The Paradox of Knowledge: How HIV/AIDS Knowledge and Empathy Shape Stigma toward PLWHA in Indonesia’s Sociocultural Context

The Paradox of Knowledge: How HIV/AIDS Knowledge and Empathy Shape Stigma toward PLWHA in Indonesia’s Sociocultural Context | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Paradox of Knowledge: How HIV/AIDS Knowledge and Empathy Shape Stigma toward PLWHA in Indonesia’s Sociocultural Context Marselius Sampe Tondok, Agnia Shaqilla Putri This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6362461/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract HIV/AIDS knowledge and empathy serve as key cognitive and emotional antecedents of stigma toward PLWHA. However, the relationship between HIV/AIDS knowledge and stigma varies across different social contexts. This study examines the roles of HIV/AIDS knowledge and empathy in shaping stigma toward PLWHA within the Indonesian sociocultural context. A quantitative cross-sectional survey was conducted with 410 undergraduate students from a university in Surabaya, Indonesia. Data were collected using the Stigmatizing Attitude Toward People Living With HIV/AIDS (SAT-PLWHA) Scale, the HIV Knowledge Questionnaire (HIV-KQ-18), and the Toronto Empathy Scale. Multiple linear regression analysis was performed to test the hypotheses. The findings indicate that both HIV/AIDS knowledge and empathy significantly influence stigma toward PLWHA [ F (2,407) = 37.91; p < .001]. Specifically, higher HIV/AIDS knowledge was positively associated with increased stigma ( β = .22, p < .001), whereas higher empathy was negatively associated with stigma ( β = -0.24, p < .001). These findings highlight the impact of HIV/AIDS knowledge and empathy on stigma toward PLWHA within Indonesia’s sociocultural context. Religion influences the relationship between knowledge and stigma through psychological mechanisms such as cognitive dissonance, belief perseverance, and fear/anxiety. This study offers insights for researchers and practitioners seeking to develop effective interventions aimed at reducing stigma, particularly in culturally sensitive contexts such as Indonesia, while engaging religious leaders in reinterpreting religious beliefs to foster understanding, empathy, and a more inclusive perspective toward PLWHA. Psychology Stigma HIV/AIDS Knowledge Empathy PLWHA Indonesia Introduction The global burden of HIV/AIDS continues to rise, with Indonesia experiencing one of the fastest-growing epidemics in Southeast Asia (1,2). The highest case concentrations are reported in East Java, followed by West Java, Central Java, Jakarta, and Papua (3,4). Despite ongoing prevention and treatment efforts, stigma and discrimination against PLWHA remain significant barriers to an effective HIV response in Indonesia and globally (1,3). In the Indonesia sociocultural context, stigma toward PLWHA remains prevalent, with rates reaching 62.8% (1). A key factor contributing to this stigma is the strong role of religion in Indonesian society as it shapes social interactions, daily routines, and moral perceptions (5,6). Religious norms often dictate attitudes toward health and morality, reinforcing the perception of HIV as a divine punishment for immoral behavior. This belief is particularly strong among those who view religion as punitive and unforgiving (3,7). Furthermore, religious discourses frequently associate HIV with moral failings, thereby perpetuating stigma and leading to discrimination against PLWHA in both communities and healthcare settings (8). HIV-related stigma in Indonesia, is shaped by healthcare settings, societal attitudes, religious beliefs, and sociocultural norms. In medical environments, stigma among healthcare professionals often leads to discrimination, including refusal of treatment and social exclusion of PLWHA (9,10). Within communities and families, stigma manifests as rejection, isolation, and negative labeling, reinforced by moralistic, religious, and cultural narratives (7,11). Stigma fuels social exclusion, obstructs HIV prevention and treatment, and harms PLWHA’s well-being. It deters healthcare access, delays diagnoses, and worsens mental health, increasing stress, anxiety, and reducing treatment adherence(12–16). HIV/AIDS knowledge covers transmission, prevention, symptoms, treatment, and correcting misconceptions (17–19). Increased awareness is generally associated with reduced stigma, as accurate knowledge decreases stigmatizing attitudes toward PLWHA (20–25). Addressing misconceptions about HIV transmission is crucial in mitigating fear and promoting more accepting attitudes (26,27). Research on HIV/AIDS knowledge and stigma toward PLWHA shows inconsistent findings. In Botswana, for instance, higher knowledge correlated with stronger stigma, highlighting cultural influences (24). Conversely, in Ethiopian and Turkey hospital-based studies, greater knowledge was linked to lower stigma, especially among educated individuals (23,28). In Nepal, no significant association was found, with stigma driven by age, experience, and fear (29). Besides knowledge, an important antecedent of stigma toward PLWHA is empathy (30,31). Empathy is defined as the ability to understand and share others' emotions and experiences (32,33). Research shows that higher empathy levels are associated with fewer stigmatizing behaviors, as empathetic individuals are less likely to engage in discrimination actions (31,34). Empathy fosters understanding and support, which improves PLWHA’s well-being, reduces isolation, and enhances mental health. Meta-analyses indicate that empathy-driven support improves HIV treatment adherence and mental health of PLWHA (35). Knowledge and empathy both contribute to shaping attitudes, but their combination is more effective in reducing stigma toward PLWHA (31,36). The intergroup contact hypothesis (37) provides a theoretical framework, suggesting that increased knowledge and empathy lead to more positive attitudes toward stigmatized groups. This theory posits that accurate information and meaningful interactions reduce stereotypes, while empathy fosters emotional connections that counteract fear and prejudice (38). While knowledge reduces misconceptions and fear-based stigma (26), it alone may not be enough due to deeply ingrained cultural norms (24). Empathy, especially perspective-taking (39), humanizes PLWHA and enhances understanding, creating a comprehensive approach to stigma reduction. Based on the existing body of knowledge, we hypothesize: (1) HIV/AIDS knowledge will be associated with stigma toward PLWHA (H1); (2) Higher levels of empathy toward PLWHA will be associated with reduced stigma toward PLWHA (H2); (3) HIV/AIDS knowledge and empathy toward PLWHA will be jointly associated with reduced stigma toward PLWHA (H3). Methods Study D esign and Participants A quantitative cross-sectional survey design was employed to test the research hypotheses, using a questionnaire as the primary data collection instrument. The study involved 410 undergraduate students from a university in Surabaya, East Java, a province with the highest number of PLWHA in Indonesia (40). University students were chosen as participants because they represent diverse societal groups, including future leaders, and are generally receptive to new ideas (41). Participants self-identified as non-PLWHA, representing the outgroup of PLWHA, and were recruited through proportional-accidental sampling to ensure the number of participants from each faculty reflected their proportion within the university’s total student population. The initial sample size was determined through an a priori power analysis using G*Power 3.1 software (42). This analysis, based on a linear multiple regression fixed model with R² deviation from zero, included two predictors, a statistical power of .80, α = .05, and an effect size of f² = .02, indicating a minimum required sample of 311 respondents. Ultimately, 410 respondents were recruited. A sensitivity power analysis ( α = .05, statistical power = .80, sample size = 410, and two predictors) revealed that the smallest detectable effect size was f² = .0151. The participants' characteristics are presented in Table 1. Instruments This study utilized three psychometric scales adapted into Indonesian to align with the research context. Stigma toward PLWHA . The Stigmatizing Attitude Toward People Living With HIV/AIDS (SAT-PLWHA) Scale, developed by Beaulieu et al. (2014), was used to assess this variable. The scale consists of 27 items measuring stigma across seven key dimensions: concern about occasional encounters, fear of personal contact, responsibility and blame, liberalism, social support, confidentiality of serological status, and criminalization of HIV transmission. These dimensions are grounded in the three primary elements of stigma: stereotypes, prejudice, and discrimination (44). Responses on the SAT-PLWHA scale were recorded using a 5-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree). In this study, the instrument demonstrated a Cronbach’s alpha coefficient of .85, indicating a fairly high level of reliability (45). HIV/AIDS Knowledge . To measure this variable, the HIV Knowledge Questionnaire (HIV-KQ-18), developed by Carey and Schroder (2002), was utilized. The questionnaire comprises 18 items designed to evaluate knowledge related to HIV/AIDS transmission. It employs a Guttman scale format with true or false responses, where correct answers indicate higher knowledge levels, while incorrect responses reflect lower knowledge levels. In this study, the HIV-KQ-18 yielded a Cronbach's alpha coefficient of .64, demonstrating satisfactory reliability (45). Empathy toward PLWHA . This variable was measured using the Toronto Empathy Scale, which consists of 16 items assessing general empathy levels and is unidimensional (Kourmousi et al., 2017). Responses were collected on a 5-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree). In this study, the scale demonstrated a Cronbach’s alpha reliability coefficient of .77, indicating a fairly high level of reliability (45). Prosedure and Data Analysis Data for this study were collected through both online surveys via Google Forms and offline distribution of printed questionnaires to participants. Prior to completing the questionnaires, participants provided voluntary consent by signing an informed consent form. Descriptive statistics were first conducted to analyze participant characteristics, followed by an examination of the research variables. Assumption tests, including assessments of normality and linearity, were performed before hypothesis testing. Multiple linear regression analysis was then conducted to test the hypothesis. All data analyses were performed using JASP (Jeffrey's Amazing Statistics Program) version 0.18.3 3 (48). Results Table 1 provides a demographic overview of the research participants, including their sex, age, and faculty affiliation. Additionally, it presents information on the sources from which they acquired HIV/AIDS knowledge. Table 1 Participant characteristics ( N = 410) Characteristics Category F % Sex Female 233 56.83 Male 177 43.17 Age ( Mean age = 20.40; SD = 1.08) 18 14 3.41 19 60 14.63 20 149 36.34 21 132 32.20 22 48 11.71 23 4 .98 24 1 .24 25 2 .49 Faculty Economics 108 26.34 Pharmacy 68 16.59 Law 60 14.63 Engineering 59 14.39 Psychology 52 12.68 Biotechnology 23 5.61 Creative Industries 23 5.61 Medicine 17 4.15 Sources of HIV/AIDS knowledge * Internet 364 38.77 Seminar 207 22.46 Book 131 13.95 TV 128 13.63 Newspaper 34 3.62 Magazine 29 3.09 Radio 23 2.45 Others 23 2.45 Note: *Participants can give more than one answer. The table above indicates that the majority of participants were female students (56.83%) with a mean age of 20.4 years ( SD = 1.08). The primary sources of HIV/AIDS knowledge were the internet (38.77%) and seminars (22.46%). Table 2 presents descriptive statistics, including the mean ( M ) and standard deviation ( SD ) of the three research variables, the reliability of the instruments (Cronbach’s alpha, α), and Pearson’s correlation coefficients among the variables. Table 2 Descriptive statistics and correlation between variables Variables Mean SD a 1 2 Stigma against PLWHA 2.97 .57 .85 Empathy toward PLWHA 3.78 .39 .77 -.26*** HIV/AIDS Knowledge .44 .23 .64 .24*** -.09 Note: *p < .05; **p < .01; ***p < .001 The table above indicates that, with a score range of 1–5 and a median of 3, the total stigma toward PLWHA score is below the median, whereas the total empathy toward PLWHA score is above the median. Additionally, the total HIV/AIDS knowledge score is .44, which is below the median of .50 (with a score range of 0–1). The correlation coefficients indicate that empathy toward PLWHA is negatively associated with stigmatization, whereas HIV/AIDS knowledge is positively associated with it. Subsequently, multiple regression analysis was conducted to examine the contributions of these significant variables, as presented in Table 3. Table 3 Summary of the research hypothesis testing Independent Variables Stigma against PLWHA (Dependent Variable) R R 2 F β Sig. Hypothesis 1/H1: X1 .10 .22 < .001 Hypothesis 2/H2: X2 .06 -.24 < .001 Hypothesis 3/H3: X1 , X2 .40 .16 37.91 < .001 Note: X1 = HIV/AIDS Knowledge; X2 = Empathy toward PLWHA As shown in Table 3, multiple regression analysis indicated that both independent variables, HIV/AIDS knowledge and empathy toward PLWHA, jointly associated with stigma toward PLWHA [ F (2, 407) = 37.91; R² = .16; p < .001]. Specifically, HIV/AIDS knowledge exhibited a highly significant positive association with increased stigma toward PLWHA ( β = .22, p < .001). In contrast, empathy toward PLWHA had a highly significant negative effect, reducing stigma toward PLWHA ( β = -.24, p < .001). Discussion This study aims to examine the role of HIV/AIDS knowledge and empathy in shaping stigma toward PLWHA within the Indonesia context, using a sample of university students. The hypothesis testing results, presented in Table 3, highlight three main findings. First, HIV/AIDS knowledge demonstrates a significant positive correlation with stigma toward PLWHA ( β = .22; p < .001). Second, empathy exhibits a significant negative correlation with stigma toward PLWHA ( β = -.24; p < .001). Third, HIV/AIDS knowledge and empathy toward PLWHA are jointly and significantly associated with HIV-related stigma [ F (2, 407) = 37.91; R² = .16; p < .001]. These findings are discussed in detail as following. As shown in Table 3, the first finding of this study reveals a positive correlation between HIV/AIDS knowledge and stigma toward PLWHA. This suggests that higher basic knowledge about the causes and transmission of HIV/AIDS is associated with stronger stigma toward PLWHA. Furthermore, the findings indicate that HIV/AIDS knowledge does not always correlate negatively with stigma, as has been commonly reported in previous studies (26,49–54). We propose three psychological mechanisms, in Indonesian sociocultural context, explaining the positive correlation between HIV/AIDS knowledge and stigma toward PLWHA: (1) cognitive dissonance, (2) belief perseverance, and (3) fear and anxiety. The first mechanism, cognitive dissonance, occurs when individuals experience discomfort from holding beliefs that contradict their behaviors or knowledge (55). In the context of HIV/AIDS in Indonesia, societal norms, particularly those rooted in religion, often perpetuate negative stereotypes about PLWHA (7,56,57). Despite having adequate HIV/AIDS knowledge, individuals may continue to stigmatize PLWHA due to these ingrained socioreligious norms, showing that knowledge alone cannot eliminate stigmatizing attitudes toward PLWHA (58,59). The second mechanism, belief perseverance, occurs when individuals maintain beliefs even after evidence discredits them (60). Despite accurate HIV/AIDS knowledge, stereotypes—primarily shaped by religious norms in Indonesian society—such as viewing PLWHA as solely responsible for their condition or perceiving HIV/AIDS as a moral failing, may persist, reinforcing stigma toward PLWHA (8,58,61). Research shows that such beliefs hinder stigma reduction, indicating that simply increasing HIV knowledge is not enough to overcome deeply ingrained stereotypes and beliefs that sustain discrimination (62). The third psychological mechanism is fear and anxiety related to HIV/AIDS transmission. Fear appeal theory suggests that perceived threats from infectious diseases can lead to prejudice against affected groups (63). Even with sufficient knowledge, individuals may stigmatize PLWHA due to fear and uncertainty. In Indonesia, religious beliefs often play a significant role in amplifying this fear, as many individuals may believe that HIV/AIDS is a divine punishment or that PLWHA are morally compromised. Such beliefs can heighten the fear of transmission, particularly in the context of close social interactions, leading to increased stigma (7,8). Fear and misinformation at the community level further shape attitudes, contributing to widespread stigmatization (64,65). The three psychological mechanisms discussed above—cognitive dissonance, belief perseverance, and fear and anxiety—highlight that stigma toward PLWHA in Indonesia is a complex social process. Despite increased HIV/AIDS knowledge, deeply ingrained sociocultural and religious norms continue to shape negative stereotypes, reinforcing stigmatization and hindering attitude change. As stigma is a powerful social phenomenon deeply rooted in social, cultural, and historical contexts (66), addressing it requires more than simply disseminating knowledge; it demands a transformation of the underlying beliefs and fears that sustain stigma toward minority groups such as PLWHA. The second finding of this study (see Table 3) reveals a negative correlation between empathy and stigma toward PLWHA. Higher empathy, reflecting an individual's ability to understand PLWHA's experiences, is linked to lower levels of stigma, while lower empathy increases stigmatization. These results align with previous studies showing that empathy reduces stigma and discrimination against PLWHA (67–69). Empathy fosters understanding, emotional connection, and supportive social networks, which buffer stigma’s effects (Luo et al., 2022). Therefore, the negative correlation between empathy and stigma is influenced by both psychological mechanisms and social dynamics, emphasizing empathy’s role in mitigating stigma and promoting more inclusive attitudes toward PLWHA (70,71). Table 3 presents the third finding, which demonstrates a significant joint association between HIV/AIDS knowledge, empathy toward PLWHA, and stigma toward PLWHA, with a coefficient of determination ( R² ) of .16. This suggests that these two variables collectively account for 16% of the variance in HIV-related stigma, representing a medium effect size (Cohen, 1988). Although empathy is associated with stigma toward PLWHA, the findings of this study (see Table 3) indicate that HIV/AIDS knowledge ( R² = .11) plays a greater role than empathy ( R² = .06) in explaining the occurrence of stigma toward PLWHA, as reflected in the coefficient of determination. This result suggests that cognitive mechanisms, represented by HIV/AIDS knowledge, have a stronger influence than emotional mechanisms, represented by empathy, in shaping stigma toward PLWHA. HIV/AIDS-related stigma is a complex issue influenced by various factors beyond knowledge and empathy. These factors are categorized into five key dimensions: socio-demographic characteristics (e.g., gender, age, marital status, education, income), personal experiences (e.g., HIV testing history, personal distress), psychological and emotional factors (e.g., internalized stigma, blame, avoidance), systemic and institutional factors (e.g., healthcare worker attitudes, community-level knowledge), and cultural and religious beliefs (e.g., social groups, cultural norms). Each dimension plays a significant role in shaping stigma toward PLWHA (23,57,72) Although this study identifies distinct psychological mechanisms through which HIV/AIDS knowledge and empathy influence stigma toward PLWHA, it has several limitations. First, the study employs a cross-sectional survey design, which limits its ability to establish causality or determine the direct effects of HIV/AIDS knowledge and empathy on stigma toward PLWHA. While cross-sectional designs are useful for identifying associations, their internal validity is constrained by temporal ambiguity and susceptibility to confounding (73). To address these limitations, future studies should employ experimental and longitudinal designs, as they provide stronger internal validity and are better suited for establishing causal relationships (74,75). Second, as this study's participants were university students from a single campus in Surabaya, its findings may not fully generalize to Indonesia's broader student population. Thus, external validity should be interpreted with caution. To assess the consistency of these results, future research should include more diverse populations and social contexts. Notably, this study diverges from previous research by identifying a positive association between HIV/AIDS knowledge and stigma toward PLWHA. The differing findings of this study underscore the need for further research, particularly in exploring how contextual factors such as culture and social norms shape psychological processes, as stateted by a social psychologist Thomas F. Pettigrew (76) in The Emergence of Contextual Social Psychology. Given that findings previously considered robust may vary across social contexts, external validation remains both a challenge and an opportunity for future research in social psychology. Conclusion These findings underscore the roles of HIV/AIDS knowledge and empathy as cognitive and emotional mechanisms in shaping stigma toward PLWHA in the Indonesian sociocultural context. The sociocultural contexts, with the strong role of religion in daily life within society, influence the dynamic relationship between HIV/AIDS knowledge and stigmatizing attitudes toward marginalized groups, such as PLWHA, through psychological mechanisms, including cognitive dissonance, belief perseverance, and fear or anxiety of HIV/AIDS transmission. The results suggest that interventions should address both cognitive and emotional aspects while considering the crucial role of religion in Indonesian society. Engaging religious leaders in HIV/AIDS education can be instrumental in reinterpreting religious beliefs to foster understanding, reduce stigma, and shift community attitudes toward PLWHA. Cognitively focused interventions should aim to correct misconceptions and challenge stereotypes, while emotionally driven approaches should cultivate empathy, promoting a more compassionate and inclusive perspective toward PLWHA. Declarations Author Contributions ASP conceptualized and wrote the first draft and critically revised the manuscript. ASP and MST set up the statistical test design. ASP conducted the data analysis, which was reviewed and verified by MST. MST prepared tables with input from ASP. MST reviewed and edited the manuscript. Competing interests The authors have no relevant financial or nonfinancial interests to disclose. Informed Consent and Ethics Approval This study protocol was approved by the Ethics Committee of the University of Surabaya under approval number 110A/KE/IC/2022. All participants signed an informed consent form before joining the study. 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Endalamaw A, Gilks CF, Ambaw F, Shiferaw WS, Assefa Y. Explaining inequity in knowledge, attitude, and services related to HIV/AIDS: A systematic review. BMC Public Health. 2024 Jul 8;24(1):1815. Huyen TNT, Pumtong S, Sangroongruangsri S, Anuratpanich L. Effects of HIV knowledge on accepting attitudes toward people living with HIV: The case of Southern Vietnam. J Pharm Pharmacogn Res. 2023 Jul 1;11(4):572–84. Njokwe G, Kijima Y. Can AIDS education reduce HIV stigma? Evidence from Zimbabwe. AIDS Care. 2025 Jan 24;1–13. Sallam M, Alabbadi AM, Abdel-Razeq S, Battah K, Malkawi L, Al-Abbadi MA, et al. HIV knowledge and stigmatizing attitude towards people living with HIV/AIDS among medical students in Jordan. IJERPH. 2022 Jan 10;19(2):745. Festinger L. A Theory of Cognitive Dissonance. Evanston, IL: Row, Peterson; 1957. Asrina A, Ikhtiar M, Idris FP, Adam A, Alim A. Community stigma and discrimination against the incidence of HIV and AIDS. Journal of Medicine and Life. 2023;16(9):1327–34. 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Nilsson Schönnesson L, Dahlberg M, Reinius M, Zeluf-Andersson G, Ekström AM, Eriksson LE. Prevalence of HIV-related stigma manifestations and their contributing factors among people living with HIV in Sweden – a nationwide study. BMC Public Health. 2024;24(1):1360. Tannenbaum MB, Hepler J, Zimmerman RS, Saul L, Jacobs S, Wilson K, et al. Appealing to fear: A meta-analysis of fear appeal effectiveness and theories. Psychological Bulletin. 2015 Nov;141(6):1178–204. Cao X, Sullivan SG, Xu J, Wu Z. Understanding HIV–Related Stigma And Discrimination in a “Blameless” Population. AIDS Education and Prevention. 2006 Dec;18(6):518–28. Chen J, Choe MK, Chen S, Zhang S. The effects of individual- and community-level knowledge, beliefs, and fear on stigmatization of people living with HIV/AIDS in China. AIDS Care. 2007 May;19(5):666–73. Goffman E. Stigma: Notes on a spoiled identity. Englewood Cliffs: Prentice-Hall; 1963. Leyva-Moral JM, Gómez-Ibáñez R, San Rafael S, Guevara-Vásquez G, Aguayo-González M. Nursing students’ satisfaction with narrative photography as a method to develop empathy towards people with Hiv: A mixed-design study. Nurse Education Today. 2021 Jan;96:104646. Mak WWS, Cheng SSY, Law RW, Cheng WWL, Chan F. Reducing HIV-related stigma among health-care professionals: a game-based experiential approach. AIDS Care. 2015 Jul 3;27(7):855–9. Shi C, Cleofas JV. Professional commitment and willingness to care for people living with HIV among undergraduate nursing students: The mediating role of empathy. Nurse Education Today. 2022 Dec;119:105610. Brener L, Broady T, Cama E, Hopwood M, De Wit JBF, Treloar C. The role of social support in moderating the relationship between HIV centrality, internalised stigma and psychological distress for people living with HIV. AIDS Care. 2020 Jul 2;32(7):850–7. Takada S, Nyakato V, Nishi A, O’Malley AJ, Kakuhikire B, Perkins JM, et al. The social network context of HIV stigma: Population-based, sociocentric network study in rural Uganda. Social Science & Medicine. 2019 Jul;233:229–36. Tadesse G, Rtbey G, Andualem F, Takelle GM, Melkam M, Tadesse Abate A, et al. HIV-related perceived stigma and internalized stigma among people living with HIV/AIDS in Africa: A systematic review and meta-analysis. Oche OM, editor. PLoS ONE. 2024 Oct 23;19(10):e0309231. Kelly SE, Brooks SPJ, Benkhedda K, MacFarlane AJ, Greene-Finestone LS, Skidmore B, et al. A scoping review shows that no single existing risk of bias assessment tool considers all sources of bias for cross-sectional studies. Journal of Clinical Epidemiology. 2024 Aug;172:111408. Phan HP, Ngu BH. Undertaking Experiments in Social Sciences: Sequential, Multiple Time Series Designs for Consideration. Educ Psychol Rev. 2017 Dec;29(4):847–67. Spector PE. Do Not Cross Me: Optimizing the Use of Cross-Sectional Designs. J Bus Psychol. 2019 Apr;34(2):125–37. Pettigrew TF. The emergence of contextual social psychology. Pers Soc Psychol Bull. 2018 Jul;44(7):963–71. Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6362461","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":437511950,"identity":"b6239b80-d79d-4dd9-97bf-e0454cdde10f","order_by":0,"name":"Marselius Sampe Tondok","email":"data:image/png;base64,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","orcid":"https://orcid.org/0000-0002-7255-5350","institution":"Faculty of Psychology, University of Surabaya, Indonesia","correspondingAuthor":true,"prefix":"","firstName":"Marselius","middleName":"Sampe","lastName":"Tondok","suffix":""},{"id":437511951,"identity":"55635632-4b6d-48c3-9091-084dd573141b","order_by":1,"name":"Agnia Shaqilla Putri","email":"","orcid":"","institution":"Faculty of Psychology, University of Surabaya, Indonesia","correspondingAuthor":false,"prefix":"","firstName":"Agnia","middleName":"Shaqilla","lastName":"Putri","suffix":""}],"badges":[],"createdAt":"2025-04-02 14:57:54","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-6362461/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6362461/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":79806766,"identity":"8209f2f3-6d9a-4dd3-bd13-4f21a0f15bfd","added_by":"auto","created_at":"2025-04-03 05:30:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":524069,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6362461/v1/c43876a2-1bc7-4721-ada6-feefabf40174.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eThe Paradox of Knowledge: How HIV/AIDS Knowledge and Empathy Shape Stigma toward PLWHA in Indonesia’s Sociocultural Context\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThe global burden of HIV/AIDS continues to rise, with Indonesia experiencing one of the fastest-growing epidemics in Southeast Asia (1,2). The highest case concentrations are reported in East Java, followed by West Java, Central Java, Jakarta, and Papua (3,4). Despite ongoing prevention and treatment efforts, stigma and discrimination against PLWHA remain significant barriers to an effective HIV response in Indonesia and globally (1,3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn the Indonesia sociocultural context, stigma toward PLWHA remains prevalent, with rates reaching 62.8%\u0026nbsp;(1). A key factor contributing to this stigma is the strong role of religion in Indonesian society as it shapes social interactions, daily routines, and moral perceptions (5,6). Religious norms often dictate attitudes toward health and morality, reinforcing the perception of HIV as a divine punishment for immoral behavior. This belief is particularly strong among those who view religion as punitive and unforgiving (3,7). Furthermore, religious discourses frequently associate HIV with moral failings, thereby perpetuating stigma and leading to discrimination against PLWHA in both communities and healthcare settings (8).\u003c/p\u003e\n\u003cp\u003eHIV-related stigma in Indonesia, is shaped by healthcare settings, societal attitudes, religious beliefs, and sociocultural norms. In medical environments, stigma among healthcare professionals often leads to discrimination, including refusal of treatment and social exclusion of PLWHA (9,10). Within communities and families, stigma manifests as rejection, isolation, and negative labeling, reinforced by moralistic, religious, and cultural narratives\u0026nbsp;(7,11). Stigma fuels social exclusion, obstructs HIV prevention and treatment, and harms PLWHA\u0026rsquo;s well-being. It deters healthcare access, delays diagnoses, and worsens mental health, increasing stress, anxiety, and reducing treatment adherence(12\u0026ndash;16).\u003c/p\u003e\n\u003cp\u003eHIV/AIDS knowledge covers transmission, prevention, symptoms, treatment, and correcting misconceptions\u0026nbsp;(17\u0026ndash;19).\u0026nbsp;Increased awareness is generally associated with reduced stigma, as accurate knowledge decreases stigmatizing attitudes toward PLWHA\u0026nbsp;(20\u0026ndash;25). Addressing misconceptions about HIV transmission is crucial in mitigating fear and promoting more accepting attitudes\u0026nbsp;(26,27).\u003c/p\u003e\n\u003cp\u003eResearch on HIV/AIDS knowledge and stigma toward PLWHA shows inconsistent findings. In Botswana, for instance, higher knowledge correlated with stronger stigma, highlighting cultural influences (24). Conversely, in Ethiopian and Turkey hospital-based studies, greater knowledge was linked to lower stigma, especially among educated individuals (23,28). In Nepal, no significant association was found, with stigma driven by age, experience, and fear (29).\u003c/p\u003e\n\u003cp\u003eBesides knowledge, an important antecedent of stigma toward PLWHA is empathy (30,31). Empathy is defined as the ability to understand and share others\u0026apos; emotions and experiences\u0026nbsp;(32,33).\u0026nbsp;Research shows that higher empathy levels are associated with fewer stigmatizing behaviors, as empathetic individuals are less likely to engage in discrimination actions\u0026nbsp;(31,34). Empathy fosters understanding and support, which improves PLWHA\u0026rsquo;s well-being, reduces isolation, and enhances mental health. Meta-analyses indicate that empathy-driven support improves HIV treatment adherence and mental health of PLWHA\u0026nbsp;(35).\u003c/p\u003e\n\u003cp\u003eKnowledge and empathy both contribute to shaping attitudes, but their combination is more effective in reducing stigma toward PLWHA (31,36). The intergroup contact hypothesis (37) provides a theoretical framework, suggesting that increased knowledge and empathy lead to more positive attitudes toward stigmatized groups. This theory posits that accurate information and meaningful interactions reduce stereotypes, while empathy fosters emotional connections that counteract fear and prejudice (38). While knowledge reduces misconceptions and fear-based stigma (26), it alone may not be enough due to deeply ingrained cultural norms (24). Empathy, especially perspective-taking (39), humanizes PLWHA and enhances understanding, creating a comprehensive approach to stigma reduction.\u003c/p\u003e\n\u003cp\u003eBased on the existing body of knowledge, we hypothesize: (1) HIV/AIDS knowledge will be associated with stigma toward PLWHA (H1); (2) Higher levels of empathy toward PLWHA will be associated with reduced stigma toward PLWHA (H2); (3) HIV/AIDS knowledge and empathy toward PLWHA will be jointly associated with reduced stigma toward PLWHA (H3).\u003c/p\u003e"},{"header":"Methods ","content":"\u003cp\u003e\u003cstrong\u003eStudy D\u003c/strong\u003e\u003cstrong\u003eesign and\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eParticipants\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA quantitative cross-sectional survey design was employed to test the research hypotheses, using a questionnaire as the primary data collection instrument. The study involved 410 undergraduate students from a university in Surabaya, East Java, a province with the highest number of PLWHA in Indonesia\u0026nbsp;(40).\u0026nbsp;University students were chosen as participants because they represent diverse societal groups, including future leaders, and are generally receptive to new ideas\u0026nbsp;(41). Participants self-identified as non-PLWHA, representing the outgroup of PLWHA, and were recruited through proportional-accidental sampling to ensure the number of participants from each faculty reflected their proportion within the university\u0026rsquo;s total student population.\u003c/p\u003e\n\u003cp\u003eThe initial sample size was determined through an a priori power analysis using G*Power 3.1 software (42). This analysis, based on a linear multiple regression fixed model with \u003cem\u003eR\u0026sup2;\u003c/em\u003e deviation from zero, included two predictors, a statistical power of .80, \u003cem\u003e\u0026alpha;\u003c/em\u003e = .05, and an effect size of \u003cem\u003ef\u0026sup2;\u003c/em\u003e = .02, indicating a minimum required sample of 311 respondents. Ultimately, 410 respondents were recruited. A sensitivity power analysis (\u003cem\u003e\u0026alpha;\u003c/em\u003e = .05, statistical power = .80, sample size = 410, and two predictors) revealed that the smallest detectable effect size was \u003cem\u003ef\u0026sup2;\u003c/em\u003e = .0151. The participants\u0026apos; characteristics are presented in Table 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInstruments\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study utilized three psychometric scales adapted into Indonesian to align with the research context.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStigma toward PLWHA\u003c/em\u003e. The Stigmatizing Attitude Toward People Living With HIV/AIDS (SAT-PLWHA) Scale, developed by Beaulieu et al. (2014), was used to assess this variable. The scale consists of 27 items measuring stigma across seven key dimensions: concern about occasional encounters, fear of personal contact, responsibility and blame, liberalism, social support, confidentiality of serological status, and criminalization of HIV transmission. These dimensions are grounded in the three primary elements of stigma: stereotypes, prejudice, and discrimination (44). Responses on the SAT-PLWHA scale were recorded using a 5-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree). In this study, the instrument demonstrated a Cronbach\u0026rsquo;s alpha coefficient of .85, indicating a fairly high level of reliability (45).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eHIV/AIDS Knowledge\u003c/em\u003e. To measure this variable, the HIV Knowledge Questionnaire (HIV-KQ-18), developed by Carey and Schroder (2002), was utilized. The questionnaire comprises 18 items designed to evaluate knowledge related to HIV/AIDS transmission.\u0026nbsp;It employs a Guttman scale format with true or false responses, where correct answers indicate higher knowledge levels, while incorrect responses reflect lower knowledge levels.\u0026nbsp;In this study, the HIV-KQ-18 yielded a Cronbach\u0026apos;s alpha coefficient of .64, demonstrating satisfactory reliability\u0026nbsp;(45).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEmpathy toward PLWHA\u003c/em\u003e.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThis variable was measured using\u003cem\u003e\u0026nbsp;\u003c/em\u003ethe\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eToronto Empathy Scale, which consists of 16 items assessing general empathy levels and is unidimensional (Kourmousi et al., 2017). Responses were collected on a 5-point Likert scale, ranging from 1 (strongly disagree) to 5 (strongly agree). In this study, the scale demonstrated a Cronbach\u0026rsquo;s alpha reliability coefficient of .77, indicating a fairly high level of reliability (45).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProsedure and Data Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData for this study were collected through both online surveys via Google Forms and offline distribution of printed questionnaires to participants. Prior to completing the questionnaires, participants provided voluntary consent by signing an informed consent form. Descriptive statistics were first conducted to analyze participant characteristics, followed by an examination of the research variables. Assumption tests, including assessments of normality and linearity, were performed before hypothesis testing. Multiple linear regression analysis was then conducted to test the hypothesis. All data analyses were performed using JASP (Jeffrey\u0026apos;s Amazing Statistics Program) version 0.18.3 3 (48).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eTable 1 provides a demographic overview of the research participants, including their sex, age, and faculty affiliation. Additionally, it presents information on the sources from which they acquired HIV/AIDS knowledge.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e Participant characteristics (\u003cem\u003eN\u0026nbsp;\u003c/em\u003e= 410)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eCategory\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u003cem\u003e%\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eFemale\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e233\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e56.83\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e177\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e43.17\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"8\" valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e \u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(\u003cem\u003eMean\u003csub\u003eage\u003c/sub\u003e\u003c/em\u003e =\u0026nbsp;20.40;\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eSD\u003c/em\u003e = 1.08)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16px;\"\u003e\n \u003cp\u003e3.41\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16px;\"\u003e\n \u003cp\u003e14.63\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e149\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16px;\"\u003e\n \u003cp\u003e36.34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e132\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16px;\"\u003e\n \u003cp\u003e32.20\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16px;\"\u003e\n \u003cp\u003e11.71\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;.98\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;.24\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 16px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;.49\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"8\" valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFaculty\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eEconomics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e108\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e26.34\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003ePharmacy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e16.59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eLaw\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e14.63\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eEngineering\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e14.39\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003ePsychology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e12.68\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eBiotechnology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e5.61\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eCreative Industries\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e5.61\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eMedicine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e4.15\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"8\" valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSources of HIV/AIDS knowledge\u003c/strong\u003e*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eInternet \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e364\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e38.77\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eSeminar\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e207\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e22.46\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eBook\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e131\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e13.95\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eTV\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e128\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e13.63\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eNewspaper\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e3.62\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eMagazine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e3.09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eRadio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e2.45\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 34px;\"\u003e\n \u003cp\u003eOthers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 18px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 16px;\"\u003e\n \u003cp\u003e2.45\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: *Participants can give more than one answer.\u003c/p\u003e\n\u003cp\u003eThe table above indicates that the majority of participants were female students (56.83%) with a mean age of 20.4 years (\u003cem\u003eSD\u003c/em\u003e = 1.08). The primary sources of HIV/AIDS knowledge were the internet (38.77%) and seminars (22.46%). Table 2 presents descriptive statistics, including the mean (\u003cem\u003eM\u003c/em\u003e) and standard deviation (\u003cem\u003eSD\u003c/em\u003e) of the three research variables, the reliability of the instruments (Cronbach\u0026rsquo;s alpha, \u0026alpha;), and Pearson\u0026rsquo;s correlation coefficients among the variables.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2\u003c/strong\u003e Descriptive statistics and correlation between variables\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003cp\u003eVariables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003eMean\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003eSD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003ea\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003col\u003e\n \u003cli\u003eStigma against PLWHA\u0026nbsp;\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e2.97\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e.85\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003col start=\"2\"\u003e\n \u003cli\u003eEmpathy toward PLWHA\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e3.78\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e.77\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e-.26***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 44px;\"\u003e\n \u003col start=\"3\"\u003e\n \u003cli\u003eHIV/AIDS Knowledge\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 10px;\"\u003e\n \u003cp\u003e.23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 11px;\"\u003e\n \u003cp\u003e.64\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 10px;\"\u003e\n \u003cp\u003e.24***\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 11px;\"\u003e\n \u003cp\u003e-.09\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: *p \u0026lt; .05; **p \u0026lt; .01; ***p \u0026lt; .001\u003c/p\u003e\n\u003cp\u003eThe table above indicates that, with a score range of 1\u0026ndash;5 and a median of 3, the total stigma toward PLWHA score is below the median, whereas the total empathy toward PLWHA score is above the median. Additionally, the total HIV/AIDS knowledge score is .44, which is below the median of .50 (with a score range of 0\u0026ndash;1). The correlation coefficients indicate that empathy toward PLWHA is negatively associated with stigmatization, whereas HIV/AIDS knowledge is positively associated with it. Subsequently, multiple regression analysis was conducted to examine the contributions of these significant variables, as presented in Table 3.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u0026nbsp;\u003c/strong\u003eSummary of the research hypothesis testing\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"center\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 31px;\"\u003e\n \u003cp\u003eIndependent Variables\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\" style=\"width: 68px;\"\u003e\n \u003cp\u003eStigma against PLWHA (Dependent Variable)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u003cem\u003eR\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u003cem\u003eR\u003csup\u003e2\u003c/sup\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u003cem\u003eF\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026beta;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u003cem\u003eSig.\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003eHypothesis 1/H1: \u003cem\u003eX1\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e.22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003eHypothesis 2/H2: \u003cem\u003eX2\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e-.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 31px;\"\u003e\n \u003cp\u003eHypothesis 3/H3: \u003cem\u003eX1\u003c/em\u003e\u003cem\u003e,\u0026nbsp;\u003c/em\u003e\u003cem\u003eX2\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 12px;\"\u003e\n \u003cp\u003e.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e37.91\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14px;\"\u003e\n \u003cp\u003e\u0026lt; .001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\" valign=\"top\" style=\"width: 100px;\"\u003e\n \u003cp\u003eNote: \u003cem\u003eX1\u003c/em\u003e = HIV/AIDS\u0026nbsp;Knowledge; \u003cem\u003eX2\u003c/em\u003e =\u0026nbsp;Empathy toward PLWHA \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;As shown in Table 3, multiple regression analysis indicated that both independent variables, HIV/AIDS knowledge and empathy toward PLWHA, jointly associated with stigma toward PLWHA [\u003cem\u003eF\u003c/em\u003e(2, 407) = 37.91; \u003cem\u003eR\u0026sup2;\u003c/em\u003e = .16; \u003cem\u003ep\u003c/em\u003e \u0026lt; .001]. Specifically, HIV/AIDS knowledge exhibited a highly significant positive association with increased stigma toward PLWHA (\u003cem\u003e\u0026beta;\u003c/em\u003e = .22, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001). In contrast, empathy toward PLWHA had a highly significant negative effect, reducing stigma toward PLWHA (\u003cem\u003e\u0026beta;\u003c/em\u003e = -.24, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study aims to examine the role of HIV/AIDS knowledge and empathy in shaping stigma toward \u0026nbsp; \u0026nbsp;PLWHA within the Indonesia context, using a sample of university students. The hypothesis testing results, presented in Table 3, highlight three main findings. First, HIV/AIDS knowledge demonstrates a significant positive correlation with stigma toward PLWHA (\u003cem\u003e\u0026beta;\u003c/em\u003e = .22; p \u0026lt; .001). Second, empathy exhibits a significant negative correlation with stigma toward PLWHA (\u003cem\u003e\u0026beta;\u003c/em\u003e = -.24; \u003cem\u003ep\u003c/em\u003e \u0026lt; .001). Third, HIV/AIDS knowledge and empathy toward PLWHA are jointly and significantly associated with HIV-related stigma [\u003cem\u003eF\u003c/em\u003e(2, 407) = 37.91; \u003cem\u003eR\u0026sup2;\u003c/em\u003e = .16; \u003cem\u003ep\u003c/em\u003e \u0026lt; .001]. These findings are discussed in detail as following. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAs shown in Table 3, the first finding of this study reveals a positive correlation between HIV/AIDS knowledge and stigma toward PLWHA. This suggests that higher basic knowledge about the causes and transmission of HIV/AIDS is associated with stronger stigma toward PLWHA. Furthermore, the findings indicate that HIV/AIDS knowledge does not always correlate negatively with stigma, as has been commonly reported in previous studies (26,49\u0026ndash;54).\u0026nbsp;We propose three psychological mechanisms, in Indonesian sociocultural context, explaining the positive correlation between HIV/AIDS knowledge and stigma toward PLWHA: (1) cognitive dissonance, (2) belief perseverance, and (3) fear and anxiety.\u003c/p\u003e\n\u003cp\u003eThe first mechanism, cognitive dissonance, occurs when individuals experience discomfort from holding beliefs that contradict their behaviors or knowledge (55). In the context of HIV/AIDS in Indonesia, societal norms, particularly those rooted in religion, often perpetuate negative stereotypes about PLWHA (7,56,57). Despite having adequate HIV/AIDS knowledge, individuals may continue to stigmatize PLWHA due to these ingrained socioreligious norms, showing that knowledge alone cannot eliminate stigmatizing attitudes toward PLWHA (58,59).\u003c/p\u003e\n\u003cp\u003eThe second mechanism, belief perseverance, occurs when individuals maintain beliefs even after evidence discredits them (60). Despite accurate HIV/AIDS knowledge, stereotypes\u0026mdash;primarily shaped by religious norms in Indonesian society\u0026mdash;such as viewing PLWHA as solely responsible for their condition or perceiving HIV/AIDS as a moral failing, may persist, reinforcing stigma toward PLWHA (8,58,61). Research shows that such beliefs hinder stigma reduction, indicating that simply increasing HIV knowledge is not enough to overcome deeply ingrained stereotypes and beliefs that sustain discrimination\u0026nbsp;(62).\u003c/p\u003e\n\u003cp\u003eThe third psychological mechanism is fear and anxiety related to HIV/AIDS transmission. Fear appeal theory suggests that perceived threats from infectious diseases can lead to prejudice against affected groups\u0026nbsp;(63).\u0026nbsp;Even with sufficient knowledge, individuals may stigmatize PLWHA due to fear and uncertainty. In Indonesia, religious beliefs often play a significant role in amplifying this fear, as many individuals may believe that HIV/AIDS is a divine punishment or that PLWHA are morally compromised. Such beliefs can heighten the fear of transmission, particularly in the context of close social interactions, leading to increased stigma\u0026nbsp;(7,8). Fear and misinformation at the community level further shape attitudes, contributing to widespread stigmatization\u0026nbsp;(64,65).\u003c/p\u003e\n\u003cp\u003eThe three psychological mechanisms discussed above\u0026mdash;cognitive dissonance, belief perseverance, and fear and anxiety\u0026mdash;highlight that stigma toward PLWHA in Indonesia is a complex social process. Despite increased HIV/AIDS knowledge, deeply ingrained sociocultural and religious norms continue to shape negative stereotypes, reinforcing stigmatization and hindering attitude change. As stigma is a powerful social phenomenon deeply rooted in social, cultural, and historical contexts (66), addressing it requires more than simply disseminating knowledge; it demands a transformation of the underlying beliefs and fears that sustain stigma toward minority groups such as PLWHA.\u003c/p\u003e\n\u003cp\u003eThe second finding of this study (see Table 3) reveals a negative correlation between empathy and stigma toward PLWHA. Higher empathy, reflecting an individual\u0026apos;s ability to understand PLWHA\u0026apos;s experiences, is linked to lower levels of stigma, while lower empathy increases stigmatization. These results align with previous studies showing that empathy reduces stigma and discrimination against PLWHA\u0026nbsp;(67\u0026ndash;69). Empathy fosters understanding, emotional connection, and supportive social networks, which buffer stigma\u0026rsquo;s effects (Luo et al., 2022). Therefore, the negative correlation between empathy and stigma is influenced by both psychological mechanisms and social dynamics, emphasizing empathy\u0026rsquo;s role in mitigating stigma and promoting more inclusive attitudes toward PLWHA (70,71).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 3 presents the third finding, which demonstrates a significant joint association between HIV/AIDS knowledge, empathy toward PLWHA, and stigma toward PLWHA, with a coefficient of determination (\u003cem\u003eR\u0026sup2;\u003c/em\u003e) of .16. This suggests that these two variables collectively account for 16% of the variance in HIV-related stigma, representing a medium effect size (Cohen, 1988). Although empathy is associated with stigma toward PLWHA, the findings of this study (see Table 3) indicate that HIV/AIDS knowledge (\u003cem\u003eR\u0026sup2;\u003c/em\u003e = .11) plays a greater role than empathy (\u003cem\u003eR\u0026sup2;\u003c/em\u003e = .06) in explaining the occurrence of stigma toward PLWHA, as reflected in the coefficient of determination. This result suggests that cognitive mechanisms, represented by HIV/AIDS knowledge, have a stronger influence than emotional mechanisms, represented by empathy, in shaping stigma toward PLWHA.\u003c/p\u003e\n\u003cp\u003eHIV/AIDS-related stigma is a complex issue influenced by various factors beyond knowledge and empathy. These factors are categorized into five key dimensions: socio-demographic characteristics (e.g., gender, age, marital status, education, income), personal experiences (e.g., HIV testing history, personal distress), psychological and emotional factors (e.g., internalized stigma, blame, avoidance), systemic and institutional factors (e.g., healthcare worker attitudes, community-level knowledge), and cultural and religious beliefs (e.g., social groups, cultural norms). Each dimension plays a significant role in shaping stigma toward PLWHA (23,57,72)\u003c/p\u003e\n\u003cp\u003eAlthough this study identifies distinct psychological mechanisms through which HIV/AIDS knowledge and empathy influence stigma toward PLWHA, it has several limitations. First, the study employs a cross-sectional survey design, which limits its ability to establish causality or determine the direct effects of HIV/AIDS knowledge and empathy on stigma toward PLWHA. While cross-sectional designs are useful for identifying associations, their internal validity is constrained by temporal ambiguity and susceptibility to confounding (73). To address these limitations, future studies should employ experimental and longitudinal designs, as they provide stronger internal validity and are better suited for establishing causal relationships (74,75).\u003c/p\u003e\n\u003cp\u003eSecond, as this study\u0026apos;s participants were university students from a single campus in Surabaya, its findings may not fully generalize to Indonesia\u0026apos;s broader student population. Thus, external validity should be interpreted with caution. To assess the consistency of these results, future research should include more diverse populations and social contexts. Notably, this study diverges from previous research by identifying a positive association between HIV/AIDS knowledge and stigma toward PLWHA. The differing findings of this study underscore the need for further research, particularly in exploring how contextual factors such as culture and social norms shape psychological processes, as stateted by a social psychologist Thomas F. Pettigrew (76) in \u003cem\u003eThe Emergence of Contextual Social Psychology.\u003c/em\u003e Given that findings previously considered robust may vary across social contexts, external validation remains both a challenge and an opportunity for future research in social psychology.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThese findings underscore the roles of HIV/AIDS knowledge and empathy as cognitive and emotional mechanisms in shaping stigma toward PLWHA in the Indonesian sociocultural context. The sociocultural contexts, with the strong role of religion in daily life within society, influence the dynamic relationship between HIV/AIDS knowledge and stigmatizing attitudes toward marginalized groups, such as PLWHA, through psychological mechanisms, including cognitive dissonance, belief perseverance, and fear or anxiety of HIV/AIDS transmission. The results suggest that interventions should address both cognitive and emotional aspects while considering the crucial role of religion in Indonesian society. Engaging religious leaders in HIV/AIDS education can be instrumental in reinterpreting religious beliefs to foster understanding, reduce stigma, and shift community attitudes toward PLWHA. Cognitively focused interventions should aim to correct misconceptions and challenge stereotypes, while emotionally driven approaches should cultivate empathy, promoting a more compassionate and inclusive perspective toward PLWHA.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e ASP conceptualized and wrote the first draft and critically revised the manuscript. ASP and MST set up the statistical test design. ASP conducted the data analysis, which was reviewed and verified by MST. MST prepared tables with input from ASP. \u0026nbsp;MST reviewed and edited the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e The authors have no relevant financial or nonfinancial interests to disclose.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent and\u003c/strong\u003e \u003cstrong\u003eEthics Approval\u003c/strong\u003e This study protocol was approved by the Ethics Committee of the University of Surabaya under approval number 110A/KE/IC/2022. All participants signed an informed consent form before joining the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of Interest\u003c/strong\u003e The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eUNAIDS. Global HIV \u0026amp; AIDS statistics \u0026mdash; Fact sheet [Internet]. 2023 [cited 2024 Jul 6]. Available from: https://www.unaids.org/en/resources/fact-sheet\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. HIV/AIDS key facts [Internet]. 2023 [cited 2024 Jul 6]. Available from: https://www.who.int/news-room/fact-sheets/detail/hiv-aids\u003c/li\u003e\n\u003cli\u003eJocelyn, Nasution FM, Nasution NA, Asshiddiqi MH, Kimura NH, Siburian MHT, et al. HIV/AIDS in Indonesia: current treatment landscape, future therapeutic horizons, and herbal approaches. Front Public Health. 2024 Feb 14;12:1298297. \u003c/li\u003e\n\u003cli\u003eLaksemi DA, Suwanti LT, Mufasirin M, Suastika K, Sudarmaja M. Opportunistic parasitic infections in patients with human immunodeficiency virus/acquired immunodeficiency syndrome: A review. Vet World. 2020;13(4):716\u0026ndash;25. \u003c/li\u003e\n\u003cli\u003eTamir C, Connaughton A, Salazar AM. Is belief in God necessary for good values? Global survey on religion [Internet]. 2020. Available from: https://www. pewresearch.org/global/2020/07/20/the-global-god- divide/\u003c/li\u003e\n\u003cli\u003eTondok MS, Suryanto S, Ardi R. Validation of the general evaluation scale for measuring ethnic and religious prejudice in an Indonesian sample. Social Sciences. 2024;13(1):21. \u003c/li\u003e\n\u003cli\u003eHutahaean BSH, Stutterheim SE, Jonas KJ. Religion, Faith, and Spirituality as Barriers and Facilitators to Antiretroviral Therapy Initiation Among People with HIV in Indonesia. 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Pers Soc Psychol Bull. 2018 Jul;44(7):963\u0026ndash;71. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"University of Surabaya","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Stigma, HIV/AIDS Knowledge, Empathy, PLWHA, Indonesia","lastPublishedDoi":"10.21203/rs.3.rs-6362461/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6362461/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eHIV/AIDS knowledge and empathy serve as key cognitive and emotional antecedents of stigma toward \u0026nbsp;PLWHA. However, the relationship between HIV/AIDS knowledge and stigma varies across different social contexts. This study examines the roles of HIV/AIDS knowledge and empathy in shaping stigma toward PLWHA within the Indonesian sociocultural context. A quantitative cross-sectional survey was conducted with 410 undergraduate students from a university in Surabaya, Indonesia. Data were collected using the Stigmatizing Attitude Toward People Living With HIV/AIDS (SAT-PLWHA) Scale, the HIV Knowledge Questionnaire (HIV-KQ-18), and the Toronto Empathy Scale. Multiple linear regression analysis was performed to test the hypotheses. The findings indicate that both HIV/AIDS knowledge and empathy significantly influence stigma toward PLWHA [\u003cem\u003eF\u003c/em\u003e(2,407) = 37.91; \u003cem\u003ep\u003c/em\u003e \u0026lt; .001]. Specifically, higher HIV/AIDS knowledge was positively associated with increased stigma (\u003cem\u003eβ\u003c/em\u003e = .22, \u003cem\u003ep\u003c/em\u003e\u0026lt; .001), whereas higher empathy was negatively associated with stigma (\u003cem\u003eβ\u003c/em\u003e= -0.24, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001). These findings highlight the impact of HIV/AIDS knowledge and empathy on stigma toward PLWHA within Indonesia’s sociocultural context. Religion influences the relationship between knowledge and stigma through psychological mechanisms such as cognitive dissonance, belief perseverance, and fear/anxiety. This study offers insights for researchers and practitioners seeking to develop effective interventions aimed at reducing stigma, particularly in culturally sensitive contexts such as Indonesia, while engaging religious leaders in reinterpreting religious beliefs to foster understanding, empathy, and a more inclusive perspective toward PLWHA.\u003c/p\u003e","manuscriptTitle":"The Paradox of Knowledge: How HIV/AIDS Knowledge and Empathy Shape Stigma toward PLWHA in Indonesia’s Sociocultural Context","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-03 05:06:04","doi":"10.21203/rs.3.rs-6362461/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"90781bc1-9a77-450b-86c7-e918ad5adecc","owner":[],"postedDate":"April 3rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":46610190,"name":"Psychology"}],"tags":[],"updatedAt":"2025-04-03T05:06:04+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-03 05:06:04","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6362461","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6362461","identity":"rs-6362461","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}