HIV Clinical Management

Journal of the International

Association of Physicians in AIDS Care
Structuration Theory: A Conceptual 2015, Vol. 14(4) 328-334
ª The Author(s) 2012
Reprints and permission:
Framework for HIV/AIDS Stigma sagepub.com/journalsPermissions.nav
DOI: 10.1177/2325957412463072
jiapac.sagepub.com

Prem Misir, PhD, MPH1

Abstract
The continuing paucity of effective interventions to reduce HIV/AIDS stigma is troubling, given that stigma has long been
recognized as a significant barrier to HIV prevention, treatment, care, and support. Ineffectual HIV/AIDS stigma-reduction
interventions are the product of inadequate conceptual frameworks and methodological tools. And while there is a paucity of
effective interventions to reduce stigma, there is no shortage of conceptual frameworks intending to offer a comprehensive
understanding of stigma, ranging from sociocognitive models at the individual level to structural models at the macrolevel.
Observations highlighting inadequacies in the individualistic and structural models are offered, followed by the theory of
structuration as a possible complementary conceptual base for designing HIV/AIDS stigma-reduction interventions.

Keywords
HIV/AIDS, stigma, intervention, structuration theory

Introduction support of PLHA, health care practitioners, risky sexual

behaviors, consumption of services by the HIV-infected
In the initial years of the HIV epidemic, Jonathan Mann
individuals, and serostatus testing.4-10
referred to stigma as becoming part of the ‘‘third epidemic,’’ Nevertheless, in pursuit of effective prevention measures,
now trailing the rapid HIV transmission and rise in AIDS cases.
both symptomatic and asymptomatic persons could receive
Mann identified stigma, discrimination, blame, and denial as
an HIV diagnosis. For the asymptomatic, HIV voluntary coun-
extremely problematic to address, yet to address them is critical
seling and testing (VCT) comprises pre- and posttest counsel-
in preventing HIV.1
ing where a person learns of his or her HIV status11,12;
AIDS is now 30 years old. Joint United Nations Programme on
wherein VCT is considered a critical first step to care and a hub
HIV/AIDS (UNAIDS) reported that in 2010 more than 34 million
for HIV prevention globally,13-15 a position fully endorsed by
people were living with HIV/AIDS (PLHA), of which 22.5
UNAIDS. Nonetheless, stigma remains a countervailing force
million were from sub-Saharan Africa, which recorded 30 against VCT’s role to act as a critical gateway to care and to
million deaths from the time AIDS was first identified on June
reduce HIV transmission.
5, 1981.2 Undoubtedly, over the past 3 decades, huge efforts to
Researchers and health care practitioners knew from the
combat HIV/AIDS have been faithfully executed. Nevertheless,
early years of the HIV/AIDS epidemic that stigma and discrim-
earlier in the HIV/AIDS pandemic, researchers and health practi-
ination would become major barriers to HIV prevention and
tioners were aware that HIV stigma was an important barrier to
uptake of services. For this reason, in 1997 when the Horizons
HIV prevention, treatment, care, and support. And in 2004,
program16 started, the impact of stigma on HIV transmission
UNAIDS/World Health Organization (WHO) confirmed that
was well known, and some programs focused on its effect;
stigma and discrimination remain a major obstacle for people to notwithstanding this improved awareness, there was minimum
engage in HIV testing. For instance, in a survey of patients obtain-
knowledge of the following: drivers of stigma, precise manner
ing antiretroviral (ARV) drugs in Botswana, it was found that
in which stigma impacts HIV outcomes, appropriate tools to
40% deferred doing the HIV test as a result of stigma; and among
injecting drug users in Indonesia, 40% indicated that they post-
poned HIV testing because of stigmatization.3
Researchers and health care practitioners knew from the
1
early years of the HIV/AIDS epidemic that stigma and discrim- University of Guyana, University House, Georgetown, Guyana
ination would become major barriers to HIV prevention and
Corresponding Author:
uptake of services including the role of stigma in HIV transmis- Prem Misir, PhD, MPH, University of Guyana, University House, Office of the
sion. Specifically, stigma negatively impacts the following Pro-Chancellor, 1-2 Pere Street, Subryanville, Georgetown, Guyana
HIV preventive efforts: HIV social support behaviors, family Email: premmisir@gmail.com
Misir
measure stigma, and minimum information available as to
which intervention design may reduce stigma.
Mahajan et al17 noted the availability of only a few HIV/
AIDS-related stigma-reduction intervention studies and that
few intervention studies were even evaluated. In fact, they
noted that although stigma was a barrier to successful responses
to the HIV/AIDS epidemic, action to combat stigma was rele-
gated to a low program priority; and furthermore, the complex-
ity of HIV/AIDS stigma and discrimination may explain the
limited response. For these reasons, efforts to reduce stigma are
critical to positively impact HIV/AIDS prevention,18-20 vis-à-vis
VCT uptake as the critical first step to care. Employing interven-
tions to neutralize HIV stigma, leading to an increased uptake in
HIV services, is now vital in the global prevention battle against
HIV/AIDS.21,22
And for a long time now, qualitative studies have shown that
stigma and discrimination impact people’s decisions to access
VCT and treatment services.23-29 This finding has consistency
with quantitative studies.30-39
In this commentary, I want to make some general observa-
tions on the individualistic and structural models of stigma and
then suggest the theory of structuration as a possible comple-
mentary conceptual base for HIV/AIDS stigma-reduction inter-
vention designs.
Perspectives on Stigma
Prevalence of a paucity of effective interventions to reduce HIV/
AIDS stigma is troubling, given that stigma has long been recog-
nized as a significant barrier to HIV prevention, treatment, care,
and support. Ineffectual HIV/AIDS stigma-reduction interven-
tions are the product of inadequate conceptual frameworks and
methodological tools.40 Without a sound conceptual framework
and evidence-based sense of a health problem and its correlates,
it may be difficult to recognize intervention outcomes. Not only
are the theories and evidence useful in recognizing outcomes but
also the strategies applied to effect desired changes in beha-
vior.41 And while there is a scarcity of effective interventions
to reduce stigma, there is no shortage of conceptual frameworks
intending to offer a comprehensive understanding of stigma,
ranging from sociocognitive models at the individual level to
structural models at the macrolevel. In fact, there has been an
excessive emphasis on perceptions of individuals and their con-
sequences for microlevel interactions.42
Nevertheless, the search for a useful conceptual framework
has been persisting now for almost 50 years since Goffman43
in a groundbreaking work defined stigma as ‘‘a dynamic process
of devaluation that ‘significantly discredits’ an individual in the
eyes of others.’’ Goffman advised that stigma be seen in ‘‘a lan-
guage of relationships, not attributes,’’ as stigma is affixed in
social interaction. Nonetheless, several population-based studies
on AIDS attitudes present the attributes as being part of the indi-
vidual’s character44,45; and using the sociocognitive model with
a focus on the individual shows how people construct negative
categories and how they relate these categories to damaging
stereotyped beliefs.46-48 The sociocognitive model, too, sees
329
stigma as something in the stigmatized person and not an attri-
bute that a person hands over to the stigmatized person.47 This
model presents stigma as a static attitude rather than as a chang-
ing social process, resulting in a failure to recognize the full
impact of stigma and discrimination in HIV and AIDS.46 This
view of stigma as a static phenomenon may be due to its major
focus on stereotyping rather than on structural conditions.
In addition, studies on stigma using the sociocognitive
model with its unequivocally individualistic focus also elimi-
nate consideration of the structural components of stigma and
the social, economic, and political processes that create and
strengthen stigma and discrimination.42,47,49 To remedy this
deficiency, Mahajan et al17 argued that Link and Phelan com-
bined the sociocognitive/structural aspects of stigma and
defined stigma as existing when the elements of labeling,
stereotyping, separation, and discrimination occur together
vis-à-vis the exercise of power. This combined conceptual
model advances the view that interventions should have both
sociocognitive and structural components, acknowledging that
social, political, and economic inequalities of power are drivers
of HIV stigma.
Nevertheless, the combined conceptual model does not con-
stitute a comprehensive framework to study the outcomes of
HIV stigma.50 Recent studies showed that lack of precision
in the conceptualization and measurement of HIV stigma at the
individual level is an important barrier to HIV prevention,
treatment, care, and support efforts; and why stigma remains
a remarkable barrier in the global battle against HIV/AIDS.51,53
Earnshaw and Chaudoir’s work54 in attempting to fill this
gap argued that the sociocognitive/structural model does not
adequately explain how the individual person experiences
stigma vis-à-vis health, psychological, and behavioral out-
comes that energize the HIV/AIDS pandemic. Furthermore,
Earnshaw and Chaudoir studied whether the individual level
interventions are a fundamental component of HIV prevention
activities,52 then understanding how HIV stigma impacts indi-
vidual outcomes becomes critical, thus the justification to pres-
ent a few general observations on the Earnshaw and Chaudoir
framework.
Figure 1 describes the HIV stigma framework. The top part
of Figure 1 shows how HIV-uninfected persons enact stigma.
Prejudice, stereotypes, and discrimination are stigma mechan-
isms that the HIV-uninfected persons use to enact stigma to
produce negative behavioral outcomes toward PLHA. The bot-
tom part of Figure 1 shows how the HIV-infected individual
develops knowledge about his or her socially devalued status
through the process of enacted stigma, anticipated stigma, and
internalized stigma, perpetrated by the HIV-uninfected patient.
Conclusion
Although Earnshaw and Chaudoir chastised the combined
sociocognitive/structural model for failing to explain how the
individual experiences stigma, their framework is unable to
present the individual’s resistant and active responses to
stigma. Nonetheless, Earnshaw and Chaudoir’s framework
330 Journal of the International Association of Physicians in AIDS Care 14(4)
Figure 1. The HIV stigma framework (Earnshaw and Chaudoir50).
provides focus on the HIV-infected patient’s passive responses.
Earnshaw and Chaudoir indicated that the HIV-uninfected indi-
viduals enact prejudice, stereotypes, and discrimination as out-
comes of stigma toward PLHA, and the outcomes of these
enactments include social distancing and policy support. Never-
theless, there is no conceptual understanding on whether PLHA
would respond to this stigma enactment. There is no shortage of
studies to explain the consequences of stigma for PLHA,53-57 with
few studies focusing on the resistant and active capacity of PLHA.
People living with HIV/AIDS and their families have the capacity
to produce active responses, notwithstanding their stigmatized
status. For instance, Poindexter58 in a narrative analysis described
the family’s experiences of stigma as they provided care for their
HIV-infected daughter and how the medical system subsequently
failed the daughter. And again, Poindexter59 reported on her per-
sonal fight against stigma to care for her adult HIV-infected son
who later succumbed to AIDS.
In fact, many individualistic studies focus on attitudes of the
HIV-uninfected individuals toward PLHA, and even where the
unit of investigation is stigmatized, methodological tools gener-
ally extract passive responses from the stigmatized. Indeed, the
Earnshaw and Chaudoir’s HIV/AIDS stigma framework has no
theory of action in the Giddensian sense60; that is, in a theory of
action, there is a conception that people (in this case, PLHA)
reflexively monitor their behaviors vis-à-vis their knowledge and
where they are in some measure conscious of conditions govern-
ing those behaviors. Earnshaw and Chaudoir’s framework,
indeed, shows that the HIV-infected individual develops knowl-
edge about his or her socially devalued status vis-à-vis enacted
stigma, anticipated stigma, and internalized stigma; yet the frame-
work without the Giddensian theory of action fails to show how
PLHA’s knowledge produces and reproduces resistance to their
experience of stigma. Apparently, in the Earnshaw and Chau-
doir’s sense, PLHA are not capable and knowledgeable about the
culture of stigma that they experience, when the reverse situation
may very well be true.
In fact, in a general sense, both individualistic and structural
models of stigma downplay the knowledge and capability of
PLHA, a line of thinking quite consistent with Talcott Parsons’
structure of social action where ‘‘the stage is set, the scripts
written, the roles established, but the performers are curiously
absent from the scene.’’61 Existing conceptual frameworks
have presented the stigmatized and the disadvantaged as pas-
sive and unable to resist their affixed stigma and transform their
situations. Lest we forget, Black American history is replete
with examples of how a stigmatized, disadvantaged, and
exploited group took on the might of White slave owners, long
before there were civil rights laws. And this happened because
notwithstanding brutal constraints, Blacks created choices and
made a difference to their situation.
And previous models of stigma are bereft of a theory of
action. For instance, stigma is perceived as a one-way materi-
alization created by structural conditions and imposed on
PLHA as passive recipients who have no control over such cir-
cumstances.62,63 The point of Giddens’ theory of action is that
actors are knowledgeable about their culture and capable to act
and resist; this understanding of action theory, therefore, makes
PLHA agents who are part of a human agency. In fact, PLHA
are not cultural dopes. People living with HIV/AIDS do make
active responses to their stigmatization supported by the resis-
tance to HIV/AIDS stigma that is gaining momentum globally
and evidenced by the following: the ‘‘Give Stigma the Index
Finger’’ project in Swaziland, Ethiopia, and Mozambique;
AIDS Discrimination in Asia project administered by PLHA
to develop capacity to resist stigma; Global Network of People
Living with HIV (GNPþ) enables PLHA to become empow-
ered to affirm their rights; HIV-infected Magid’s activists work
in Egypt through the forum to Fight Stigma and Discrimination
Against People Living with HIV/AIDS, Volunteer Positive,
among others. In addition, the availability of ARV drugs to pro-
long the life of PLHA has provided them with some maneuver-
ability to actively and positively respond to their experience of
Misir
stigma, and where they do not allow the stigma to predomi-
nantly impact their lives.
The Giddensian perspective considers PLHA as active and
knowledgeable about their culture, and becoming empowered
provides the wherewithal to positively resist their stigma. I
want to explain this perspective on the stigma affixed to PLHA
through the lens of Giddens’ theory of structuration, an attempt
to integrate agency and structure. The theory starts off with
addressing the absence of a theory of action in the social
sciences and the accompanying deficiencies of structural func-
tionalism and orthodox Marxism, thus
But those traditions of thought which have concentrated upon
such problems, particularly functionalism and orthodox Marx-
ism, have done so from the point of view of social determinism.
In their eagerness to ‘get behind the backs’ of the social actors
whose conduct they seek to understand, these schools of
thought largely ignore just those phenomena that action philo-
sophy makes central to human conduct . . . The philosophy of
action suffered from two sources of limitation . . . an adequate
account of human agency must, first, be connected to a theory
of the acting subject; and second, must situate action in time
and space as a continuous flow of conduct, rather than treating
purposes, reasons, etc., as somehow aggregated together.64
Giddens argued that functionalism (voluntaristic theory) and
orthodox Marxism (deterministic theory), in not presenting
action as a constant flow through time and space, have pro-
duced the dualisms of individual/society, subject/object, and
conscious/unconscious forms of cognition; these dualisms have
incapacitated the development of a theory of action. For these
reasons, Giddens, in his theory of structuration, replaces these
dualisms with a singular duality of structure that refers to the
critical recursiveness of social life. Giddens’ theorem that
people are knowledgeable about the social systems which they
establish and reproduce in their actions is strategic to the
duality of structure. Giddens sees structure as dual, meaning
that structures are ‘‘both the medium and the outcome of the
practices which constitute social systems.’’65 That is, structure
produces action and action produces structure. Apparently,
structures shape people’s actions, and people’s actions, in turn,
produce and reproduce structures, prompting Sewell66 to say
that ‘‘In this view of things, human agency and structure, far
from being opposed, in fact presuppose each other.’’
There are some significant elements of structuration theory as
presented by Ritzer64: (1) agents (PLHA) reflexively monitor
their action including their social and physical contexts; (2) agents
pursue a sense of security vis-à-vis rationalization which enables
them to cultivate routines; (3) use of practical consciousness pro-
vides a spotlight on what agents do; agents initiate events in their
agency to make things happen; (4) the concept of unintended con-
sequences delineates the movement from agency to a social sys-
tem; (5) agents possess power and action, in order to transform the
situation; (6) structure refers to rules and practices which have the
potential to be both constraining and enabling; and structure is
present only through the action of agents; (7) social systems are
reproduced social practices between agents, generally the product
331
Table 1. The Duality of Structurea
x
Interaction ? Communication Power Morality
(Modality) ?
?
Interpretative Scheme Facility Norm
Structure y Signification Domination Legitimation
(Weltanschauung)
a
Reprinted with permission from Giddens.68
of unanticipated consequences of their action; (8) time and space
are critical in structuration theory, as they rely on the presence of
people temporally and spatially.
With these building blocks of structuration theory (1-8), I
now present Giddens’ duality of structure as a critical element
of the theory.
Bryant and Jary67 explain the structuration theory through
reference to the three rows on the duality of structure in Table
1.68 In the first row, social interaction across time and space
entails the communication of meaning, the exercise of power,
and the evaluative judgement of conduct; in the second row,
interpretative schemes are the typical symbols and codes
included in the agent’s stock of knowledge to sustain commu-
nication; facility is the medium through which the agent exer-
cises command over people, resources, and practices; and
norms comprise the agent’s expectations; this second row with
the modalities shows ways in which the agent accesses rules
and resources and engages in practices to generate interaction;
and in the third row, significant structure entails semantic rules,
dominant structure produces unequal distribution of resources;
and legitimate structure involves moral or evaluative rules.
Nevertheless, structure referring to rules, resources, and
practices restrain and empower action and are themselves
replicated through that action,69 constituting a modification of
Giddens’ definition of structure, by showing the affinity between
agency and structure. Stones70 also reworked Giddens’
structuration theory, introducing the concept of the agent’s con-
text analysis, where the focus is on the strategic context of the
agent’s action vis-à-vis connection of interdependencies, rights
and obligations, power asymmetries, and the conditions and
costs of the agent’s action. In fact, agents’ actions will vary in
accordance with their contexts. For this reason, varying contexts
will limit or enable the agent’s knowledge and capability to act.
And the HIV/AIDS pandemic presents a phenomenally new
transitional context for the HIV-infected individuals. Giddens71
would probably refer to the transition from a healthy status to the
contraction of HIV as a ‘‘critical situation,’’ where familiar and
comfortable routines of living for many years instantly now
become inapplicable and irrelevant to navigating life with HIV/
AIDS stigma. Several studies63,68,72-76 on HIV/AIDS stigma refer
to Giddens’ structuration theory to explain this critical situation.
Furthermore, to propose structuration theory as a conceptual
framework for HIV/AIDS stigma would necessitate showing
how the theory is useful in designing practical interventions
to reduce stigma. There are several studies on stigma and
discrimination that use structuration theory, which depict the
stigmatized individual as knowlegable and capable of
reflexively monitoring his or her own action and, at the same
332 Journal of the International Association of Physicians in AIDS Care 14(4)
time, portray the relationship between agency and structure.
The HIV-positive person’s family relations were reconstructed
in Turkey through Giddens’ concept of signification in
structuration theory, whereby the HIV infection now has new
meanings, as the infection is being seen as no longer deadly
to the infection being manageable.77 Doctors provided the new
signification or new semantic codes, ‘‘Those semantic codes
are: preferring the term HIV positive instead of AIDS and
defining it as a chronic illness. These semantic codes pave the
way for production of new meanings. Thus, the infection sheds
its label ‘being deadly’ and it is transformed to an illness
manageable by drugs. Thus, the semantic shift takes HIV from
incurable to curable.’’78 These new semantic codes indicating
that the HIV infection is less deadly will enhance relationship
formation, particularly within the family, the mainstay of care
and support for the HIV-infected patients in many parts of the
world. These authors also asserted that reconstruction of these
meanings is probably a major step to deconstruct the current
stigmas that perpetually have been constructing such horrifying
metaphors of death, shame, guilt, and so on.
In applying this Giddensian theory of structuration in
another study, Harter et al79 studied homeless youth in a mid-
western community in the United States, where stigma fre-
quently pushes homeless youth underground, thereby adding
to their invisibility and stigmatization. Even though their work
is among homeless youth, their analysis is applicable to HIV/
AIDS stigma as outlined in their analysis in these areas: struc-
turation theory shows how those with power employ ‘‘stigma-
tized’’ values, identities, and discourse through interactions
between PLHA and the nonstigmatized person; calls for dis-
mantling the domination of these values, identities, and dis-
course; and interactions between health professionals and the
stigmatized person can weaken or strengthen these dominating
patterns of behavior-sustaining stigma. Undermining these
dominating behaviors can happen vis-à-vis, establishing and
sustaining national and international collectives that would
equate with Giddens’ concept of new facility to reduce the
unequal distribution of resources between the stigmatized and
the nonstigmatized, and at the same time, for the stigmatized
to strive toward a competitive position against stigmatizers. For
example, as aforementioned, review how PLHA stand firm
globally against stigma: the Give Stigma the Index Finger
project in Swaziland, Ethiopia, and Mozambique; AIDS
Discrimination in Asia project by PLHA; Global Network of
People Living with HIV (GNPþ) to assert their rights; HIV-
infected Magid’s activist efforts in Egypt through the Forum
to Fight Stigma and Discrimination against People Living with
HIV/AIDS, Volunteer Positive, among others. Another form of
Giddens’ concept of a new facility to improve PLHA’s control
of resources and to shed stigma is the accessibility of ARVs
that now enables PLHA to live longer and to live a normal life.
Cunningham et al80 reviewed the activities of churches in
Baltimore, Maryland, pertaining to sexuality issues, and
whether they can possibly stigmatize a person with or at risk
for HIV/AIDS, and whether the individual agency or institu-
tional behavior influences churches on these matters. To a
large extent, the churches’ activities on sexuality issues
were reconstructed through Giddens’ concept of legitima-
tion in structuration theory, whereby the church leaders
(agency) themselves adopted new normative frameworks
and activities to address HIV infection. These new norms
included the distribution of condoms by one pastor to the
congregation that was sexually active; and church leaders’
reconciliation of the official teachings on sex and sexuality
with HIV prevention work. These researchers pulled from
structuration theory the notion that church leader/pastor
(agency) and structure (church) are a duality, whereby the
church is a moving force with the pastor, and at the same
time, the church experiences a vacuum without the pastor.
Church leaders’ engagement in actions on sex and sexuality
issues was influenced by the church of which they are a
constituency; nevertheless, it is through the church leaders’
actions that the church is transformed or preserved.
This commentary concentrates on the stigmatizer’s action
that enacts stigma on the one hand, and the stigmatized whose
action resists stigma, on the other hand. The modalities (second
row in Figure 1) which are the interpretive scheme, facility, and
norm transform structure into action and action into structure
and explain people’s behaviors in enabling and constraining con-
texts. And if we accept Goffman’s position that stigma is
acquired through social interaction, then in interpreting Giddens’
work, I would propose that enactment of HIV/AIDS stigma
occurs when the modalities convert the structure into action and
action into structure. Furthermore, given the theoretical view
that modalities provide the means in which structures become
transformed into action and action into structure, and that stigma
happens during interactions, then HIV/AIDS stigma-reduction
intervention designs could target these modalities.
The Giddensian model accommodates both the person who
enacts the stigma and the recipient of stigma (where both are
agents with power), in that both can reflexively monitor the flow
of stigma vis-à-vis their own action, one intending to enact
stigma and the other intent on reducing the surge of stigma.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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