Sexual Norms, Religiosity, and Stigma in the Epidemiology of HIV and STI: A Cross-National Ecological Study of 68 Countries

Background/Objectives: Whether country-level sexual norms, religious salience and belief, and HIV-related social distancing are independently associated with HIV and non-HIV STI burden beyond economic conditions remains uncertain. Methods: We analyzed harmonized cross-national data from 68 countries (WVS waves 1996–2021; outcomes matched through 2022) using hierarchical OLS with HC3 robust standard errors, PCA-derived normative components, and GDP-adjusted inequality (Net GINI). Results: Higher GDP was associated with lower burden (HIV: b = −1.063; STI: b = −0.537; both p < 0.001), whereas higher inequality was independently associated with HIV (b = 0.074, p = 0.014) but not STI burden (p = 0.381). The religious salience-and-belief component showed no independent association after economic factors and HIV-related social distancing were included (HIV: p = 0.791; STI: p = 0.101). Sexual-attitude permissiveness was associated with HIV before social distancing entered the model (b = 0.461, p = 0.014) but not afterward (p = 0.922). Greater social distancing was inversely associated with measured burden (HIV: b = −3.157, p = 0.002; STI: b = −1.561, p < 0.001), but these associations attenuated to non-significance after adjustment for World Bank region (HIV: p = 0.745; STI: p = 0.187). Conclusions: Lower social distancing may facilitate testing and disclosure, increasing epidemiological visibility rather than true transmission. Programs should integrate stigma reduction into confidential testing and clinician training, anticipating short-term rises in recorded cases where testing improves.