlate negatively with
disclosure of one’s HIV-positive status. The average,
weighted observed correlation between stigma and
disclosure was negative, r.189, k8, n1325.
The correlation is significantly different from zero, z
(1323)6.87, pB.05. Hypothesis 2 was consistent
with the observed data. The variance around the
weighted correlation (i.e. heterogeneity) was not
statistically significant, Q (k8,N1325)15.09,
p.057, indicating that homogeneity in this relation-
ship among studies. This evidence does not support
concerns that different researchers’ methodological
choices in studying stigma and disclosure exerted an
influence on their relationship.
Stigma and social support. Hypothesis 3 proposed
that greater HIV stigma would correlate negatively
with more social support. The average, weighted,
observed correlation between stigma and social sup-
port was negative, r .344, k6, n 1849. The
correlation is significantly different from zero, z
(1847)14.80, p B.05. Hypothesis 3 was consis-
tent with the observed data. The variance around the
weighted correlation (i.e. heterogeneity) was statisti-
cally significant, Q (k 6,N1849)61.12, p B.05,
indicating that mediators exist among studies.
Post hoc analysis. A post-hoc analysis was conducted
to explore the impact of study characteristics, includ-
ing gender distribution, age and publication year, on
the weighted correlations between social support and
stigma, and social support and disclosure. Although
the significance tests are underpowered, the explora-
tion can be instructive as it provides an indication of
possible trends. Only correlations with alpha levels of
.20 and lower are reported. The positive relationship
between disclosure and social support was stronger
for studies with older participants, r (12) .42, p
.14, but unrelated to publication year or gender. The
negative relationship between stigma and disclosure
was unrelated to publication year, age or gender. The
4 R. Smith et al.
Downloaded By: [Smith, Rachel] At: 15:08 18 June 2008
Table 1. Characteristics of studies included in the meta-analysis.
First author HIVD Age Gender (%) Race (%) Country Design Sampling Region Type
Berger 4.2 30.0 19 68 W US Cross Conv National PRJ
Clark n/a 44.5 100 100 AF US Cross Conv South PRJ
Emlet n/a 36.6 0 70 W US Cross Conv NW PRJ
Greenberg n/a 36.0 0 62 W US Cross Conv NE DISS
Idowu n/a 37.0 100 100 AF US Cross Conv NE/MW DISS
Kalichman 8.6 43.5 30 72 AF US Cross Conv n/a PRJ
Katz n/a 34.0 100 66 AF US Cross Conv NE PRJ
Kimberely 4.01 38.0 16 68 W US Cross Conv SW PRJ
Lee n/a 37.7 82 45 H US Cross Conv NE PRJ
Letteney n/a 42.1 100 40 AF US Cross Conv NE DISS
Mak 5.02 40.0 15 HK Cross Conv PRJ
Perry n/a 37.7 0 74 W US Cross Conv NE PRJ
Petrak 5.08 37.4 17 87 W UK Cross Conv PRJ
Serovich n/a 14.7 0 74 W US Cross Conv MW PRJ
Shellmer n/a 30.0 39 US DISS
Simbayi 2.7 39.7 60 68 AF SA Cross Conv PRJ
Simoni 4.09 23.0 100 46 AF US Cross Conv NE PRJ
Swendeman n/a 37.7 21 44 H US Cross Conv National PRJ
Vira 3.33 37.7 0 I Long Conv DISS
Vira 7 37.0 0 68 W US Long Conv MW DISS
Weiss 7.6 (5.4) 30.0 2.6 59 W US Long Conv West DISS
Notes. Gender percent female. W White. AFAfrican American. HHispanic. US United States. UKUnited Kingdom. SASouth Africa. IIndia. All studies used self-reports to
gather information about all three constructs. They also used convenience sampling. All samples include respondents that have been diagnoses as HIV-positive. HIVDYears since HIV-positive
diagnosis (standard deviations, when available, are presented in the parentheses). PRJPeer reviewed journal article. DISS Dissertation. Crosscross-sectional design. Longlongitudinal
design. Region describes area in the US.
AIDS Care 5
Downloaded By: [Smith, Rachel] At: 15:08 18 June 2008
negative relationship between stigma and social
support was stronger for more recent studies, r
(6).63, p .18, but unaffected by gender and age.
Discussion
This study provided a meta-analytic test of the
relationships between stigma, disclosure and social
support for those living with HIV. From the litera-
ture surrounding these issues, we suggested three
hypotheses that all received empirical support.
Disclosure and social support
When people living with HIV disclosed their status to
more people, they reported more social support. That
said, this relationship (.159) was small (Cohen, 1988),
the confidence interval around it included zero and it
was not stable among studies. These findings coincide
with the general conflict within the literature (e.g.
Emlet, 2006; Holt et al., 1998; Idowu, 2004; Landau
& York, 2004; Serovich, 2001) surrounding the
relationship between disclosure and social support.
One of the reasons for the conflicting findings
may result from varying measurements of social
support. In the studies used in this meta-analysis,
social support included measures of the size of
support networks (e.g. Emlet, 2006; Lee &
Rotheram-Borus, 2002; Petrak et al., 2001) and the
sense of belonging to a network (e.g. Kimberly &
Serovich, 1996). Social support measures also showed
differences in sources of social support (e.g. Shellmer,
2005) or relationship-specific support (e.g. Kalich-
man et al., 2003; Simoni et al., 2000), frequency of
support (e.g. Emlet, 2006; Simoni et al., 2000) and
satisfaction with support (e.g. Petrak et al., 2001;
Simoni et al., 2000).
These differences could explain the inconsistent
findings. Emmerick (2006) argues that different types
of people and resources should better meet different
types of social support goals. For example, it is
possible that social support increased because certain
types of disclosure targets provide different types of
support (e.g. integration) or it could be due to the
strength of multiple sources or ‘‘weak ties’’ (e.g.
colleagues or neighbors). The weak tie argument, in
brief, claims that although intimate sources can
provide emotional support, weak ties can connect
people to a more diverse and wider range of resources
(Granovetter, 1973). Thus, these studies could have
captured the notion that weak ties put people living
Table 2. Effect sizes included in the meta-analysis.
First author Year nr
st, d
r
st, ss
r
ss, d
Berger 2001 318 0.540
Clark 2003 50 0.447
Emlet 2006 88 0.189 0.286 0.265
Greenberg 2000 119 0.170
Idowu 2004 446 0.13 0.090
Kalichman 2003 331 0.070
Katz 2005 105 0.390
Kimberely 1996 77 0.010
Lee 2002 301 0.270 0.160
Letteney 1997 88 0.260 0.200
Mak 2007 119 0.380
Perry 1994 129 0.240
Petrak 2001 95 0.230
Serovich 2003 49 0.310
Shellmer 2005 41 0.062
Simbayi 2007 1063 0.290
Simoni 2000 143 0.470
Swendeman 2006 147 0.024
Vira 2003a 100 0.398
Vira 2003b 139 0.058
Weiss 2003 156 0.24 0.29 0.060
Total n 4104 .189 .344 .159
95%CI .114,
.262
.199,
.490
.283, .044
Notes. r
st.d
correlation between stigma and disclosure. r
st. ss
correlation between stigma and social support. r
ss.d
correlation between
social support and disclosure. Correlations are presented between variables.
6 R. Smith et al.
Downloaded By: [Smith, Rachel] At: 15:08 18 June 2008
with HIV in connection with the ‘‘right people’’ who
could provide more social support or a sense of
integration into the community that was less possible
for family or sexual partners to provide.
Additionally, in our post-hoc analysis, studies
with older participants exhibited a stronger relation-
ship between disclosure and social support. Although
the finding must be viewed as tentative due to issues
of power, it may shed some light on previous findings
that increases in age related to decreases in disclosure
(Shehan et al., 2005). It is possible that over the
lifespan, perceptions of social support play a more
important role in decisions to disclose one’s status.
The impact of stigma
The other two hypotheses focused on the relationship
between stigma and social support and between
stigma and disclosure. When people living with HIV
felt that HIV carried a greater stigma, they reported
less social support ( .344). This relationship was
moderate (Cohen, 1988); however, it was inconsistent
among studies. The instability may result from
different conceptualizations of social support noted
in the previous section.
Also as predicted, greater HIV stigma corre-
sponded to fewer disclosures of one’s HIV status.
Although this relationship (.189) was small (Co-
hen, 1988), it was stable between studies. It is possible
that the stability in this relationship resulted from the
samples included in this meta-analysis; most reported
living with HIV for many years. Consequently, these
participants may differentiate less between perceived,
enacted or anticipated stigma than they might have
earlier in their experiences with HIV. It is also
possible that the stability resulted from their shared
methods; all participants were asked to recall their
disclosures and their stigma perceptions.
One may note that although age and gender did
not modify these relationships, more recent studies
found stronger negative relationships between stigma
and social support. It is possible that recent studies
represent people who have lived with HIV for longer
and a society that has reacted to HIV for longer.
Time may have also allowed those living with HIV to
perceive stigma of HIV from anticipated as well as
experienced reactions. Due to the combination of
anticipated and experienced stigma over time, re-
spondents may be less able or less likely to seek
support.
Limitations
These findings should be interpreted with caution
because of the small pool of studies and the primary
representation of US respondents. Second, the
weighted correlations cannot be used to test for
causality.
Practical implications
For future campaign designers, these findings suggest
that stigma was associated with both fewer disclo-
sures and less social support. Until the stigma
surrounding HIV is reduced, both disclosure and
social support may be compromised. Recent research
(e.g. Smith, 2007) sheds some light on what commu-
nication content could generate and support stigmas.
Reducing the existing stigma surrounding HIV and
providing another way to discuss it without inducing
stigmas may, in the long term, influence how often
those living with HIV disclose their status to others,
allowing them the opportunity to gain support and
limit further transmission. Now, 25 years after the
first reported cases of HIV, we can tentatively claim
that reported disclosure correlates positively to social
support and stigma correlates negatively to both
reported disclosure and social support.
Note
1. To include dissertations helps us to avoid concerns only
using peer-reviewed journal articles, in which studies
without strong effects often do not make it into
publication (i.e. the ‘‘file drawer’’ syndrome). Multiple
scholars (e.g. Hunter & Schmidt, 2004) argue that
eliminating studies from a meta-analysis, even if they
have methodological inadequacies, is not as desirable or
reasonable as one might think. Eliminating studies often
provides a greater bias than methodological weakness
(Hunter & Schmidt, 2004). Hunter and Schmidt (2004)
suggest that one should determine if the variation across
studies can be accounted for by sampling error before
eliminating studies.
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