Vicious Circle of Perceived Stigma, Enacted Stigma and Depressive Symptoms Among Children Affected by HIV/AIDS in China


Previous research has found a deleterious impact of stigma on the mental health of children affected by HIV/AIDS. Little is known about the longitudinal relationship of stigma and children’s mental health. This study explores the longitudinal reciprocal effects of depressive symptoms and stigma, specifically enacted stigma and perceived stigma, among children affected by HIV/AIDS aged 6–12. Longitudinal data were collected from 272 children orphaned by AIDS and 249 children of HIV-positive parents in rural China. Cross-lagged panel analysis was conducted in the study. Results showed that the autoregressive effects were stable for depressive symptoms, perceived stigma and enacted stigma suggesting the substantially stable individual differences over time. The cross-lagged effects indicated a vicious circle among the three variables in an order of enacted stigma → depressive symptom → perceived stigma → enacted stigma. The possibility of employing equal constraints on cross-lagged paths suggested that the cross-lagged effects were repeatable over time. The dynamic interplay of enacted stigma, perceived stigma and depressive symptoms suggests the need of a multilevel intervention in stigma reduction programming to promote mental health of children affected by HIV/AIDS.

This is a preview of subscription content, log in to check access.

Fig. 1
Fig. 2
Fig. 3


  1. 1.

    UNICEF. Statistics by Area/HIV/AIDS. 2013 [cited 2013 Jan 15, 2013]; Available from:

  2. 2.

    Chi P, Li X. Impact of parental HIV/AIDS on children’s psychological well-being: a systematic review of global literature. AIDS Behav. 2013;17(7):2554–74.

    PubMed  Article  Google Scholar 

  3. 3.

    Crocker J, Major B, Steele R. Social stigma. In: Gilbert DT, Fiske ST, Lindzey G, editors. The handbook of social psychology. New York: McGraw Hill; 1998. p. 504–33.

    Google Scholar 

  4. 4.

    Goffman E. Stigma: notes on the management of spoiled identity. New York: Simon & Schuster Inc.; 1963.

    Google Scholar 

  5. 5.

    Steward WT, Herek GM, Ramakrishna J, Bharat S, Chandy S, Wrubel J, et al. HIV-related stigma: adapting a theoretical framework for use in India. Soc Sci Med. 2008;67(8):1225–35.

    PubMed Central  PubMed  Article  Google Scholar 

  6. 6.

    Herek GM, Capitanio JP, Widaman KF. HIV-related stigma and knowledge in the United States: prevalence and trends, 1991–1999. Am J Public Health. 2002;92(3):371–7.

    PubMed Central  PubMed  Article  Google Scholar 

  7. 7.

    Herek GM, Gillis JR, Cogan JC. Internalized stigma among sexual minority adults: insights from a social psychological perspective. J Couns Psychol. 2009;56(1):32.

    Article  Google Scholar 

  8. 8.

    Parker R, Aggleton P. HIV and AIDS-related stigma and discrimination: a conceptual framework and implications for action. Soc Sci Med. 2003;57(1):13–24.

    PubMed  Article  Google Scholar 

  9. 9.

    Brown L, Macintyre K, Trujillo L. Interventions to reduce HIV/AIDS stigma: what have we learned? AIDS Educ Prev. 2003;15(1):49–69.

    PubMed  Article  Google Scholar 

  10. 10.

    Campbell C, Skovdal M, Mupambireyi Z, Madanhire C, Robertson L, Nyamukapa CA, et al. Can AIDS stigma be reduced to poverty stigma? exploring Zimbabwean children’s representations of poverty and AIDS. Child Care Health Dev. 2012;38(5):732–42.

    PubMed  Article  Google Scholar 

  11. 11.

    Gausset Q, Mogensen HO, Yameogo WME, Berthé A, Konaté B. The ambivalence of stigma and the double-edged sword of HIV/AIDS intervention in Burkina Faso. Soc Sci Med. 2012;74(7):1037–44.

    PubMed  Article  Google Scholar 

  12. 12.

    Logie C, Gadalla T. Meta-analysis of health and demographic correlates of stigma towards people living with HIV. AIDS Care. 2009;21(6):742–53.

    CAS  PubMed  Article  Google Scholar 

  13. 13.

    Mak WWS, Poon CYM, Pun LYK, Cheung SF. Meta-analysis of stigma and mental health. Soc Sci Med. 2007;65(2):245–61.

    PubMed  Article  Google Scholar 

  14. 14.

    Surkan PJ, Mukherjee JS, Williams DR, Eustache E, Louis E, Jean-Paul T, et al. Perceived discrimination and stigma toward children affected by HIV/AIDS and their HIV-positive caregivers in central Haiti. AIDS Care. 2010;22(7):803–15.

    PubMed Central  PubMed  Article  Google Scholar 

  15. 15.

    Nyamukapa CA, Gregson S, Wambe M, Mushore P, Lopman B, Mupambireyi Z, et al. Causes and consequences of psychological distress among orphans in eastern Zimbabwe. AIDS Care. 2010;22(8):988–96.

    CAS  PubMed Central  PubMed  Article  Google Scholar 

  16. 16.

    Zhao J, Li X, Fang X, Hong Y, Zhao G, Lin X, et al. Stigma Against Children Affected by AIDS (SACAA): psychometric evaluation of a brief measurement scale. AIDS Behav. 2010;14(6):1302–12.

    PubMed  Article  Google Scholar 

  17. 17.

    Boyes ME, Cluver LD. Relationships among HIV/AIDS orphanhood, stigma, and symptoms of anxiety and depression in south african youth a longitudinal investigation using a path analysis framework. Clin Psychol Sci. 2013;1(3):323–30.

    Article  Google Scholar 

  18. 18.

    Cluver LD, Orkin M. Cumulative risk and AIDS-orphanhood: interactions of stigma, bullying and poverty on child mental health in South Africa. Soc Sci Med. 2009;69(8):1186–93.

    PubMed  Article  Google Scholar 

  19. 19.

    Lin X, Zhao G, Li X, Stanton B, Zhang L, Hong Y, et al. Perceived HIV stigma among children in a high HIV-prevalence area in central China: beyond the parental HIV-related illness and death. AIDS Care. 2010;22(5):545–55.

    PubMed Central  PubMed  Article  Google Scholar 

  20. 20.

    Zhao G, Li X, Zhao J, Zhang L, Stanton B. Relative importance of various measures of HIV-related stigma in predicting psychological outcomes among children affected by HIV. Community Ment Health J. 2012;48(3):275–83 Epub 2011/06/18.

    PubMed Central  PubMed  Article  Google Scholar 

  21. 21.

    Scambler G. Epilepsy. London: Routledge; 1989.

    Google Scholar 

  22. 22.

    Liamputtong P, Haritavorn N, Kiatying-Angsulee N. HIV and AIDS, stigma and AIDS support groups: perspectives from women living with HIV and AIDS in central Thailand. Soc Sci Med. 2009;69(6):862–8.

    PubMed  Article  Google Scholar 

  23. 23.

    Letteney S, LaPorte HH. Deconstructing stigma: perceptions of HIV-seropositive mothers and their disclosure to children. Soc Work Health Care. 2004;38(3):105–23.

    PubMed  Article  Google Scholar 

  24. 24.

    Maman S, Abler L, Parker L, Lane T, Chirowodza A, Ntogwisangu J, et al. A comparison of HIV stigma and discrimination in five international sites: the influence of care and treatment resources in high prevalence settings. Soc Sci Med. 2009;68(12):2271–8.

    PubMed Central  PubMed  Article  Google Scholar 

  25. 25.

    Smith R, Rossetto K, Peterson BL. A meta-analysis of disclosure of one’s HIV-positive status, stigma and social support. AIDS Care. 2008;20(10):1266–75.

    PubMed  Article  Google Scholar 

  26. 26.

    Uys L, Chirwa M, Kohi T, Greeff M, Naidoo J, Makoae L, et al. Evaluation of a health setting-based stigma intervention in five African countries. AIDS Patient Care and STDS. 2009;23(12):1059–66.

    PubMed Central  PubMed  Article  Google Scholar 

  27. 27.

    Whetten K, Ostermann J, Whetten RA, Pence BW, O’Donnell K, Messer LC, et al. A comparison of the wellbeing of orphans and abandoned children Ages 6–12 in institutional and community-based care settings in 5 less wealthy nations. PLoS One. 2009;4(12):e8169.

    PubMed Central  PubMed  Article  Google Scholar 

  28. 28.

    Li L, Lee SJ, Thammawijaya P, Jiraphongsa C, Rotheram-Borus MJ. Stigma, social support, and depression among people living with HIV in Thailand. AIDS Care. 2009;21(8):1007–13.

    PubMed Central  PubMed  Article  Google Scholar 

  29. 29.

    Simbayi LC, Kalichman S, Strebel A, Cloete A, Henda N, Mqeketo A. Internalized stigma, discrimination, and depression among men and women living with HIV/AIDS in Cape Town South Africa. Soc Sci Med. 2007;64(9):1823–31.

    PubMed  Article  Google Scholar 

  30. 30.

    He Z, Ji C. Nutritional status, psychological well-being and the quality of life of AIDS orphans in rural Henan Province China. Trop Med Int Health. 2007;12(10):1180–90.

    PubMed  Article  Google Scholar 

  31. 31.

    West A, Wedgwood K. Children affected by AIDS, orphans and impact mitigation in China. In: Kaufman J, Kleinman A, Saich T, editors. AIDS and social policy in China. Cambridge: Harvard University Asia Center; 2006. p. 243–64.

    Google Scholar 

  32. 32.

    UNAIDS, UNICEF, USAID. Children on the brink 2004: A joint report of new orphan, estimates and a framework for Action. New York: 2004.

  33. 33.

    Xu T, Yan Z, Duan S, Wang C, Rou K, Wu Z. Psychosocial well-being of children in HIV/AIDS-affected families in southwest China: a qualitative study. J Child Fam Stud. 2009;18(1):21–30.

    Article  Google Scholar 

  34. 34.

    Li X, Barnett D, Fang X, Lin X, Zhao G, Zhao J, et al. Lifetime incidence of traumatic events and mental health among children affected by HIV/AIDS in rural China. J Clin Child Adolesc Psychol. 2009;38(5):731–44.

    PubMed  Article  Google Scholar 

  35. 35.

    Dowdney L. Annotation: childhood bereavement following parental death. J Child Psychol Psychiatry. 2000;41(7):819–30.

    CAS  PubMed  Article  Google Scholar 

  36. 36.

    Fendrich M, Wessiman MM, Warner V. Screening for depressive disorder in children and adolescents: validating the Center for Epidemiologic Studies Depression Scale for Children. Am J Epidemiol. 1990;131(3):538–51.

    CAS  PubMed  Google Scholar 

  37. 37.

    Wang X. Rating scales for mental health (Chinese Journal of Mental Health Supplement). Beijing: Chinese Association of Mental Health; 1993.

    Google Scholar 

  38. 38.

    Muthén LK, Muthén BO. Mplus user’s guide: Fifth edition. Los angeles: Author; 2007.

    Google Scholar 

  39. 39.

    Quintana SM, Maxwell SE. Implications of recent developments in structural equation modeling for counseling psychology. Couns Psychol. 1999;27(4):485–527.

    Article  Google Scholar 

  40. 40.

    Mukolo A, Heflinger CA, Wallston KA. The stigma of childhood mental disorders: a conceptual framework. J Am Acad Child Adolesc Psychiatry. 2010;49(2):92–103.

    PubMed Central  PubMed  Google Scholar 

  41. 41.

    Green SE. The impact of stigma on maternal attitudes toward placement of children with disabilities in residential care facilities. Soc Sci Med. 2004;59(4):799–812.

    PubMed  Article  Google Scholar 

  42. 42.

    Bronfenbrenner U. The ecology of human development: experiments by nature and design. Cambridge: Harvard University Press; 1979.

    Google Scholar 

  43. 43.

    Ungar M, Ghazinour M, Richter J. Annual research review: what is resilience within the social ecology of human development? J Child Psychol Psychiatry. 2013;54(4):348–66.

    PubMed  Article  Google Scholar 

Download references


This study reported in this article was supported by NIH Research Grant from the National Institute of Mental health (R01MH76488) and the National Institute of Nursing Research (R01NR13466). The content of the article is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Mental health and the National Institute of Nursing Research. The authors wish to thank Joanne Zwemer for help in preparing the manuscript.

Author information



Corresponding author

Correspondence to Peilian Chi.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Chi, P., Li, X., Zhao, J. et al. Vicious Circle of Perceived Stigma, Enacted Stigma and Depressive Symptoms Among Children Affected by HIV/AIDS in China. AIDS Behav 18, 1054–1062 (2014).

Download citation


  • Children
  • Enacted stigma
  • Perceived stigma
  • Depressive symptoms
  • Cross-lagged
  • Longitudinal