The Knowledge Paradox: An Inverted U-Shaped Association between HIV Knowledge and Stigma among Older Men in Sichuan Province, Southwest China

Zhihua Ye¹Jin Peng¹Shu Liang²Yuan Li³Jiang Yuan³Ruixi Zhang¹Jia He¹Shuangru Li¹Bihui Yang³Xiaochun Zhang¹YI YANG^1*

• ¹School of Management, Chengdu University of Chinese Medicine, Cheng Du, China
• ²Institute for the Prevention and Control of Sexually Transmitted Diseases and AIDS, Sichuan Center for Disease Control and Prevention, Chengdu, China
• ³School of Public Health, Chengdu University of Chinese Medicine, Cheng Du, China

Background: Older men (≥50 years) in China face elevated HIV infection risks, yet HIV stigma remains a significant barrier to prevention. Although HIV knowledge is frequently assumed to reduce stigma, the evidence is inconsistent. This cross-sectional study examined the association between HIV knowledge and stigma among older men in Southwest China, specifically investigating potential nonlinear patterns within sociocultural contexts. Methods: We conducted a cross-sectional survey from July to August 2023 in three high-HIV-burden areas of Sichuan Province. Using a multi-stage cluster random sampling design, 841 HIV-negative men completed structured interviews. All analyses incorporated survey weights to ensure representativeness. HIV knowledge was assessed via a validated 8-item scale (score range 0-8). Stigma was measured with an adapted 10-item scale (score range 10-50). Survey-weighted hierarchical linear regression was used to test linear and quadratic associations adjusted for covariates. Survey-weighted segmented regression analyses confirmed robustness. Results: The weighted mean HIV knowledge score was 4.39 (SD = 2.13), and the weighted mean stigma score was 31.78 (SD = 5.60). Regression analysis revealed an inverted U-shaped association. Stigma initially increased with increasing knowledge (linear β = 1.71, p < 0.001), peaked at a knowledge score of 4.14, and subsequently decreased with increasing knowledge gain (quadratic β = -0.21, p < 0.001). Robustness analyses confirmed differential knowledge-stigma associations across knowledge levels (interaction β = -1.47, p < 0.001). Lower stigma was independently associated with nonrural household registration (β = -2.39, p < 0.001), access to a greater number of HIV health education channels (2-3 types: β = -1.07, p < 0.01; ≥4 types: β = -2.29, p < 0.05), and more liberal sexual attitudes (β = -0.19, p<0.001). Social support and socioeconomic status were not associated. Conclusions: Among older Chinese men, HIV knowledge has an inverted U-shaped association with stigma. Initial knowledge acquisition correlates with heightened stigma, potentially reflecting sociocultural interpretations of fragmented information. Only beyond a specific threshold does further knowledge correlate with reduced stigma. Interventions may need to be staged or tailored based on individuals’ existing knowledge levels, addressing both the nonlinear knowledge-stigma dynamic and underlying sociocultural norms.