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People Living with HIV Stigma Index 2.0 Bastrop, Caldwell, Hays, Travis, & Williamson Counties, Texas, 2026 November 16, 2026 Rick Astray-Caneda III, MPA, PhD President, Friends of the David Powell Clinic Michelle Osorio, MPH HIV Funding Specialist, Austin Public Health Agenda 01 Report Overview and Approach 02 What We Heard: Key Findings 03 Emerging Opportunities for Action 04 Discussion and next steps Report Overview and Approach What is the Stigma Index? • Global community-led assessment documenting how stigma and discrimination affects the lives of people living with HIV (PLHIV) and how these experiences intersect over time o Since 2008, the Stigma Index has been implemented in more than 100 countries, engaging over 100,000 PLHIV worldwide o The Stigma Index 2.0 was developed in 2018 to reflect changes in the HIV epidemic and global response • Grounded in four core principles: Capacity Building Accountabilit y & Ownership Equality & Diversity Advocacy- Oriented Action • Community-led approach ensures that the experiences and voices of PLHIV remain at the center of documenting and addressing HIV stigma REPORT OVERVIEW Austin TGA Implementation • Implemented across the Austin Transitional Grant Area (TGA)* from 2024 – 2026 • Proposal developed by the Social Determinants of Health & Equity Workgroup, Fast-Track Cities • Partners: o PLHIV-led Steering Committee o Austin Public Health o Cardea Services (research partner) *Austin TGA includes Travis, Williamson, Hays, Bastrop, and Caldwell counties, eligible for federal funding under Ryan White HIV/AIDS program. Central Texas PLHIV Stigma Index Process Formed from Fast Track Cities in July 2023 Shepherded by core team including one PLHIV Steering Committee formed in July 2024 (five PLHIV + five status neutral) Interviews started August 2025 Recruitment • Recruitment strategies: In-person recruitment at HIV clinic (David Powell Clinic), flyers, posters, social media, word of mouth, referrals from community organizations, and trusted community networks • Incentives: o Participants received $100 (two $50 gift cards) per interview o Interviewers received $125 per interview • Interviewers: PLHIV, ages 20 – 70, fluent in English or bilingual English and Spanish • Format: In-person interviews were conducted in private, participant-centered locations and lasted approximately 60 to 90 minutes Slide courtesy of Austin Public Health Participant Demographics • 113 people interviewed • Gender (N=113) o Male (73.5%) o Female (20.4%) o Transgender (<5%) o Do not identify as male, female, or transgender (<5%) • Race and Ethnicity (N=54) o White (33.3%) o Black/African American (31.5%) o Latino/Hispanic (20.4%) o Multiracial (14.8%) o Asian (0%) o American Indian/Alaska Native (0%) • Age (N=113) o 18-24 (<5%) o 25-34 (20.4%) o 35-44 (28.3%) o 45-54 (13.3%) o 55+ (37.2%) • County of Residence (N=102) o Travis County (85.0%) o Hays (<5%) o Bastrop (<5%) o Caldwell (0%) o Williamson (<5%) Participant Demographics • Priority Populations o Gay men and men who have sex with men (57.5%) o Transgender people (<5%) o Sex workers of all genders (46.9%) o People who use drugs (58.4%) o People who are unhoused (<5%) • Length of time knowing HIV status o 0-5 years (26%) o 6-9 years (7%) o 10+ years (68%) What We Heard: Key Results & Discussion Key Findings • Support and stigma coexisted: many participants found acceptance after disclosure, yet more than half still reported difficulty disclosing or hiding their HIV status. • Stigma influenced relationships and social participation, contributing to isolation, reduced intimacy, and avoidance of support networks. • Participants described significant emotional impacts, including shame, guilt, lower self- confidence, and challenges forming close relationships. • Stigma affected healthcare decisions, but participants also highlighted actionable solutions, including education, confidentiality protections, U=U awareness, and peer-led support. Disclosure • Participants most often disclosed their HIV status to close contacts: o Friends (75.2%) o Family members (60.2%) o Spouses or partners (50.4%) o Neighbors (47.8%) o Children (20.4%) • 34 participants told their partners; 2 did not • Participants disclosed less often to employers, coworkers, and other community contacts • Disclosure to close contacts was largely positive, with 83.2% calling it a positive experience, and 84.0% reporting support • Disclosure to acquaintances was more mixed, with responses split between positive (54.9%) and some less positive experiences (28.3%) • Many participants reported that disclosure became easier over time (78.7%), though some continued to find it difficult (18.6%) Disclosure • Some participants reported experiences of HIV status being disclosed without their consent by: o Family members (23%) o Friends (14.2%) o Authority figures such as police, judges, or law enforcement (10.6%) • Smaller proportions (<10%) of participants reported disclosure without consent by neighbors and local leaders (6.2% each), co-workers (5.3%), employers (3.5%), children (2.7%), partners (1.8%), teachers or school administrators (0.9%) Disclosure When seeking care for non-HIV related health needs (N=113) Variables Yes No N/A In the past 12 months, when seeking care for non-HIV related health needs, have you experienced any of the following treatment by health facility staff? Specific question: Telling other people about your HIV status without your consent When you go outside the HIV clinic for general (non-HIV related) health services, do you usually disclose that you are living with HIV? 6 (5.3%) 84 (74.3%) 23 (20.4%) 82 (72.6%) 31 (27.4%) 0 (0.0%) "I had to disclose about any kind of medical issues I had and…when I disclosed that to the HR person he about jumped out of his chair and he goes, “oh my”, and he backed up from the desk, and we used to be on good talking terms...But from that point on, he never spoke to me again…It was awful. Well, it was just awful. I don't know if he ever disclosed it to anybody else, but he started treating me differently. Yeah, he basically shunned me.” Austin TGA Stigma Index 2.0 Participant Externalized Stigma • Most-reported experiences of stigma from others: o Discriminatory remarks or gossip about HIV status: 29.2% within the past year, 23.9% earlier o Family-related gossip or slurs: 13.3% in the past year, 29.2% earlier o Others faced verbal harassment; social, family, or religious exclusion; blackmail; physical harm; workplace bias; and discrimination toward partners or children Internalized Stigma Internalized stigma over the last 12 months (n=113) Feelings of shame and guilt due to HIV status (n=113) Chosen not to attend social gatherings Chosen not to seek social support Avoided going to a clinic or hospital Chosen not to apply for a job(s) 26.5% 19.5% 11.5% 10.6% It is difficult to tell people that I am HIV positive I hide my HIV status from others I am ashamed that I am HIV positive I feel guilty that I am HIV positive I sometimes feel worthless because I am HIV positive Being HIV positive makes me feel dirty 57.5% 54.0% 41.6% 41.6% 35.4% 31.9% Note: All 113 participants responded to this question, with some participants having multiple internalized stigmas Interaction with Health Services Time between diagnosis and starting treatment (N=113) 31.9% 40.7% Immediately - or the same day I was diagnosed >1 day to 1 month (30 days) after being diagnosed >1 month to 6 months after being diagnosed >6 months to 2 years after being diagnosed >2 years after being diagnosed 12.4% 5.3% 8.0% I can't remember 1.8% Interaction with Health Services Reason for hesitating, delaying, or avoiding HIV care or treatment • Stigma shaped participants’ choices around HIV testing, care, and treatment o Over a quarter delayed testing, wary of how others might react to a positive result • For some participants, stigma hindered engagement with HIV testing, care, and treatment o Fearing reactions to a positive result, over a quarter hesitated to test (28.3%) • Why participants delayed or avoided HIV care: o Feeling unready to face HIV infection (37.2%) o Worry that outsiders would learn their status (32.7%) o Fear of mistreatment or unauthorized disclosure by health workers (30.1%) o Disclosure to partners, family, or friends (21.2%); past bad experiences with health workers (19.5%) • Fear of mistreatment or disclosure (30.1%) and prior negative encounters with health workers (19.5%) drove hesitation or delay in starting HIV care Qualitative Responses Themes reflected both the persistence of stigma and the resilience of individuals and communities working to create more informed, respectful, and supportive environments. Top Coded Theme Number of Responses Expanding public education about HIV Directly challenging HIV-related stigma Addressing stigma in healthcare settings Navigating stigma within families Increasing awareness of U=U 45 22 19 15 15 Emerging Opportunities for Action Emerging Opportunities Provide stigma- free, trauma- informed, culturally responsive community training Expand peer-led support, education, and community connection Increase awareness of legal protections and advocacy pathways Launch community-wide HIV education and anti-stigma campaigns Form PLHIV-led community advisory board Conduct additional research to deepen understanding of stigma experiences Improve data systems for tracking stigma and discrimination Discussion and Next Steps "Stand up for somebody. Stop it. Shut them down and tell them that's not the appropriate way to behave with people. Even if you do not understand their sickness, don't mishandle them." Austin TGA Stigma Index 2.0 Participant Summary • Stigma remains a central barrier to safety, dignity, disclosure, and care engagement for PLHIV • Disclosure is more supportive within trusted relationships, but riskier outside close circles • Internalized stigma continues to affect relationships, social participation, and well-being • Treatment access is shaped by more than care availability, including trust, mental health, housing, insurance, medication access, and fear of disclosure • Stigma reduction must be integrated into the broader HIV prevention and care system, not treated as a separate effort • Future advocacy, policy, and programmatic action must be led and informed by PLHIV Next Steps & Discussion • Next Steps • Community engagement to co-create an anti-stigma action plan – starting with four community presentations to define the dimensions of the plan • Seeking publication and presentation outlets in the TGA, state, and country – wherever this information can help • Potential expansion to full 320 interviews • What questions does this leave you with? What more should we cover if we do a Phase II? • What partnerships are needed to move these findings into action? Stay Connected Michelle Osorio, MPH Social Services Funding Specialist HIV Resources Administration Austin Public Health Michelle.Osorio@austintexas.gov Rick Astray-Caneda III, MPA, PhD President Friends of the David Powell Clinic rickyaciii@gmail.com Thank you! Appendix Participant Demographics Gender (n=113) 73.50% 86.80% Male Female 20.40% 13.20% Austin TGA Stigma Index 2.0 2024 Austin TGA Population Note: The Austin TGA 2024 PLHIV population size is 8,298. Participant Demographics Race/Ethnicity (n=54) 33.30% 31.90% 31.50% 19.90% 20.40% 41.30% 5.30% 14.80% White Black/African American Latino/Hispanic Multiracial Asian American Indian/Alaska Native 0% 0% <5% <5% Austin Stigma Index 2.0 2024 Austin TGA Population Notes: The total number of responses may not equal 113 because not every participant completed the interest form that included the questions asking for participant race and ethnicity, and county of residence or participants could decline to answer. The Austin TGA 2024 PLHIV population size is 8,298. Participant Demographics Age (n=113) <5% <5% 18- 24 25- 34 35- 44 45- 54 55+ 20.40% 20.80% 28.30% 25.90% 13.30% 20.2… 30.70% 37.20% Austin Stigma Index 2.0 2024 Austin TGA Population Note: The Austin TGA 2024 PLHIV population size is 8,298. Participant Demographics County of Residence (n=102) Travis Williamson <5% 16.10% Hays <5% 6% Bastrop Caldwell <5% <5… 0% <5% 85.00% 73.70% Austin Stigma Index 2.0 2024 Austin TGA Population Notes: The total number of responses may not equal 113 because not every participant completed the interest form that included the questions asking for participant race and ethnicity, and county of residence or participants could decline to answer. The Austin TGA 2024 PLHIV population size is 8,298.