HIV stigma and fears surrounding the disease pose a challenge for public health interventions, particularly those that target pregnant women. In order to reduce stigma and improve the lives of vulnerable populations, researchers have recognized a need to integrate different types of support at various levels. To better inform HIV interventions, the current study draws on social-ecological and evolutionary theories of reproduction to predict stigma and fear of contracting HIV among pregnant women in South India. The aims of this study were twofold: compare the social-ecological model to a modified maternal-fetal protection model and test a combined model that included strong predictors from each model. The study took place in 2008–2011 in Mysore District, Karnataka, India. Using data from a cross-sectional survey and biological indicators of health, we statistically modeled social-ecological variables representing individual, interpersonal, and community/institutional levels. Participants were 645 pregnant women. The social-ecological and combined models were the best-fitting models for HIV-related stigma, and the combined model was the best fit for HIV-related fear. Our findings suggest that combining reproductive life history factors along with individual, interpersonal, and community/institutional factors are significant indicators of HIV-related stigma and fear. Results of this study support a multifaceted approach to intervention development for HIV-related stigma and fear. The combined model in this study can be used as a predictive model for future research focused on HIV stigma and fear, with the intent that dual consideration of social-ecological and evolutionary theories will improve public health communication efforts.
This is a preview of subscription content, log in to check access.
Buy single article
Instant access to the full article PDF.
Price includes VAT for USA
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
This is the net price. Taxes to be calculated in checkout.
Aagaard, K., Riehle, K., Ma, J., Segata, N., Mistretta, T.-A., Coarfa, C., Raza, S., Rosenbaum, S., Van den Veyver, I., Milosavljevic, A., Gevers, D., Huttenhower, C., Petrosino, J., & Versalovic, J. (2012). A metagenomic approach to characterization of the vaginal microbiome signature in pregnancy. PLoS One, 7(6), e36466.
Baidya, M., Gopichandran, V., & Kosalram, K. (2014). Patient-physician trust among adults of rural Tamil Nadu: A community-based survey. Journal of Postgraduate Medicine, 60(1), 21–26.
Blackmore, E. R., Moynihan, J. A., Rubinow, D. R., Pressman, E. K., Gilchrist, M., & O’Connor, T. G. (2011). Psychiatric symptoms and proinflammatory cytokines in pregnancy. Psychosomatic Medicine, 73(8), 656–663.
Brashers, D. E., Neidig, J. L., & Goldsmith, D. J. (2004). Social support and the management of uncertainty for people living with HIV or AIDS. Health Communication, 16(3), 305–331.
Brown, L., Macintyre, K., & Trujillo, L. (2003). Interventions to reduce HIV/AIDS stigma: What have we learned? AIDS Education and Prevention, 15(1), 49–69.
Cameron, A. C., & Trivedi, P. K. (2005). Microeconometrics: Methods and applications. Cambridge: Cambridge University Press.
Census of India. (2011). Census of India: census data online. Retrieved from http://censusindia.gov.in/2011-common/censusdataonline.html?drpQuick=anddrpQuickSelect=andq=jenukuruba.
Chisholm, J. S., Quinlivan, J. A., Petersen, R. W., & Coall, D. A. (2005). Early stress predicts age at menarche and first birth, adult attachment, and expected lifespan. Human Nature, 16(3), 233–265.
Corrigan, P. (2004). How stigma interferes with mental health care. American Psychologist, 59(7), 614–625.
Cumberland, P., Shulman, C. E., Maple, C., A, P., Bulmer, J. N., Dorman, E. K., Kawuondo, K., Marsh, K., & Cutts, F. T. (2007). Maternal HIV infection and placental malaria reduce transplacental antibody transfer and tetanus antibody levels in newborns in Kenya. The Journal of Infectious Diseases, 196(4), 550–557.
D’Souza, M. S., Karkada, S. N., Somayaji, G., & Venkatesaperumal, R. (2013). Women’s well-being and reproductive health in Indian mining community: Need for empowerment. Reproductive Health, 10, 24.
Derlega, V. J., Winstead, B. A., Greene, K., Serovich, J., & Elwood, W. N. (2002). Perceived HIV-related stigma and HIV disclosure to relationship partners after finding out about the seropositive diagnosis. Journal of Health Psychology, 7(4), 415–432.
Drake, A., Wagner, A., Richardson, B., & John-Stewart, G. (2014). Incident HIV during pregnancy and postpartum and risk of mother-to-child HIV transmission: A systematic review and meta-analysis. PLoS Medicine, 11. Retrieved from http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001608.
Ekstrand, M. L., Ramakrishna, J., Bharat, S., & Heylen, E. (2013). Prevalence and drivers of HIV stigma among health providers in urban India: Implications for interventions. Journal of the International AIDS Society, 16(3, Suppl 2), 18717.
Fessler, D. M. T. (2002). Reproductive immunosuppression and diet: An evolutionary perspective on pregnancy sickness and meat consumption. Current Anthropology, 43(1), 19–61.
Fessler, D. M. T., Eng, S. J., & Navarrete, C. D. (2005). Elevated disgust sensitivity in the first trimester of pregnancy. Evolution and Human Behavior, 26(4), 344–351.
Flaxman, S. M., & Sherman, P. W. (2000). Morning sickness: A mechanism for protecting mother and embryo. Quarterly Review of Biology, 75(2), 113–148.
Georgiev, A. V., Kuzawa, C. W., & McDade, T. W. (2016). Early developmental exposures shape trade-offs between acquired and innate immunity in humans. Evolution, Medicine, and Public Health, 2016(1), 256–269.
Gibbs, C. M., Wendt, A., Peters, S., & Hogue, C. J. (2012). The impact of early age at first childbirth on maternal and infant health. Paediatric and Perinatal Epidemiology, 26(s1), 259–284.
Go, V. F., Sethulakshmi, C. J., Bentley, M. E., Sivaram, S., Srikrishnan, A. K., Solomon, S., & Celentano, D. D. (2003). When HIV-prevention messages and gender norms clash: The impact of domestic violence on women’s HIV risk in slums of Chennai, India. AIDS and Behavior, 7(3), 263–272.
Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. New York: Simon & Schuster.
Gopichandran, V., & Chetlapalli, S. K. (2013). Factors influencing trust in doctors: A community segmentation strategy for quality improvement in healthcare. BMJ Open, 3(12), e004115.
Gray, R. H., Li, X., Kigozi, G., Serwadda, D., Brahmbhatt, H., Wabwire-Mangen, F., Nalugoda, F., Kiddugavu, M., Sewankambo, N., Quinn, T. C., Reynolds, S. J., & Wawer, M. J. (2005). Increased risk of incident HIV during pregnancy in Rakai, Uganda: A prospective study. The Lancet, 366(9492), 1182–1188.
Hamilton, W. D. (1964). The genetical evolution of social behaviour, II. Journal of Theoretical Biology, 7(1), 17–52.
Hatzenbuehler, M. L., Phelan, J. C., & Link, B. G. (2013). Stigma as a fundamental cause of population health inequalities. American Journal of Public Health, 103(5), 813–821.
Henrich, J., & Henrich, N. (2010). The evolution of cultural adaptations: Fijian food taboos protect against dangerous marine toxins. Proceedings of the Royal Society of London B: Biological Sciences, 277(1701), 3715–3724.
Herek, G. M., & Capitanio, J. P. (1994). Conspiracies, contagion, and compassion: Trust and public reactions to AIDS. AIDS Education and Prevention, 6(4), 365–375.
Herek, G. M., & Capitanio, J. P. (1997). AIDS stigma and contact with persons with AIDS: Effects of direct and vicarious contact. Journal of Applied Social Psychology, 27(1), 1–36.
Herek, G. M., Capitanio, J. P., & Widaman, K. F. (2002). HIV-related stigma and knowledge in the United States: Prevalence and trends 1991–1999. American Journal of Public Health, 92(3), 371–377.
Hewlett, B. S., & Hewlett, B. L. (2007). Ebola, culture and politics: The anthropology of an emerging disease. Cengage Learning.
Hook, E. B. (1978). Dietary cravings and aversions during pregnancy. The American Journal of Clinical Nutrition, 31(8), 1355–1362.
Jones, B. C., Hahn, A. C., Fisher, C. I., Wang, H., Kandrik, M., Lee, A. J., Tybur, J. M., & DeBruine, L. M. (2018). Hormonal correlates of pathogen disgust: Testing the compensatory prophylaxis hypothesis. Evolution and Human Behavior, 39(2), 166–169.
Kerrigan, D., Moreno, L., Rosario, S., Gomez, B., Jerez, H., Barrington, C., Weiss, E., & Sweat, M. (2006). Environmental–structural interventions to reduce HIV/STI risk among female sex workers in the Dominican Republic. American Journal of Public Health, 96(1), 120–125.
Kojima, N., Krupp, K., Ravi, K., Gowda, S., Jaykrishna, P., Leonardson-Placek, C., Siddhaiah, A., Bristow, C., Arun, A., Klausner, J., & Madhivanan, P. (2017). Implementing and sustaining a mobile medical clinic for prenatal care and sexually transmitted infection prevention in rural Mysore, India. BMC Infectious Diseases, 17, 189.
Kourtis, A. P., Read, J. S., & Jamieson, D. J. (2014). Pregnancy and infection. New England Journal of Medicine, 370(23), 2211–2218.
Kumar, V., & Choudhry, V. P. (2010). Iron deficiency and infection. The Indian Journal of Pediatrics, 77(7), 789–793.
Kurzban, R., & Leary, M. R. (2001). Evolutionary origins of stigmatization: The functions of social exclusion. Psychological Bulletin, 127(2), 187–208.
Larios, S. E., Lozada, R., Strathdee, S. A., Semple, S. J., Roesch, S., Staines, H., Orozovich, P., Fraga, M., Amaro, H., de la Torre, A., Magis-Rodriguez, C., & Patterson, T. L. (2009). An exploration of contextual factors that influence HIV risk in female sex workers in Mexico: The social ecological model applied to HIV risk behaviors. AIDS Care, 21(10), 1335–1342.
Lieberman, D., Tybur, J., & Latner, J. (2012). Disgust sensitivity, obesity stigma, and gender: Contamination psychology predicts weight bias for women, not men. Obesity, 20(9), 1803–1814.
Mahendra, V. S., Gilborn, L., Bharat, S., Mudoi, R., Gupta, I., George, B., Samson, L., Daly, C., & Pulerwitz, J. (2007). Understanding and measuring AIDS-related settings: A developing country perspective. SAHARA-J: Journal of Social Aspects of HIV/AIDS, 4(2), 616–625. Retrieved from https://www.ajol.info/index.php/saharaj/article/view/30125.
McLeroy, K. R., Bibeau, D., Steckler, A., & Glanz, K. (1988). An ecological perspective on health promotion programs. Health Education Quarterly, 15(4), 351–377.
Mikolić, A. (2016). Disgust and facial expression recognition across the menstrual cycle. Human Ethology Bulletin, 1, 31–60.
Miller, E. M. (2010). Maternal hemoglobin depletion in a settled northern Kenyan pastoral population. American Journal of Human Biology, 22(6), 768–774. https://doi.org/10.1002/ajhb.21078.
Miller, E. M. (2016). The reproductive ecology of iron in women. American Journal of Physical Anthropology, 159(S61), 172–195.
Navarrete, C. D., Fessler, D. M. T., & Eng, S. J. (2007). Elevated ethnocentrism in the first trimester of pregnancy. Evolution and Human Behavior, 28(1), 60–65.
Nettle, D., Coall, D. A., & Dickins, T. E. (2011). Early-life conditions and age at first pregnancy in British women. Proceedings of the Royal Society of London B: Biological Sciences, 278(1712), 1721–1727.
Norgan, N. G. (1997). The beneficial effects of body fat and adipose tissue in humans. International Journal of Obesity, 21(9), 738–746.
Osamor, P. E., & Grady, C. (2016). Women’s autonomy in health care decision-making in developing countries: A synthesis of the literature. International Journal of Women’s Health, 8, 191–202.
Park, J. H., Schaller, M., & Crandall, C. S. (2007). Pathogen-avoidance mechanisms and the stigmatization of obese people. Evolution and Human Behavior, 28(6), 410–414.
Parker, R., & Aggleton, P. (2003). HIV and AIDS-related stigma and discrimination: A conceptual framework and implications for action. Social Science and Medicine, 57(1), 13–24.
Parker, B. J., Barribeau, S. M., Laughton, A. M., de Roode, J. C., & Gerardo, N. M. (2011). Non-immunological defense in an evolutionary framework. Trends in Ecology and Evolution, 26(5), 242–248.
Placek, C. D. (2017). A test of four evolutionary hypotheses of pregnancy food cravings: Evidence for the social bargaining model. Royal Society Open Science, 4(10), 170243.
Placek, C. D., & Hagen, E. H. (2013). A test of three hypotheses of pica and amylophagy among pregnant women in Tamil Nadu, India. American Journal of Human Biology, 25(6), 803–813.
Placek, C. D., & Hagen, E. H. (2015). Fetal protection: The roles of social learning and innate food aversions in South India. Human Nature, 26(3), 255–276.
Placek, C. D., & Madhivanan, P. (2017). Exploring the perceptions of pregnancy loss between two South Indian women: A pilot study. Public Health, 148, 9–12.
Placek, C. D., Madhivanan, P., & Hagen, E. H. (2017). Innate food aversions and culturally transmitted food taboos in pregnant women in rural Southwest India: Separate systems to protect the fetus? Evolution and Human Behavior, 38(6), 714–728.
Price, V., & Hsu, M.-L. (1992). Public opinion about AIDS policies: The role of misinformation and attitudes toward homosexuals. The Public Opinion Quarterly, 56(1), 29–52.
Profet, M. (1988). The evolution of pregnancy sickness as protection to the embryo against Pleistocene teratogens. Evolutionary Theory, 8(3), 177–190.
Profet, M. (1995). Pregnancy sickness as adaptation: A deterrent to maternal ingestion of teratogens. In J. H. Barkow, L. Cosmides, & J. Tooby (Eds.), The adapted mind: Evolutionary psychology and the generation of culture (pp. 327–366). New York: Oxford University Press.
Puhl, R. M., & Latner, J. D. (2007). Stigma, obesity, and the health of the nation’s children. Psychological Bulletin, 133(4), 557–580.
Qiao, S., Li, X., Zhou, Y., Shen, Z., Tang, Z., & Stanton, B. (2015). Factors influencing the decision-making of parental HIV disclosure: A socio-ecological approach. AIDS, 29(1). Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4618838/.
Racicot, K., Kwon, J.-Y., Aldo, P., Silasi, M., & Mor, G. (2014). Understanding the complexity of the immune system during pregnancy. American Journal of Reproductive Immunology, 72(2), 107–116.
Rastogi, S., Kapur, S., Salhan, S., & Mittal, A. (1999). Chlamydia trachomatis infection in pregnancy: Risk factor for an adverse outcome. British Journal of Biomedical Science; London, 56(2), 94–98.
Sandelowski, M., Lambe, C., & Barroso, J. (2004). Stigma in HIV-positive women. Journal of Nursing Scholarship, 36(2), 122–128.
Saute, F., Menendez, C., Mayor, A., Aponte, J., Gomez-Olive, X., Dgedge, M., & Alonso, P. (2002). Malaria in pregnancy in rural Mozambique: The role of parity, submicroscopic and multiple plasmodium falciparum infections. Tropical Medicine and International Health, 7(1), 19–28.
Sayles, J. N., Wong, M. D., Kinsler, J. J., Martins, D., & Cunningham, W. E. (2009). The association of stigma with self-reported access to medical care and antiretroviral therapy adherence in persons living with HIV/AIDS. Journal of General Internal Medicine, 24(10), 1101.
Schaller, M., & Park, J. H. (2011). The behavioral immune system (and why it matters). Current Directions in Psychological Science, 20(2), 99–103.
Senarath, U., & Gunawardena, N. S. (2009). Women’s autonomy in decision making for health care in South Asia. Asia Pacific Journal of Public Health, 21(2), 137–143.
Sengupta, S., Banks, B., Jonas, D., Miles, M. S., & Smith, G. C. (2011). HIV interventions to reduce HIV/AIDS stigma: A systematic review. AIDS and Behavior, 15(6), 1075–1087.
Shulman, C. E., Marshall, T., Dorman, E. K., Bulmer, J. N., Cutts, F., Peshu, N., & Marsh, K. (2001). Malaria in pregnancy: Adverse effects on haemoglobin levels and birthweight in primigravidae and multigravidae. Tropical Medicine and International Health, 6(10), 770–778.
Silverman, J. G., Decker, M. R., Saggurti, N., Balaiah, D., & Raj, A. (2008). Intimate partner violence and HIV infection among married Indian women. Journal of the American Medical Association, 300(6), 703–710.
Smith, R., Rossetto, K., & Peterson, B. (2008). A meta-analysis of disclosure of one’s HIV-positive status, stigma and social support. AIDS Care, 20(10). Retrieved from https://www.tandfonline.com/doi/abs/10.1080/09540120801926977.
Stangl, A. L., Lloyd, J. K., Brady, L. M., Holland, C. E., & Baral, S. (2013). A systematic review of interventions to reduce HIV-related stigma and discrimination from 2002 to 2013: How far have we come? Journal of the International AIDS Society, 16(3). https://doi.org/10.7448/ias.16.3.18734.
Steketee, R. W. (2003). Pregnancy, nutrition and parasitic diseases. The Journal of Nutrition, 133(5), 1661S–1667S.
Stephenson, R. (2007). Human immunodeficiency virus and domestic violence: The sleeping giants of Indian health? Indian Journal of Medical Sciences, 61(5). Retrieved from http://go.galegroup.com/ps/i.do?p=AONEandsw=wandissn=00195359andv=2.1andit=randid=GALE%7CA163159785andsid=googleScholarandlinkaccess=abs.
Steward, W. T., Herek, G. M., Ramakrishna, J., Bharat, S., Chandy, S., Wrubel, J., & Ekstrand, M. L. (2008). HIV-related stigma: Adapting a theoretical framework for use in India. Social Science and Medicine (1982), 67(8), 1225–1235.
Stokols, D. (1996). Translating social ecological theory into guidelines for community health promotion. American Journal of Health Promotion, 10(4), 282–298.
Taha, T., Dallabetta, G., Hoover, D., Chiphangwi, J., Mtimavalye, L., Liomba, G., Newton, I., Kumwenda, N. I., & Miotti, P. (1998). Trends of HIV-1 and sexually transmitted diseases among pregnant and postpartum women in urban Malawi. AIDS, 12(2), 197–203.
Timmers, A. D., Bossio, J. A., & Chivers, M. L. (2018). Disgust, sexual cues, and the prophylaxis hypothesis. Evolutionary Psychological Science, 4(2), 179–190.
Trivers, R. L. (1971). The evolution of reciprocal altruism. Quarterly Review of Biology, 46(1), 35–57.
Turan, J. M., & Nyblade, L. (2013). HIV-related stigma as a barrier to achievement of global PMTCT and maternal health goals: A review of the evidence. AIDS and Behavior, 17(7), 2528–2539.
UNAIDS. (2003). UNAIDS fact sheet on stigma and discrimination. Retrieved from http://data.unaids.org/publications/fact-sheets03/fs_stigma_discrimination_en.pdf.
Van Hollen, C. (2007). Navigating HIV, pregnancy, and childbearing in South India: Pragmatics and constraints in women’s decision making. Medical Anthropology, 26(1), 7–52.
Young, A. G., & Pike, I. L. (2012). A biocultural framework for examining maternal cravings and aversions among pastoral women in East Africa. Ecology of Food and Nutrition, 51(5), 444–462.
Zou, J., Yamanaka, Y., John, M., Watt, M., Ostermann, J., & Thielman, N. (2009). Religion and HIV in Tanzania: Influence of religious beliefs on HIV stigma, disclosure, and treatment attitudes. BMC Public Health, 9, 75.
The authors would like to thank study participants, research assistants, and PHRII staff for their assistance in the study design and data collection process. Thank you to James Jones, Edward Hagen, and Marsha Quinlan for comments and suggestions on earlier iterations of this manuscript. The Kisalaya mobile clinic project was funded by the Elizabeth Glaser Pediatric AIDS Foundation International Leadership Award to Purnima Madhivanan. Caitlyn Placek was supported by the Global Health Equity Scholars Training Grant from Fogarty International Center at National Institutes of Health (R25 TW009338). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Placek, C.D., Nishimura, H., Hudanick, N. et al. Reframing HIV Stigma and Fear. Hum Nat 30, 1–22 (2019). https://doi.org/10.1007/s12110-018-09335-z
- Social-ecological model
- Maternal-fetal protection
- HIV/AIDS stigma
- Evolutionary medicine