Experienced HIV-Related Stigma in Health Care and Community Settings: Mediated Associations With Psychosocial and Health Outcomes

Discrimination, Medical Distrust, Stigma, Depressive Symptoms, Antiretroviral Medication Adherence, Engagement in Care, and Quality of Life Among Women Living With HIV in North Carolina: A Mediated Structural Equation Model

BACKGROUND

Women represent 23% of all Americans living with HIV. By 2020, more than 70% of Americans living with HIV are expected to be 50 years and older.

SETTING

This study was conducted in the Southern United States-a geographic region with the highest number of new HIV infections and deaths.

OBJECTIVE

To explore the moderating effect of age on everyday discrimination (EVD); group-based medical (GBM) distrust; enacted, anticipated, internalized HIV stigma; depressive symptoms; HIV disclosure; engagement in care; antiretroviral medication adherence; and quality of life (QOL) among women living with HIV.

METHODS

We used multigroup structural equation modeling to analyze baseline data from 123 participants enrolled at the University of North Carolina at Chapel Hill site of the Women's Interagency HIV Study during October 2013-May 2015.

RESULTS

Although age did not moderate the pathways hypothesized, age had a direct effect on internalized stigma and QOL. EVD had a direct effect on anticipated stigma and depressive symptoms. GBM distrust had a direct effect on depressive symptoms and a mediated effect through internalized stigma. Internalized stigma was the only form of stigma directly related to disclosure. Depressive symptoms were a significant mediator between GBM, EVD, and internalized stigma reducing antiretroviral therapy medication adherence, engagement in care, and QOL.

CONCLUSIONS

EVD, GBM, and internalized stigma adversely affect depressive symptoms, antiretroviral therapy medication adherence, and engagement in care, which collectively influence the QOL of women living with HIV.

Poor Self-efficacy for Healthcare Provider Interactions Among Individuals with HIV-Associated Neurocognitive Disorders

Two factors that influence HIV health behaviors and therefore may contribute to gaps in the HIV treatment continuum are poor health-related self-efficacy and HIV-associated neurocognitive disorders (HAND). However, the relationship between HAND and self-efficacy has not been assessed. In an HIV sample, 91 individuals with intact cognition (HAND-) and 40 individuals with HAND (HAND+) were administered a measure of self-efficacy for healthcare interactions with providers. Participants with HAND had significantly lower scores on this measure, which were correlated with poorer episodic and semantic memory performance, as well as self-reported memory symptoms in daily life. Findings suggest that neurocognitive impairment, and particularly memory dysfunction, may play an important role in self-efficacy for healthcare interactions in HIV. Further examination of the interplay between HAND and self-efficacy is warranted as these two factors may be important for the public health goal of identifying targets for improving access, delivery, and maintenance of HIV care.

Reorienting health systems to care for people with HIV beyond viral suppression

The effectiveness of antiretroviral therapy and its increasing availability globally means that millions of people living with HIV now have a much longer life expectancy. However, people living with HIV have disproportionately high incidence of major comorbidities and reduced health-related quality of life. Health systems must respond to this situation by pioneering care and service delivery models that promote wellness rather than mere survival. In this Series paper, we review evidence about the emerging challenges of the care of people with HIV beyond viral suppression and identify four priority areas for action: integrating HIV services and non-HIV services, reducing HIV-related discrimination in health-care settings, identifying indicators to monitor health systems' progress toward new goals, and catalysing new forms of civil society engagement in the more broadly focused HIV response that is now needed worldwide. Furthermore, in the context of an increasing burden of chronic diseases, we must consider the shift that is underway in the HIV field in relation to burgeoning policy and programmatic efforts to promote healthy ageing.

HIV stigma and viral load among African-American women receiving treatment for HIV

OBJECTIVE

African-American women are more likely than other women in the United States to experience poor HIV-related health; HIV stigma may contribute to these outcomes. This study assessed the relationship between HIV stigma and viral load, over time, among a sample of African-American women receiving treatment for HIV, and explored social support and depressive symptoms as mediators.

DESIGN

Secondary analysis of longitudinal data.

METHODS

Data came from a randomized trial of an intervention to reduce HIV stigma among African-American women in HIV care in Chicago, Illinois and Birmingham, Alabama. Sociodemographic and psychosocial data were collected at up to six study visits over 14 months. Viral loads were extracted from medical records during the study period. Generalized linear mixed effects models were used to estimate associations among overall, internalized, and enacted HIV stigma and viral load over time. Mediation analyses were used to estimate indirect effects via social support and depressive symptoms.

RESULTS

Data from 234 women were analyzed. Overall HIV stigma was significantly associated with subsequent viral load (adjusted β = 0.24, P = 0.005). Both between-subject (adjusted β = 0.74, P < 0.001) and within-subject (adjusted β = 0.34, P = 0.005) differences in enacted stigma were associated with viral load. Neither social support nor depressive symptoms were statistically significant mediators.

CONCLUSION

Ongoing experiences of HIV stigmatization may contribute to increased viral load among African-American women in primary HIV care. Interventions should aim to alleviate the consequences of stigma experienced by patients and prevent future stigmatization.

Poverty stigma is associated with suboptimal HIV care and treatment outcomes among women living with HIV in the United States

OBJECTIVE

To examine whether experienced poverty stigma is associated with worse HIV care and treatment outcomes.

DESIGN

We analyzed cross-sectional data from 433 women living with HIV enrolled in the Women's Adherence and Visit Engagement substudy of the Women's Interagency HIV Study.

METHODS

Exposure was experienced poverty stigma, measured using the Perceived Stigma of Poverty Scale. Outcomes were viral suppression, CD4 cell count at least 350 cells/μl, and attending all HIV care visits in the past 6 months. Multivariable logistic regression models adjusted for income, age, race/ethnicity, education, substance use, months taking antiretroviral therapy (ART), number of antiretroviral pills in ART regimen, unstable housing, relationship status, and exchanging sex for money, drugs, or shelter. We also explored whether self-reported at least 95% ART adherence mediated the relationship between poverty stigma and viral suppression and CD4 cell count at least 350 cells/μl.

RESULTS

Experienced poverty stigma was associated with lower adjusted odds of viral suppression [adjusted odds ratio (aOR) 0.76; 95% confidence interval (CI) 0.61-0.96], CD4 cell count at least 350 cells/μl (aOR 0.69; 95% CI 0.52-0.91), and attending all HIV care visits (aOR 0.73; 95% CI: 0.54-0.98). Exploratory mediation analysis suggests that at least 95% ART adherence significantly mediates the relationship between experienced poverty stigma and viral suppression and CD4 cell count at least 350 cells/μl.

CONCLUSION

Longitudinal research should assess these relationships over time. Findings support interventions and policies that seek to reduce poverty stigma among people living with HIV.

Neighborhood Racial Diversity, Socioeconomic Status, and Perceptions of HIV-Related Discrimination and Internalized HIV Stigma Among Women Living with HIV in the United States

Relationships that traverse sociodemographic categories may improve community attitudes toward marginalized groups and potentially protect members of those groups from stigma and discrimination. The present study evaluated whether internalized HIV stigma and perceived HIV-related discrimination in health care settings differ based on individual- and neighborhood-level characteristics of women living with HIV (WLHIV). We also sought to extend previous conceptual and empirical work to explore whether perceived HIV-related discrimination mediated the association between neighborhood racial diversity and internalized HIV stigma. A total of 1256 WLHIV in the Women's Interagency HIV Study (WIHS) attending 10 sites in metropolitan areas across the United States completed measures of internalized HIV stigma and perceived HIV-related discrimination in health care settings. Participants also provided residential information that was geocoded into Federal Information Processing Standard (FIPS) codes and linked with census-tract level indicators. In cross-sectional analyses, greater neighborhood racial diversity was associated with less internalized HIV stigma and less perceived HIV-related discrimination regardless of individual race. Neighborhood median income was positively associated with internalized HIV stigma and perceived discrimination, while individual income was negatively associated with perceptions of stigma and discrimination. In an exploratory mediation analysis, neighborhood racial diversity had a significant indirect effect on internalized HIV stigma through perceived HIV-related discrimination. An indirect effect between neighborhood income and internalized stigma was not supported. These findings suggest that greater neighborhood racial diversity may lessen HIV stigma processes at the individual level and that HIV stigma-reduction interventions may be most needed in communities that lack racial diversity.

A Mixed Methods Study of Anticipated and Experienced Stigma in Health Care Settings Among Women Living with HIV in the United States

Among places where people living with HIV experience and anticipate HIV-related stigma, stigma in health care settings may be particularly harmful. Utilizing an exploratory sequential mixed methods approach, we conducted interviews (n = 76) and questionnaires (N = 460) with older adult women living with HIV enrolled in the Women's Interagency HIV Study in Birmingham, AL; Jackson, MS; Atlanta, GA; and San Francisco, CA. Interviews addressed facilitators and barriers to HIV treatment adherence, including HIV-related stigma. Qualitative data were coded using thematic analysis. Questionnaires assessed self-reported antiretroviral therapy (ART) adherence and experienced and anticipated HIV-related stigma from various sources (i.e., health care personnel, family, partner, and community). Covariate-adjusted logistic regression analyses examined total and mediated effects of stigma on ART adherence. Interviewees described fears and experiences of stigma in health care settings; including privacy violations, disrespect for patient autonomy, and reproductive coercion; and how these influenced their adherence to HIV treatment recommendations. Experienced and anticipated HIV-related stigma in health care settings were associated with suboptimal (or <95%) ART adherence in separate models controlling for experienced or anticipated stigma, respectively, from other sources. When entered together, only anticipated stigma in health care settings was associated with suboptimal ART adherence, controlling for anticipated and experienced stigma from other sources. The effect of anticipated stigma in health care settings on suboptimal ART adherence may work through the pathways of lower adherence self-efficacy, higher depressive symptoms, and higher coping by substance use. These findings indicate that interventions should promote cultures of acceptance within health care settings and resilience-based strategies for women to combat stigma and promote life-sustaining behaviors.

Experience Sampling Method Versus Questionnaire Measurement of HIV Stigma: Psychosocial Predictors of Response Discrepancies and Associations With HIV Outcomes

Accurate measurement of HIV-related stigma is key in understanding and reducing stigma for people living with HIV (PLWH). Experience sampling method (ESM) measures "state"-level phenomena and may improve understanding of daily stigma experiences of PLWH. In 109 men living with HIV, we examined: 1) associations between questionnaire (Q) and ESM internalized and enacted stigma measures; 2) psychosocial predictors (e.g., coping style, perceived HIV community stigma, helplessness) of discrepancies between Q and ESM internalized and enacted stigma; 3) whether Q or ESM measures better predict HIV outcomes. Hierarchical Linear Modeling showed moderate associations between ESM and Q measures of both internalized and enacted stigma. A majority of the psychosocial measures were associated with larger differences between both Q- and ESM-internalized stigma and enacted stigma, respectively. ESM measures were stronger predictors of visit adherence than Q measures. ESM may be advantageous in understanding moment-to-moment changes in stigma and associated processes in PLWH, particularly those with maladaptive psychological traits.

Mediating Effects of Depressive Symptoms on Perceived Social Support and HIV Disclosure: Assessing Moderation by Sex

People living with HIV may decide to disclose their HIV-positive status after considering the benefits and costs. Studies have shown associations between perceived social support, depressive symptoms and HIV disclosure among men and women; however, research assessing the mediating pathway among these variables and the associated disparities by sex are lacking. Therefore, the aims of this study were to determine the association between perceived social support from family and friends and HIV disclosure to sexual partners; assess the mediating effects of depressive symptoms; and examine the disparities by sex. Participants included 147 men and 115 women living with HIV who took part in a disclosure intervention study. Mediation analyses were conducted to determine the direct and indirect associations between perceived social support from family and friends, depressive symptoms, and disclosure behavior. Depressive symptoms mediated the association between perceived social support (from family: β = 0.103, p = 0.019; and from friends: β = 0.111, p = 0.009) and HIV disclosure to sexual partners, specifically among women. However, these pathways were not statistically significant among men. Women living with HIV may benefit from two types of interventions: (1) Disclosure to sexual partners interventions, which aim to accentuate perceived social support from family and friends through attenuating depressive symptoms; and (2) Social support interventions, which may increase disclosure to sexual partners via reducing depressive symptoms.