{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,16]],"date-time":"2026-10-16T10:31:00Z","timestamp":1792146660866,"version":"4.4.0"},"reference-count":49,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2025,12,3]],"date-time":"2025-12-03T00:00:00Z","timestamp":1764720000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Public Health"],"abstract":"\n Background<\/jats:title>\n Older men (\u226550\u202fyears) in China face elevated HIV infection risks, yet HIV stigma remains a significant barrier to prevention. Although HIV knowledge is frequently assumed to reduce stigma, the evidence is inconsistent. This cross-sectional study examined the association between HIV knowledge and stigma among older men in Southwest China, specifically investigating potential nonlinear patterns within sociocultural contexts.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n We conducted a cross-sectional survey from July to August 2023 in three high-HIV-burden areas of Sichuan Province. Using a multi-stage cluster random sampling design, 841 HIV-negative men completed structured interviews. All analyses incorporated survey weights to ensure representativeness. HIV knowledge was assessed via a validated 8-item scale (score range 0\u20138). Stigma was measured with an adapted 10-item scale (score range 10\u201350). Survey-weighted hierarchical linear regression was used to test linear and quadratic associations adjusted for covariates. Survey-weighted segmented regression analyses confirmed robustness.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n \n The weighted mean HIV knowledge score was 4.39 (SD\u202f=\u202f2.13), and the weighted mean stigma score was 31.78 (SD\u202f=\u202f5.60). Regression analysis revealed an inverted U-shaped association. Stigma initially increased with increasing knowledge (linear\n \u03b2<\/jats:italic>\n \u202f=\u202f1.71,\n p<\/jats:italic>\n \u202f&lt;\u202f0.001), peaked at a knowledge score of 4.14, and subsequently decreased with increasing knowledge gain (quadratic\n \u03b2<\/jats:italic>\n \u202f=\u202f\u22120.21,\n p<\/jats:italic>\n \u202f&lt;\u202f0.001). Robustness analyses confirmed differential knowledge-stigma associations across knowledge levels (interaction\n \u03b2<\/jats:italic>\n \u202f=\u202f\u22121.47,\n p<\/jats:italic>\n \u202f&lt;\u202f0.001). Lower stigma was independently associated with non-rural household registration (\n \u03b2<\/jats:italic>\n \u202f=\u202f\u22122.39, p\u202f&lt;\u202f0.001), access to a greater number of HIV health education channels (2\u20133 types:\n \u03b2<\/jats:italic>\n \u202f=\u202f\u22121.07,\n p<\/jats:italic>\n \u202f&lt;\u202f0.01; \u22654 types:\n \u03b2<\/jats:italic>\n \u202f=\u202f\u22122.29,\n p<\/jats:italic>\n \u202f&lt;\u202f0.05), and more liberal sexual attitudes (\n \u03b2<\/jats:italic>\n \u202f=\u202f\u22120.19,\n p<\/jats:italic>\n \u202f&lt;\u202f0.001). Social support and socioeconomic status were not associated.\n <\/jats:p>\n <\/jats:sec>\n \n Conclusion<\/jats:title>\n Among older Chinese men, HIV knowledge has an inverted U-shaped association with stigma. Initial knowledge acquisition correlates with heightened stigma, potentially reflecting sociocultural interpretations of fragmented information. Only beyond a specific threshold does further knowledge correlate with reduced stigma. Interventions may need to be staged or tailored based on individuals\u2019 existing knowledge levels, addressing both the nonlinear knowledge-stigma dynamic and underlying sociocultural norms.<\/jats:p>\n <\/jats:sec>","DOI":"10.3389\/fpubh.2025.1685602","type":"journal-article","created":{"date-parts":[[2025,12,3]],"date-time":"2025-12-03T06:39:36Z","timestamp":1764743976000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":2,"title":["The knowledge paradox: an inverted U-shaped association between HIV knowledge and stigma among older men in Sichuan Province, Southwest China"],"prefix":"10.3389","volume":"13","author":[{"given":"Zhihua","family":"Ye","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jin","family":"Peng","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shu","family":"Liang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yuan","family":"Li","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jiang","family":"Yuan","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ruixi","family":"Zhang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jia","family":"He","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shuangru","family":"Li","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bihui","family":"Yang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xiaochun","family":"Zhang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yi","family":"Yang","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2025,12,3]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"e119","DOI":"10.1016\/S2666-7568(22)00041-1","article-title":"The lancet healthy L. ageing with HIV","volume":"3","year":"2022","journal-title":"Lancet Healthy Longev"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"e281","DOI":"10.1016\/S2352-3018(22)00009-1","article-title":"How health systems can adapt to a population ageing with HIV and comorbid disease","volume":"9","author":"Kiplagat","year":"2022","journal-title":"Lancet HIV."},{"key":"ref3","doi-asserted-by":"publisher","first-page":"16077","DOI":"10.1038\/s41598-022-20146-2","article-title":"An exploratory transmission mode of HIV\/AIDS among older people based on data from multiple sources in China","volume":"12","author":"Sun","year":"2022","journal-title":"Sci Rep"},{"key":"ref4","doi-asserted-by":"publisher","first-page":"399","DOI":"10.3967\/bes2024.044","article-title":"Characteristics of the HIV\/AIDS epidemic among people aged \u2265 50 years in China during 2018\u20132021","volume":"37","author":"Hou","year":"2024","journal-title":"Biomed Environ Sci"},{"key":"ref5","doi-asserted-by":"publisher","first-page":"2095","DOI":"10.1186\/s12889-021-12139-z","article-title":"Lifetime commercial heterosexual behavior among HIV negative elderly men from rural Chengdu, China: a modified knowledge-attitude-practice perspective","volume":"21","author":"Yang","year":"2021","journal-title":"BMC Public Health"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"356","DOI":"10.1186\/s12879-023-08178-z","article-title":"Experiences of visiting female sex workers, social interaction, support and HIV infection among elderly men from rural China","volume":"23","author":"Yang","year":"2023","journal-title":"BMC Infect Dis"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"96","DOI":"10.1186\/s12981-021-00415-2","article-title":"HIV\/AIDS late presentation and its associated factors in China from 2010 to 2020: a systematic review and meta-analysis","volume":"18","author":"Sun","year":"2021","journal-title":"AIDS Res Ther"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"e106","DOI":"10.1016\/S2352-3018(20)30309-X","article-title":"Stigma reduction: an essential ingredient to ending AIDS by 2030","volume":"8","author":"Nyblade","year":"2021","journal-title":"Lancet HIV"},{"key":"ref9","doi-asserted-by":"publisher","first-page":"848","DOI":"10.1186\/s12889-015-2197-0","article-title":"Stigma, HIV and health: a qualitative synthesis","volume":"15","author":"Chambers","year":"2015","journal-title":"BMC Public Health"},{"key":"ref10","doi-asserted-by":"publisher","first-page":"e011453","DOI":"10.1136\/bmjopen-2016-011453","article-title":"Examining the associations between HIV-related stigma and health outcomes in people living with HIV\/AIDS: a series of meta-analyses","volume":"6","author":"Rueda","year":"2016","journal-title":"BMJ Open"},{"key":"ref11","doi-asserted-by":"publisher","first-page":"392","DOI":"10.1097\/JNC.0000000000000237","article-title":"A review of the state of the science of HIV and stigma: context, conceptualization, measurement, interventions, gaps, and future priorities","volume":"32","author":"Relf","year":"2021","journal-title":"J Assoc Nurses AIDS Care"},{"key":"ref12","doi-asserted-by":"publisher","first-page":"943","DOI":"10.1111\/hex.12535","article-title":"Stigmatization among people living with HIV in Hong Kong: a qualitative study","volume":"20","author":"Mo","year":"2017","journal-title":"Health Expect"},{"key":"ref13","doi-asserted-by":"publisher","first-page":"706","DOI":"10.1080\/09540121.2017.1396282","article-title":"Independent and synergistic effects of self- and public stigmas on quality of life of HIV-infected persons","volume":"30","author":"Lindayani","year":"2018","journal-title":"AIDS Care"},{"key":"ref14","doi-asserted-by":"publisher","first-page":"10709","DOI":"10.1038\/s41598-023-37948-7","article-title":"HIV\/AIDS stigma accumulation among people living with HIV: a role of general and relative minority status","volume":"13","author":"Gruszczy\u0144ska","year":"2023","journal-title":"Sci Rep"},{"key":"ref15","doi-asserted-by":"publisher","first-page":"311","DOI":"10.1037\/a0031889","article-title":"Is stigma internalized? The longitudinal impact of public stigma on self-stigma","volume":"60","author":"Vogel","year":"2013","journal-title":"J Couns Psychol"},{"key":"ref16","doi-asserted-by":"publisher","first-page":"231","DOI":"10.1089\/apc.2020.0236","article-title":"Role of self-stigma in pathways from HIV-related stigma to quality of life among people living with HIV","volume":"35","author":"van der Kooij","year":"2021","journal-title":"AIDS Patient Care STDs"},{"key":"ref17","volume-title":"UNAIDS Global AIDS Update 2025","year":"2025"},{"key":"ref18","doi-asserted-by":"publisher","first-page":"1255","DOI":"10.1080\/09540121.2017.1282601","article-title":"Social-cultural factors of HIV-related stigma among the Chinese general population in Hong Kong","volume":"29","author":"Yeo","year":"2017","journal-title":"AIDS Care"},{"key":"ref19","doi-asserted-by":"publisher","first-page":"29247","DOI":"10.3402\/gha.v9.29247","article-title":"Secular trends in HIV knowledge and attitudes among Vietnamese women based on the multiple Indicator cluster surveys, 2000, 2006, and 2011: what do we know and what should we do to protect them?","volume":"9","author":"Van Huy","year":"2016","journal-title":"Glob Health Action"},{"key":"ref20","doi-asserted-by":"publisher","first-page":"154","DOI":"10.1186\/s12879-017-2216-0","article-title":"Factors associated with stigma attitude towards people living with HIV among general individuals in Heilongjiang, Northeast China","volume":"17","author":"Li","year":"2017","journal-title":"BMC Infect Dis"},{"key":"ref21","doi-asserted-by":"publisher","first-page":"1517","DOI":"10.1186\/s12889-024-18974-0","article-title":"HIV-related public stigma in the era of \"undetectable\u202f=\u202fUntransmittable\": a population-based study in Hong Kong","volume":"24","author":"Lau","year":"2024","journal-title":"BMC Public Health"},{"key":"ref22","doi-asserted-by":"publisher","first-page":"83","DOI":"10.1111\/hiv.13536","article-title":"Prevalence and sociodemographic determinants of public stigma towards people with HIV and its impact on HIV testing uptake: a cross-sectional study in 64 low- and middle-income countries","volume":"25","author":"Mendez-Lopez","year":"2024","journal-title":"HIV Med"},{"key":"ref23","doi-asserted-by":"publisher","first-page":"1912","DOI":"10.1016\/j.socscimed.2006.04.016","article-title":"Comparative stigma of HIV\/AIDS, SARS, and tuberculosis in Hong Kong","volume":"63","author":"Mak","year":"2006","journal-title":"Soc Sci Med"},{"key":"ref24","doi-asserted-by":"publisher","first-page":"S60","DOI":"10.1016\/j.ypmed.2013.03.013","article-title":"Prevalence and factors associated with HIV\/AIDS-related stigma and discriminatory attitudes: a cross-sectional nationwide study","volume":"57","author":"Wong","year":"2013","journal-title":"Prev Med"},{"key":"ref25","doi-asserted-by":"publisher","first-page":"557","DOI":"10.60787\/nmj.v65i3.517","article-title":"Influence of knowledge of stigmatization and discriminatory practices against HIV-positive persons on pregnant women's HIV testing in Nigeria","volume":"65","author":"Nzelu","year":"2024","journal-title":"Niger Med J"},{"key":"ref26","doi-asserted-by":"publisher","first-page":"347","DOI":"10.1017\/S0021932025000203","article-title":"Association between HIV-related knowledge and attitudes towards persons living with HIV in northern Kosovo: the quantile regression approach","volume":"57","author":"Milic","year":"2025","journal-title":"J Biosoc Sci"},{"key":"ref27","doi-asserted-by":"publisher","first-page":"1398980","DOI":"10.3389\/fpubh.2024.1398980","article-title":"HIV\/AIDS-related knowledge and attitudes toward people living with HIV among college students in Xuzhou, Jiangsu Province, China: a cross-sectional survey","volume":"12","author":"Li","year":"2024","journal-title":"Front Public Health"},{"key":"ref28","doi-asserted-by":"publisher","first-page":"e65674","DOI":"10.2196\/65674","article-title":"The effect of a brief video-based intervention to improve AIDS prevention in older men: randomized controlled trial","volume":"11","author":"Huaju","year":"2025","journal-title":"JMIR Public Health Surveill"},{"key":"ref29","doi-asserted-by":"publisher","first-page":"56","DOI":"10.2174\/1570162X21666230123154718","article-title":"An observational study on HIV and syphilis rates and associated risk factors among elderly men in Wuxi, China","volume":"21","author":"Huang","year":"2023","journal-title":"Curr HIV Res"},{"key":"ref30","doi-asserted-by":"crossref","first-page":"515","DOI":"10.1007\/978-981-13-8518-6_28","article-title":"HIV-related stigma and discrimination in China","volume-title":"HIV\/AIDS in China: Epidemiology, prevention and treatment","author":"Yin","year":"2020"},{"key":"ref31","doi-asserted-by":"publisher","first-page":"769","DOI":"10.1016\/j.ijid.2021.02.077","article-title":"Epidemiological and spatiotemporal analyses of HIV\/AIDS prevalence among older adults in Sichuan, China between 2008 and 2019: a population-based study","volume":"105","author":"Yuan","year":"2021","journal-title":"Int J Infect Dis"},{"key":"ref32","doi-asserted-by":"publisher","first-page":"781","DOI":"10.1007\/s10461-007-9331-7","article-title":"HIV\/AIDS stigma: reliability and validity of a new measurement instrument in Chennai, India","volume":"12","author":"Zelaya","year":"2008","journal-title":"AIDS Behav"},{"key":"ref33","doi-asserted-by":"publisher","first-page":"1708","DOI":"10.1186\/s12889-019-8054-9","article-title":"Application of the Chinese version of Zelaya's HIV-related stigma scale to undergraduates in mainland China","volume":"19","author":"Ruan","year":"2019","journal-title":"BMC Public Health"},{"key":"ref34","doi-asserted-by":"publisher","first-page":"572","DOI":"10.1136\/jech-2021-218265","article-title":"Measuring older people's socioeconomic position: a scoping review of studies of self-rated health, health service and social care use","volume":"76","author":"Spiers","year":"2022","journal-title":"J Epidemiol Community Health"},{"key":"ref35","doi-asserted-by":"publisher","first-page":"131","DOI":"10.1186\/s12889-024-21201-5","article-title":"Socioeconomic status moderate the relationship between mental health literacy, social participation, and active aging among Chinese older adults: evidence from a moderated network analysis","volume":"25","author":"Huang","year":"2025","journal-title":"BMC Public Health"},{"key":"ref36","doi-asserted-by":"publisher","first-page":"e297","DOI":"10.1371\/journal.pmed.0040297","article-title":"Strengthening the reporting of observational studies in epidemiology (STROBE): explanation and elaboration","volume":"4","author":"Vandenbroucke","year":"2007","journal-title":"PLoS Med"},{"key":"ref37","doi-asserted-by":"publisher","first-page":"109","DOI":"10.1111\/j.1468-0084.2009.00569.x","article-title":"With or without U? The appropriate test for a U-shaped relationship","volume":"72","author":"Lind","year":"2010","journal-title":"Oxf Bull Econ Stat"},{"key":"ref38","doi-asserted-by":"publisher","first-page":"591","DOI":"10.1177\/109019810002700506","article-title":"A meta-analysis of fear appeals: implications for effective public health campaigns","volume":"27","author":"Witte","year":"2000","journal-title":"Health Educ Behav"},{"key":"ref39","doi-asserted-by":"publisher","first-page":"130","DOI":"10.1080\/09540120600866473","article-title":"Fear appeals and treatment side-effects: an effective combination for HIV prevention?","volume":"19","author":"Slavin","year":"2007","journal-title":"AIDS Care"},{"key":"ref40","doi-asserted-by":"publisher","first-page":"1230","DOI":"10.1080\/09540120701402848","article-title":"Associations between stigmatization toward HIV-related vulnerable groups and similar attitudes toward people living with HIV\/AIDS: branches of the same tree?","volume":"19","author":"Lau","year":"2007","journal-title":"AIDS Care"},{"key":"ref41","doi-asserted-by":"publisher","first-page":"398","DOI":"10.1016\/j.socscimed.2008.03.011","article-title":"'Face' and the embodiment of stigma in China: the cases of schizophrenia and AIDS","volume":"67","author":"Yang","year":"2008","journal-title":"Soc Sci Med"},{"key":"ref42","doi-asserted-by":"publisher","first-page":"8","DOI":"10.1093\/phe\/phaf002","article-title":"Association with immorality explains HIV stigma in the USA","volume":"18","author":"Davoudpour","year":"2025","journal-title":"Public Health Ethics"},{"key":"ref43","doi-asserted-by":"publisher","first-page":"540","DOI":"10.1521\/aeap.2017.29.6.540","article-title":"Understanding HIV transmission and illness stigma: a relationship revisited in rural Rwanda","volume":"29","author":"Kang","year":"2017","journal-title":"AIDS Educ Prev"},{"key":"ref44","doi-asserted-by":"publisher","first-page":"e0261978","DOI":"10.1371\/journal.pone.0261978","article-title":"Discriminatory attitude towards people living with HIV\/AIDS and its associated factors among adult population in 15 sub-Saharan African nations","volume":"17","author":"Teshale","year":"2022","journal-title":"PLoS One"},{"key":"ref45","doi-asserted-by":"publisher","first-page":"2755","DOI":"10.2147\/RMHP.S489989","article-title":"The relationship between HIV\/AIDS knowledge and stigmatizing attitudes towards people living with HIV\/AIDS: an educational intervention study","volume":"17","author":"Yap\u0131c\u0131","year":"2024","journal-title":"Risk Manag Healthc Policy"},{"key":"ref46","doi-asserted-by":"publisher","first-page":"41","DOI":"10.1186\/s12916-018-1244-y","article-title":"A systematic review of multi-level stigma interventions: state of the science and future directions","volume":"17","author":"Rao","year":"2019","journal-title":"BMC Med"},{"key":"ref47","doi-asserted-by":"publisher","first-page":"3414","DOI":"10.1007\/s10461-023-04057-5","article-title":"Impact of mass media on HIV\/AIDS stigma reduction: a systematic review and meta-analysis","volume":"27","author":"Aghaei","year":"2023","journal-title":"AIDS Behav"},{"key":"ref48","doi-asserted-by":"publisher","first-page":"5575","DOI":"10.4103\/jfmpc.jfmpc_651_24","article-title":"The elderly population's social networks and HIV perceptions: evidence from China","volume":"13","author":"Shen","year":"2024","journal-title":"J Family Med Prim Care"},{"key":"ref49","doi-asserted-by":"publisher","first-page":"e074694","DOI":"10.1136\/bmjopen-2023-074694","article-title":"Socioeconomic inequality and contributors in accepting attitudes toward people living with HIV among adults in Ethiopia from 2005 to 2016: a population-based cross-sectional study","volume":"13","author":"Endalamaw","year":"2023","journal-title":"BMJ Open"}],"container-title":["Frontiers in Public Health"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpubh.2025.1685602\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,12,3]],"date-time":"2025-12-03T06:39:38Z","timestamp":1764743978000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpubh.2025.1685602\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,12,3]]},"references-count":49,"alternative-id":["10.3389\/fpubh.2025.1685602"],"URL":"https:\/\/doi.org\/10.3389\/fpubh.2025.1685602","relation":{},"ISSN":["2296-2565"],"issn-type":[{"value":"2296-2565","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,12,3]]},"article-number":"1685602"}}