Social stigma concerns and HIV medication adherence

Multi-level factors affecting entry into and engagement in the HIV continuum of care in Iringa, Tanzania

Progression through the HIV continuum of care, from HIV testing to lifelong retention in antiretroviral therapy (ART) care and treatment programs, is critical to the success of HIV treatment and prevention efforts. However, significant losses occur at each stage of the continuum and little is known about contextual factors contributing to disengagement at these stages. This study sought to explore multi-level barriers and facilitators influencing entry into and engagement in the continuum of care in Iringa, Tanzania. We used a mixed-methods study design including facility-based assessments and interviews with providers and clients of HIV testing and treatment services; interviews, focus group discussions and observations with community-based providers and clients of HIV care and support services; and longitudinal interviews with men and women living with HIV to understand their trajectories in care. Data were analyzed using narrative analysis to identify key themes across levels and stages in the continuum of care. Participants identified multiple compounding barriers to progression through the continuum of care at the individual, facility, community and structural levels. Key barriers included the reluctance to engage in HIV services while healthy, rigid clinic policies, disrespectful treatment from service providers, stock-outs of supplies, stigma and discrimination, alternate healing systems, distance to health facilities and poverty. Social support from family, friends or support groups, home-based care providers, income generating opportunities and community mobilization activities facilitated engagement throughout the HIV continuum. Findings highlight the complex, multi-dimensional dynamics that individuals experience throughout the continuum of care and underscore the importance of a holistic and multi-level perspective to understand this process. Addressing barriers at each level is important to promoting increased engagement throughout the continuum.

HIV-Infected Individuals Who Delay, Decline, or Discontinue Antiretroviral Therapy: Comparing Clinic- and Peer-Recruited Cohorts

A substantial proportion of persons living with HIV/AIDS (PLHA) delay, decline, or discontinue antiretroviral therapy (ART) when it is medically indicated (40–45%), largely African-Americans and Latinos/Hispanics. This study explores the feasibility of locating PLHA, who are not on ART (PLHA-NOA) through clinics and peer-referral; compares the two cohorts on multi-level barriers to ART; and examines readiness to initiate/reinitiate ART, a predictor of treatment outcomes. We recruited adult HIV-infected African-American and Latino/Hispanic PLHA-NOA through HIV hospital clinics and peer-referral in 2012–2013. Participants were engaged in structured 1-h assessments with reliable/valid measures on barriers to ART. We found that recruitment through peers (63.2%, 60/95) was more feasible than in clinics (36.8%, 35/90). Participants were 48.0 years old and had lived with HIV for 14.7 years on average, and 56.8% had taken ART previously. Most (61.1%) were male and African-American (76.8%), and 23.2% were Latino/Hispanic. Peer-recruited participants were older, had lived with HIV longer, were less engaged in HIV care, and were more likely to have taken ART previously. The cohorts differed in reasons for discontinuing ART. Levels of ART knowledge were comparable between cohorts (68.5% correct), and there were no differences in attitudes toward ART (e.g., mistrust), which were in the neutral range. In bivariate linear regression, readiness for ART was negatively associated with physician mistrust (B = −10.4) and positively associated with self-efficacy (B = 5.5), positive outcome expectancies (B = 6.3), beliefs about personal necessity of ART (B = 17.5), and positive internal norms (B = 7.9). This study demonstrates the feasibility of engaging this vulnerable population through peer-referral. Peer-recruited PLHA evidence particularly high rates of risk factors compared to those in hospital clinics. Interventions to support ART initiation and continuation are sorely needed for both subgroups.

Stigma against people with HIV/AIDS in rural Ethiopia, 2005 to 2011: signs and predictors of improvement

This study sought to determine trends in and factors associated with stigma against people with HIV/AIDS in Ethiopia. Rural data from the 2005 and 2011 Demographic and Health Surveys were analyzed. HIV testing rates among males increased dramatically from 2005 to 2011 (8-35 %). Among females, testing rates dropped 10 % during the same period. HIV knowledge was associated with stigma, shown by a negative correlation in both data waves, but groups with higher knowledge tended to have lower stigma. Lower levels of knowledge were uniformly associated with higher levels of stigma, but higher levels of knowledge, combined with higher levels of education, were associated with lower levels of stigma in a multiplicative way. Improvements in knowledge can serve as an important intermediate process to behavior change. The found interaction suggests improvements in either education or knowledge can reduce stigma, and when both are improved, stigma reduction will be more dramatic.

Psychosocial burdens negatively impact HIV antiretroviral adherence in gay, bisexual, and other men who have sex with men aged 50 and older

We sought to characterize HIV antiretroviral therapy (ART) adherence and psychosocial correlates of adherence in a sample of gay, bisexual, and other non-gay or -bisexual identified men who have sex with men aged 50 and over. As part of a cross-sectional study we recruited a community-based sample of 199 men and assessed adherence to current ART medications along four domains: (1) missing doses in the past 4 days, (2) taking doses on the specified schedule in the past 4 days, (3) following instructions about how to take the medications (e.g., to take medications with food), and (4) missing doses in the last weekend. A total adherence score was also computed. Bivariable analyses indicated negative associations between depression, sexual compulsivity, and HIV-related stigma with each of the individual adherence variables and the composite adherence score, while an older age was found to be protective. In multivariable analyses, controlling for age and educational attainment, a higher likelihood of missing doses and failing to follow instructions were related to higher levels of HIV-related stigma, while dosing off-schedule and missing doses on weekends was associated with higher levels of sexual compulsivity. These results indicate that psychosocial burdens undermine the adherence behaviors of older HIV-positive sexual minority men. Programming and services to address this compromising health behavior must embrace a holistic approach to health as informed by syndemics theory, while attending to the developmental and age-specific needs of older men.

Persistent HIV-related stigma among an outpatient US clinic population

Despite advancements in the public's understanding of HIV infection, felt stigma towards individuals living with HIV persists. Stigma has been associated with adverse health outcomes, including poor adherence to care, and increased participation in HIV transmission risk behaviours. We evaluated the level of felt stigma and its relationship to other psychosocial and medical factors among a sample of 201 individuals with HIV engaged in care. The overall mean stigma score, as measured by the Reece Stigma Scale, was 21.7 (SD 8.7). In univariate analysis, felt stigma scores were higher among women, African Americans, younger participants, and individuals with less education. Higher felt stigma scores were also found among individuals who reported having fair to poor overall health, moderate to severe symptoms of depression and anxiety, and those with a current diagnosis of alcohol dependence, generalised anxiety disorder, agoraphobia, pain disorder, and current smokers. Higher felt stigma scores were independently associated with individuals with anxiety symptoms. These analyses highlight that stigma persists among individuals with HIV and may play an important role in HIV care. The relationship between psychiatric disorders and psychosocial factors highlights an opportunity to develop interventions that will address these common comorbidities and reduce stigma.

Assessment of stigma in patients with cystic fibrosis

Background

Research that explores stigma in Cystic Fibrosis (CF) is limited. Productive cough, repeated lung infections, and periods of serious illness requiring hospitalizations are among common symptoms of CF. These symptoms may cause a negative perception by others. We developed a CF-specific Stigma Scale and tested its psychometric properties.

Methods

We conducted a focus group with 11 participants including adult patients with CF (n = 5) and their informal caregivers (n = 6). The thematic content of the focus group was analyzed to find key themes. We developed a CF-specific Stigma Scale and assessed its psychometric properties in a 3-month prospective cohort study of adult CF outpatients (n = 45).

Results

Stigma emerged as consistent concern for people living and caring for those with CF, affecting both patients’ lives and health through the focus group. Using the newly developed CF Stigma scale, the mean baseline score was 16.6 (SD = 4.5, Range = 10-25). The CF Stigma Scale demonstrated robust psychometric properties: 1) Internal consistency: α = 0.79; 2) Mean inter-item correlation: 0.30 with good test-retest reliability; 3) Convergent validity: Positive associations with depression, severity of CF symptoms and anxiety; negative associations with validated quality of life scores were observed.

Conclusions

Stigma is measurable and significantly impacts the lives of CF patients. Further research should investigate the role of stigma in patients living with CF.

Enacted and internalized stigma and quality of life among people with HIV: the role of group identity

PURPOSE

This study analyzes the mediating role of social identity in the relationship between enacted stigma and internalized stigma and quality of life of people with HIV.

METHODS

A total of 557 people with HIV participated in this study. Participants were recruited from hospitals and non-governmental organizations. Questionnaires measuring perceived stigma (Berger's HIV Stigma Scale), social identity (Cameron's three factor identity scale), and quality of life (Ruiz and Baca's Quality of Life Questionnaire) were administered. The instruments were adapted for use with the Spanish population. Structural equation modeling (SEM) was used to test the mediation model, and multigroup SEM was conducted to evaluate its invariance.

RESULTS

Both enacted stigma and internalized stigma had a negative influence on the quality of life of people with HIV, but this influence occurred in different ways. Enacted stigma had a direct negative influence on quality of life. No dimension of group identity protected people with HIV from its negative influence. However, the negative influence of internalized stigma was totally mediated by some dimensions of group identification, mainly through in-group affect.

CONCLUSIONS

Group identification not only did not protect people with HIV from the negative effects of stigmatization, but it may even be detrimental in the case of internalized stigma. This suggests that in highly stigmatized groups, the salience of identity is negative and worsens the members' opinion of their own group. This argues for different kinds of intervention to improve the quality of life of people with HIV.

Treatment as long-term prevention: sustained reduction in HIV sexual transmission risk with use of antiretroviral therapy in rural Uganda

OBJECTIVES

Suppressive antiretroviral therapy (ART) substantially decreases HIV transmission in clinical research settings. We sought to measure the frequency and correlates of periods of transmission risk among individuals taking ART during multiple years of observation in rural, southwestern Uganda.

DESIGN

Observational cohort study.

METHODS

We collected sexual behavior and viral load data in a Ugandan cohort of people living with HIV/AIDS from the time of ART initiation. We defined each 90-day visit as a potential transmission period if HIV-1 RNA was more than 400 copies/ml and the participant reported sexual transmission risk behavior, defined as unprotected sexual contact with at least 1 HIV-uninfected partners or partners of unknown serostatus in the prior 90 days.

RESULTS

We evaluated data from 463 individuals on ART over a median 3.5 years of observation and 5293 total study visits. During that time, over half (259, 56%) had detectable viremia or reported sexual transmission risk behavior at least once. However, only 23 (5%) had both simultaneously, at 28 (<1%) of all visits. Transmission sexual behavior was reported at 6% of visits with detectable viremia. In multivariable regression modeling, correlates of transmission risk periods included younger age, lower CD4 cell count, low household asset ownership and increased internalized stigma.

CONCLUSION

Although detectable viremia and/or sexual transmission risk behavior occurred in over half of individuals, ART reduced periods of HIV transmission risk by over 90% during up to 6 years of observation time. These findings provide further support for provision of ART, along with interventions to promote long-term adherence, to reduce HIV transmission in HIV-endemic settings.

Editorial: Global action to reduce HIV stigma and discrimination

There is no question that the stigma and discrimination associated with HIV and AIDS can be reduced through intervention. The inclusion of stigma and discrimination reduction as a critical component of achieving an AIDS-free generation in recent UNAIDS, UN and PEPFAR political initiatives is promising. Yet national governments need evidence on effective interventions at the individual, community and societal levels in order to strategically incorporate stigma and discrimination reduction into national AIDS plans. Currently, the heterogeneity of stigma and discrimination reduction approaches and measurement makes it challenging to compare and contrast evaluated interventions. Moving forward, it is critical for the research community to: (1) clearly link intervention activities to the domains of stigma to be shifted; (2) assess the stigma domains in a consistent manner; and (3) link stigma and discrimination reduction with HIV prevention, care and treatment outcomes (e.g., uptake, adherence and retention of ART). These steps would further advance the scientific evidence base of stigma and discrimination reduction and allow for the identification of effective interventions that could be scaled up by national governments.

A systematic review of interventions to reduce HIV-related stigma and discrimination from 2002 to 2013: how far have we come?

INTRODUCTION

HIV-related stigma and discrimination continue to hamper efforts to prevent new infections and engage people in HIV treatment, care and support programmes. The identification of effective interventions to reduce stigma and discrimination that can be integrated into national responses is crucial to the success of the global AIDS response.

METHODS

We conducted a systematic review of studies and reports that assessed the effectiveness of interventions to reduce HIV stigma and discrimination between 1 January 2002 and 1 March 2013. Databases searched for peer-reviewed articles included PubMed, Scopus, EBSCO Host -CINAHL Plus, Psycinfo, Ovid, Sociofile and Popline. Reports were obtained from the www.HIVAIDSClearinghouse.eu, USAID Development Experience Clearinghouse, UNESCO HIV and AIDS Education Clearinghouse, Google, WHO and UNAIDS. Ancestry searches for articles included in the systematic review were also conducted. Studies of any design that sought to reduce stigma as a primary or secondary objective and included pre- and post-intervention measures of stigma were included.

RESULTS

Of 2368 peer-reviewed articles and reports identified, 48 were included in our review representing 14 different target populations in 28 countries. The majority of interventions utilized two or more strategies to reduce stigma and discrimination, and ten included structural or biomedical components. However, most interventions targeted a single socio-ecological level and a single domain of stigma. Outcome measures lacked uniformity and validity, making both interpretation and comparison of study results difficult. While the majority of studies were effective at reducing the aspects of stigma they measured, none assessed the influence of stigma or discrimination reduction on HIV-related health outcomes.

CONCLUSIONS

Our review revealed considerable progress in the stigma-reduction field. However, critical challenges and gaps remain which are impeding the identification of effective stigma-reduction strategies that can be implemented by national governments on a larger scale. The development, validation, and consistent use of globally relevant scales of stigma and discrimination are a critical next step for advancing the field of research in this area. Studies comparing the effectiveness of different stigma-reduction strategies and studies assessing the influence of stigma reduction on key behavioural and biomedical outcomes are also needed to maximize biomedical prevention efforts.

Impact of HIV-related stigma on treatment adherence: systematic review and meta-synthesis

INTRODUCTION

Adherence to HIV antiretroviral therapy (ART) is a critical determinant of HIV-1 RNA viral suppression and health outcomes. It is generally accepted that HIV-related stigma is correlated with factors that may undermine ART adherence, but its relationship with ART adherence itself is not well established. We therefore undertook this review to systematically assess the relationship between HIV-related stigma and ART adherence.

METHODS

We searched nine electronic databases for published and unpublished literature, with no language restrictions. First we screened the titles and abstracts for studies that potentially contained data on ART adherence. Then we reviewed the full text of these studies to identify articles that reported data on the relationship between ART adherence and either HIV-related stigma or serostatus disclosure. We used the method of meta-synthesis to summarize the findings from the qualitative studies.

RESULTS

Our search protocol yielded 14,854 initial records. After eliminating duplicates and screening the titles and abstracts, we retrieved the full text of 960 journal articles, dissertations and unpublished conference abstracts for review. We included 75 studies conducted among 26,715 HIV-positive persons living in 32 countries worldwide, with less representation of work from Eastern Europe and Central Asia. Among the 34 qualitative studies, our meta-synthesis identified five distinct third-order labels through an inductive process that we categorized as themes and organized in a conceptual model spanning intrapersonal, interpersonal and structural levels. HIV-related stigma undermined ART adherence by compromising general psychological processes, such as adaptive coping and social support. We also identified psychological processes specific to HIV-positive persons driven by predominant stigmatizing attitudes and which undermined adherence, such as internalized stigma and concealment. Adaptive coping and social support were critical determinants of participants' ability to overcome the structural and economic barriers associated with poverty in order to successfully adhere to ART. Among the 41 quantitative studies, 24 of 33 cross-sectional studies (71%) reported a positive finding between HIV stigma and ART non-adherence, while 6 of 7 longitudinal studies (86%) reported a null finding (Pearson's χ (2)=7.7; p=0.005).

CONCLUSIONS

We found that HIV-related stigma compromised participants' abilities to successfully adhere to ART. Interventions to reduce stigma should target multiple levels of influence (intrapersonal, interpersonal and structural) in order to have maximum effectiveness on improving ART adherence.

HIV infection and awareness among men who have sex with men-20 cities, United States, 2008 and 2011

Over half of HIV infections in the United States occur among men who have sex with men (MSM). Awareness of infection is a necessary precursor to antiretroviral treatment and risk reduction among HIV-infected persons. We report data on prevalence and awareness of HIV infection among MSM in 2008 and 2011, using data from 20 cities participating in the 2008 and 2011 National HIV Behavioral Surveillance System (NHBS) among MSM. Venue-based, time-space sampling was used to recruit men for interview and HIV testing. We analyzed data for men who reported ≥ 1 male sex partner in the past 12 months. Participants who tested positive were considered to be aware of their infection if they reported a prior positive HIV test. We used multivariable analysis to examine differences between results from 2011 vs. 2008. HIV prevalence was 19% in 2008 and 18% in 2011 (p = 0.14). In both years, HIV prevalence was highest among older age groups, blacks, and men with lower education and income. In multivariable analysis, HIV prevalence did not change significantly from 2008 to 2011 overall (p = 0.51) or in any age or racial/ethnic category (p>0.15 in each category). Among those testing positive, a greater proportion was aware of their infection in 2011 (66%) than in 2008 (56%) (p<0.001). In both years, HIV awareness was higher for older age groups, whites, and men with higher education and income. In multivariable analysis, HIV awareness increased from 2008 to 2011 overall (p<0.001) and for all age and racial/ethnic categories (p<0.01 in each category). In both years, black MSM had the highest HIV prevalence and the lowest awareness among racial/ethnic groups. These findings suggest that HIV-positive MSM are increasingly aware of their infections.

Perceived stigma reductions following participation in mental health services integrated within community-based HIV primary care

HIV stigma remains a significant challenge for individuals living with HIV disease that can adversely affect overall well-being and patterns of HIV health service engagement. Finding ways to effectively address stigma concerns is, therefore, an important consideration in the clinical management of HIV disease. This study examined changes in perceived stigma in a sample of 48 adults living with HIV disease as an outcome of their participation in a mental health services program integrated with community-based HIV primary care. Participants completed a self-report instrument that provided a multidimensional measure of perceived HIV stigma, including distancing, blaming, and discrimination dimensions. This scale was administered at the baseline mental health service visit and then re-administered at the three-month follow-up point. Study results showed reductions in self-reported perceived HIV stigma over time for the distancing (t = 4.01, p = 0.000, d = 0.43), blaming (t = 2.79, p = 0.008, d = 0.35), and discrimination (t = 2.90, p = 0.006, d = 0.42) dimensions of stigma. These findings suggest that participation in HIV mental health services may have a favorable impact on perceived HIV stigma. Implications of these findings are discussed, including possible mechanisms that might explain the observed results as well as suggested directions for future research in this area. Randomized controlled trials would represent an important next step to investigate the extent to which HIV mental health services can reduce levels of perceived HIV stigma.

Relationship between HIV stigma and self-isolation among people living with HIV in Tennessee

INTRODUCTION

HIV stigma is a contributing factor to poor patient outcomes. Although HIV stigma has been documented, its impact on patient well-being in the southern US is not well understood.

METHODS

Thirty-two adults participated in cognitive interviews after completing the Berger HIV or the Van Rie stigma scale. Participant responses were probed to ensure the scales accurately measured stigma and to assess the impact stigma had on behavior.

RESULTS

Three main themes emerged regarding HIV stigma: (1) negative attitudes, fear of contagion, and misperceptions about transmission; (2) acts of discrimination by families, friends, health care providers, and within the workplace; and (3) participants' use of self-isolation as a coping mechanism. Overwhelming reluctance to disclose a person's HIV status made identifying enacted stigma with a quantitative scale difficult.

DISCUSSION

Fear of discrimination resulted in participants isolating themselves from friends or experiences to avoid disclosure. Participant unwillingness to disclose their HIV status to friends and family could lead to an underestimation of enacted HIV stigma in quantitative scales.

Self-esteem and quality of life of people living with HIV/AIDS

In India in 2009, it was estimated that 2.4 million people were living with HIV, which equates to a prevalence of 0.3 percent. While this seems low, because India’s population is so large, this rate is third in the world in terms of the absolute number of people living with HIV/AIDS. This study evaluated the self-esteem and quality of life of people living with HIV/AIDS in the Indian population using a correlational design. A significant positive correlation between self esteem and the different dimensions of quality of life was established. Interventions designed for people with HIV/AIDS could well include self esteem as a moderator of quality of life.

The patient-provider relationship as experienced by a diverse sample of highly adherent HIV-infected people

Qualitative interviews with 23 HIV-infected people who self-reported high-level adherence to antiretroviral therapy were used to examine the process by which they came to accept their HIV infection and engage in high-level adherence behaviors. A major theme that emerged during data analysis was the importance of the patient-provider relationship. The quality of the relationship between patient and provider emerged as an important component of working through early struggles with diagnosis and the on-going struggles of living with a chronic illness. A variety of factors impacting the patient-provider relationship emerged as subthemes. What can be taken from this study is the importance of the patient-provider relationship in the effective self-management of HIV infection. Additionally, several specific behaviors can enhance the patient-provider relationship and help assure movement toward patient acceptance of the illness and engagement in high-level adherence behaviors.

Experiences of stigma, discrimination, care and support among people living with HIV: a four country study

While it is widely agreed that HIV-related stigma may impede access to treatment and support, there is little evidence describing who is most likely to experience different forms of stigma and discrimination and how these affect disclosure and access to care. This study examined experiences of interpersonal discrimination, internalized stigma, and discrimination at health care facilities among HIV-positive adults aged 18 years and older utilizing health facilities in four countries in Sub-Saharan Africa (N = 536). Prevalence of interpersonal discrimination across all countries was 34.6 %, with women significantly more likely to experience interpersonal discrimination than men. Prevalences of internalized stigma varied across countries, ranging from 9.6 % (Malawi) to 45.0 % (Burkina Faso). Prevalence of health care discrimination was 10.4 % across all countries. In multiple regression analyses, we found positive, significant, and independent associations between disclosure and interpersonal discrimination and disclosure and support group utilization, and positive associations between both internalized stigma and health care discrimination and referral for medications.

Access to HIV/AIDS care: a systematic review of socio-cultural determinants in low and high income countries

BACKGROUND

The role of socio-cultural factors in influencing access to HIV/AIDS treatment, care and support is increasingly recognized by researchers, international donors and policy makers. Although many of them have been identified through qualitative studies, the evidence gathered by quantitative studies has not been systematically analysed. To fill this knowledge gap, we did a systematic review of quantitative studies comparing surveys done in high and low income countries to assess the extent to which socio-cultural determinants of access, identified through qualitative studies, have been addressed in epidemiological survey studies.

METHODS

Ten electronic databases were searched (Cinahl, EMBASE, ISI Web of Science, IBSS, JSTOR, MedLine, Psyinfo, Psyindex and Cochrane). Two independent reviewers selected eligible publications based on the inclusion/exclusion criteria. Meta-analysis was used to synthesize data comparing studies between low and high income countries.

RESULTS

Thirty-four studies were included in the final review, 21 (62%) done in high income countries and 13 (38%) in low income countries. In low income settings, epidemiological research on access to HIV/AIDS services focused on socio-economic and health system factors while in high income countries the focus was on medical and psychosocial factors. These differences depict the perceived different barriers in the two regions. Common factors between the two regions were also found to affect HIV testing, including stigma, high risk sexual behaviours such as multiple sexual partners and not using condoms, and alcohol abuse. On the other hand, having experienced previous illness or other health conditions and good family communication was associated with adherence to ART uptake. Due to insufficient consistent data, a meta-analysis was only possible on adherence to treatment.

CONCLUSIONS

This review offers evidence of the current challenges for interdisciplinary work in epidemiology and public health. Quantitative studies did not systematically address in their surveys important factors identified in qualitative studies as playing a critical role on the access to HIV/AIDS services. The evidences suggest that the problem lies in the exclusion of the qualitative information during the questionnaire design. With the changing face of the epidemic, we need a new and improved research strategy that integrates the results of qualitative studies into quantitative surveys.

Relationship between food insecurity and mortality among HIV-positive injection drug users receiving antiretroviral therapy in British Columbia, Canada

Objectives

Little is known about the potential impact of food insecurity on mortality among people living with HIV/AIDS. We examined the potential relationship between food insecurity and all-cause mortality among HIV-positive injection drug users (IDU) initiating antiretroviral therapy (ART) across British Columbia (BC).

Methods

Cross-sectional measurement of food security status was taken at participant ART initiation. Participants were prospectively followed from June 1998 to September 2011 within the fully subsidized ART program. Cox proportional hazard models were used to ascertain the association between food insecurity and mortality, controlling for potential confounders.

Results

Among 254 IDU, 181 (71.3%) were food insecure and 108 (42.5%) were hungry. After 13.3 years of median follow-up, 105 (41.3%) participants died. In multivariate analyses, food insecurity remained significantly associated with mortality (adjusted hazard ratio [AHR] = 1.95, 95% CI: 1.07–3.53), after adjusting for potential confounders.

Conclusions

HIV-positive IDU reporting food insecurity were almost twice as likely to die, compared to food secure IDU. Further research is required to understand how and why food insecurity is associated with excess mortality in this population. Public health organizations should evaluate the possible role of food supplementation and socio-structural supports for IDU within harm reduction and HIV treatment programs.

Perceived discrimination and physical health among HIV-positive Black and Latino men who have sex with men

We conducted the first study to examine health correlates of discrimination due to race/ethnicity, HIV-status, and sexual orientation among 348 HIV-positive Black (n = 181) and Latino (n = 167) men who have sex with men. Participants completed audio computer-assisted self-interviews. In multivariate analyses, Black participants who experienced greater racial discrimination were less likely to have a high CD4 cell count [OR = 0.7, 95 % CI = (0.5, 0.9), p = 0.02], and an undetectable viral load [OR = 0.8, 95 % CI = (0.6, 1.0), p = 0.03], and were more likely to visit the emergency department [OR = 1.3, 95 % CI = (1.0, 1.7), p = 0.04]; the combined three types of discrimination predicted greater AIDS symptoms [F (3,176) = 3.8, p < 0.01]. Among Latinos, the combined three types of discrimination predicted greater medication side effect severity [F (3,163) = 4.6, p < 0.01] and AIDS symptoms [F (3,163) = 3.1, p < 0.05]. Findings suggest that the stress of multiple types of discrimination plays a role in health outcomes.

Effects of stigmatization/discrimination on antiretroviral therapy adherence among HIV-infected patients in a rural tertiary medical center in Nigeria

INTRODUCTION

Stigmatization and discrimination impact negatively on interventions and act as barriers to all HIV/AIDS activities. This study assessed the relationship between stigmatization and discrimination and adherence to antiretroviral therapy (ART) among HIV-infected patients attending the Federal Medical Centre, Ido-Ekiti, Nigeria.

METHODS

A cross-sectional study was carried out among respondents selected by systematic random sampling. Structured, interviewer-administered questionnaires were used to collect data subsequently analyzed with SPSS 16.

RESULTS

A total of 100 respondents comprising 61 (61.0%) female participants were interviewed. A large proportion, 92.0%, had a low level of stigmatization. In all, 88 (88.0%) had a good level of antiretroviral adherence using a threshold of >95%. More people living with HIV/AIDS (PLWHAs) with low stigmatization and discrimination had good adherence to ART (P < .001).

CONCLUSION

The PLWHAs with low levels of stigmatization and discrimination are more likely to adhere to ART than those with high levels. Counseling services and health education on adherence should be a strong component of all PLWHA care.

Treatment adherence redefined: a critical analysis of technotherapeutics

Treatment adherence issues in the context of chronic illnesses have become an important concern worldwide and a top priority in the field of health-care. The development of devices that will allow healthcare providers to track treatment adherence and monitor physiological parameters with exact precision raises important questions and concerns. The aim of this study is to interrogate the use of these new technological devices which allow for previously unavailable data to be recorded on an ongoing basis and transmitted via a tiny microchip inserted into the body. Drawing on the work of Michel Foucault, we analyze how this anatomo-political and bio-political instrument serves to discipline chronically ill individuals and govern the health of entire populations who suffer from chronic conditions. To support our analysis, this article comprises three sections. First, we provide an overview of treatment adherence and technotherapeutics. Then, we explain how technotherapeutics concern the government of bodies and conducts at the individual level and population level more generally. Lastly, we provide an example of how this analysis can be connected to routine nursing practice in the field of HIV.

Women-specific HIV/AIDS services: identifying and defining the components of holistic service delivery for women living with HIV/AIDS

Introduction

The increasing proportion of women living with HIV has evoked calls for tailored services that respond to women's specific needs. The objective of this investigation was to explore the concept of women-specific HIV/AIDS services to identify and define what key elements underlie this approach to care.

Methods

A comprehensive review was conducted using online databases (CSA Social Service Abstracts, OvidSP, Proquest, Psycinfo, PubMed, CINAHL), augmented with a search for grey literature. In total, 84 articles were retrieved and 30 were included for a full review. Of these 30, 15 were specific to HIV/AIDS, 11 for mental health and addictions and four stemmed from other disciplines.

Results and discussion

The review demonstrated the absence of a consensual definition of women-specific HIV/AIDS services in the literature. We distilled this concept into its defining features and 12 additional dimensions (1) creating an atmosphere of safety, respect and acceptance; (2) facilitating communication and interaction among peers; (3) involving women in the planning, delivery and evaluation of services; (4) providing self-determination opportunities; (5) providing tailored programming for women; (6) facilitating meaningful access to care through the provision of social and supportive services; (7) facilitating access to women-specific and culturally sensitive information; (8) considering family as the unit of intervention; (9) providing multidisciplinary integration and coordination of a comprehensive array of services; (10) meeting women “where they are”; (11) providing gender-, culture- and HIV-sensitive training to health and social care providers; and (12) conducting gendered HIV/AIDS research.

Conclusions

This review highlights that the concept of women-specific HIV/AIDS services is a complex and multidimensional one that has been shaped by diverse theoretical perspectives. Further research is needed to better understand this emerging concept and ultimately assess the effectiveness of women-specific services on HIV-positive women's health outcomes.

The development of an inventory to assess the structural barriers to clinic attendance and pill-taking amongst users of antiretroviral therapy

In addition to personal and psychological factors, structural factors may reduce the likelihood of optimal adherence to antiretroviral therapy (ART) among persons living with HIV. In this mixed-method study we report on the development of a scale to assess the salience of various structural barriers to ART adherence. After following conventional guidelines for scale development, two scales measuring structural barriers to adherence to clinic attendance and pill-taking were administered to 291 patients receiving ART at a public hospital in South Africa. Both exploratory and higher order factor analysis indicated that a single underlying general factor was appropriate for both scales. The final scales consisted of 12 items for the structural barriers to clinic attendance scale and 13 items for the structural barriers to medication-taking scale. Both scales displayed excellent internal consistency with Cronbach alpha coefficients above 0.80. Research to determine the construct validity of the scales may be a next step in this line of research.

Prevalence and factors associated with HIV/AIDS-related stigma and discriminatory attitudes: a cross-sectional nationwide study

OBJECTIVE

The prime purpose of this study is to assess HIV/AIDS-related self-stigma and discrimination (S&D) attitudes and associated factors using multivariate analysis of data from the 2010-11 National Survey of Understanding the Root of HIV/AIDS Related Stigma and Discrimination.

METHOD

A national telephone survey was carried out with 2271 of the Malaysian public aged 18-60 years. The sample was contacted by random digit dialing covering the whole of Peninsular Malaysia from December 2010 to May 2011. The HIV-transmission knowledge, HIV-related self-stigma, and public stigma were investigated.

RESULTS

Despite high level of HIV-transmission knowledge [mean (SD)=10.56 (2.42), mean score at 70th percentile] the respondents in this study had moderate levels (mean scores near midpoints) of self-stigma and public stigma attitudes. HIV-transmission knowledge score was not significantly correlated with self-stigma score, but showed a significantly small positive effect (r<0.2) for public stigma scores. Ethnicity is the strongest correlate of HIV-transmission knowledge, self-stigma, and public stigma attitudes in the multivariate analyses. Other significant correlates were age, socioeconomic group, and urban-rural setting.

CONCLUSIONS

The root causes of HIV stigma and discriminatory attitudes were not associated with knowledge deficiency. Interventions should be oriented towards promoting de-stigmatization of HIV/AIDS, and tailored socio-culturally.

Barriers to medication adherence in behaviorally and perinatally infected youth living with HIV

The study explored barriers to antiretroviral medication adherence in perinatally and behaviorally HIV infected adolescents and young adults in a cross-sectional, multisite sample. The study included a subset of a convenience sample from a cross-sectional analysis. Participants were youth with HIV ages 12-24 who were prescribed HIV medication and reported missing medication in the past 7 days (n = 484, 28.4 % of protocol sample). The top barriers were similar for perinatally and behaviorally infected youth, but perinatally infected youth reported significantly more barriers. Forgetting, not feeling like taking medication and not wanting to be reminded of HIV infection were the most common barriers reported. Number of barriers was significantly correlated with percent of doses missed, viral load, and psychological distress for perinatally infected youth and with doses missed, psychological distress, and substance use for behaviorally infected youth. Interventions to improve adherence to HIV medications should not only address forgetfulness and choosing not to take medications, but also consider route of infection.

Gender and ethnicity differences in HIV-related stigma experienced by people living with HIV in Ontario, Canada

This study aimed to understand gender and ethnicity differences in HIV-related stigma experienced by 1026 HIV-positive individuals living in Ontario, Canada that were enrolled in the OHTN Cohort Study. Total and subscale HIV-related stigma scores were measured using the revised HIV-related Stigma Scale. Correlates of total stigma scores were assessed in univariate and multivariate linear regression. Women had significantly higher total and subscale stigma scores than men (total, median = 56.0 vs. 48.0, p<0.0001). Among men and women, Black individuals had the highest, Aboriginal and Asian/Latin-American/Unspecified people intermediate, and White individuals the lowest total stigma scores. The gender-ethnicity interaction term was significant in multivariate analysis: Black women and Asian/Latin-American/Unspecified men reported the highest HIV-related stigma scores. Gender and ethnicity differences in HIV-related stigma were identified in our cohort. Findings suggest differing approaches may be required to address HIV-related stigma based on gender and ethnicity; and such strategies should challenge racist and sexist stereotypes.

Stigma, medication adherence and coping mechanism among people living with HIV attending General Hospital, Lagos Island, Nigeria

Background

People living with HIV and AIDS (PLWHA) experience some form of stigma which could lead to poor medication adherence.

Objectives

This study assessed the various domains of stigma experienced by PLWHAs attending an HIV clinic at General Hospital, Lagos Island, their medication adherence patterns and their coping mechanisms for ensuring adherence to antiretroviral therapy.

Method

A cross-sectional study design with a sample size of 200 was used. Respondents were selected using systematic random sampling. Interviewers administered structured questionnaires were used to collect information on the domains of stigma. Data was analysed using EPI info^©. This was followed by a focus group discussion (FGD) with seven participants at the clinic using an interview guide with open-ended questions.

Results

Overall, stigma was experienced by 35% of the respondents. Within this group, 6.6%, 37.1%, 43.1% and 98.0% of the respondents reported experiencing negative self image stigma, personalised stigma, disclosure stigma and public attitude stigma respectively. Almost 90% of the respondents were adherent. The FGD revealed that disclosure was usually confined to family members and the coping mechanism for achieving adherence was to put antiretroviral (ARVs) in unlabelled pill boxes.

Conclusion

This study found that stigma was low and that the most common domain of stigma experienced was public attitude stigma. Medication adherence of respondents was good as a result of the coping mechanism, which involves putting ARVs in unlabelled pill boxes.

The paradox of family support: concerns of tuberculosis-infected HIV patients about involving family and friends in their treatment

Despite the widely documented evidence that family support improves adherence to HIV treatment, some studies have reported no benefit or even a negative association between family support and adherence. This study reexamined the role of family support in treatment adherence to find out the circumstances under which family support for HIV and tuberculosis coinfected patients promotes or hinders treatment adherence in Cross River State, Nigeria. We conducted eight focus group discussions (FGDs) and four case histories with coinfected patients. In addition, 21 in-depth interviews (IDIs) were conducted with: 8 family members, 6 friends, and 7 care providers. Data were analyzed in a thematic format with the aid of NVIVO software. Overall, family support promotes adherence in coinfected patients. Family support may, however, have a negative effect on adherence when the recipient perceives that the support is given with ulterior motives (e.g., gossiping about them and becoming indebted to the support givers) and when the recipient is the primary breadwinner and feels that this role is being undermined. Family support is useful as a tool for scaling up adherence but the usefulness is context-specific and mediated by the patient's subjective interpretation of the support givers' motives.

Feasibility, acceptability, and preliminary efficacy of the unity workshop: an internalized stigma reduction intervention for African American women living with HIV

Observational studies have examined the prevalence and impact of internalized stigma among African American women living with HIV, but there are no intervention studies investigating stigma reduction strategies in this population. Based on qualitative data previously collected, we adapted the International Center for Research on Women's HIV Stigma Toolkit for a domestic population of African American women to be consistent with Corrigan's principles of strategic stigma change. We implemented the intervention, led by an African American woman living with HIV, as a workshop across two afternoons. The participants discussed issues "triggered" by videos produced specifically for this purpose, learned coping mechanisms from each other, and practiced them in role plays with each other. We pilot tested the intervention with two groups of women (total N=24), measuring change in internalized stigma with the Stigma Scale for Chronic Illness before and after workshop participation. Sixty-two percent of the participants self-reported acquiring HIV through heterosexual sexual contact, 17% through intravenous drug use, 4% in utero, and 13% did not know the route of transmission. The intervention was feasible, enthusiastically accepted by the women, and led to decreased stigma from the start of the workshop to the end (p=0.05) and 1 week after (p=0.07) the last session of workshop. Findings suggest the intervention warrants further investigation.

Factors associated with experiences of stigma in a sample of HIV-positive, methamphetamine-using men who have sex with men

BACKGROUND

While methamphetamine users report high rates of internalized or self-stigma, few studies have examined experiences of stigma (i.e., stigmatization by others) and its correlates.

METHODS

This study identified correlates of stigma experiences in a sample of 438 HIV-positive men who have sex with men (MSM) who were enrolled in a sexual risk reduction intervention in San Diego, CA.

RESULTS

Approximately 96% of the sample reported experiences of stigma related to their use of methamphetamine. In multiple regression analysis, experiences of stigma were associated with binge use of methamphetamine, injection drug use, increased anger symptoms, reduced emotional support, and lifetime treatment for methamphetamine use.

CONCLUSIONS

These findings suggest that experiences of stigma are common among methamphetamine users and that interventions to address this type of stigma and its correlates may offer social, psychological, and health benefits to HIV-positive methamphetamine-using MSM.

Factors influencing adherence to antiretroviral treatment in Nepal: a mixed-methods study

Background

Antiretroviral therapy (ART) is a lifesaver for individual patients treated for Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS). Maintaining optimal adherence to antiretroviral drugs is essential for HIV infection management. This study aimed to understand the factors influencing adherence amongst ART-prescribed patients and care providers in Nepal.

Methods

A cross-sectional mixed-methods study surveying 330 ART-prescribed patients and 34 in-depth interviews with three different types of stakeholders: patients, care providers, and key people at policy level. Adherence was assessed through survey self-reporting and during the interviews. A multivariate logistic regression model was used to identify factors associated with adherence, supplemented with a thematic analysis of the interview transcripts.

Results

A total of 282 (85.5%) respondents reported complete adherence, i.e. no missed doses in the four-weeks prior to interview. Major factors influencing adherence were: non-disclosure of HIV status (OR = 17.99, p =  0.014); alcohol use (OR = 12.89, p = <0.001), being female (OR = 6.91, p = 0.001), being illiterate (OR = 4.58, p = 0.015), side-effects (OR = 6.04, p = 0.025), ART started ≤24 months (OR = 3.18, p = 0.009), travel time to hospital >1 hour (OR = 2.84, p = 0.035). Similarly, lack of knowledge and negative perception towards ART medications also significantly affected non-adherence. Transport costs (for repeat prescription), followed by pills running out, not wanting others to notice, side-effects, and being busy were the most common reasons for non-adherence. The interviews also revealed religious or ritual obstacles, stigma and discrimination, ART-associated costs, transport problems, lack of support, and side-effects as contributing to non-adherence.

Conclusion

Improving adherence requires a supportive environment; accessible treatment; clear instructions about regimens; and regimens tailored to individual patients’ lifestyles. Healthcare workers should address some of the practical and cultural issues around ART medicine whilst policy-makers should develop appropriate social policy to promote adherence among ART-prescribed patients.

HIV prevention and transmission myths among heterosexually active adults in low-income areas of South Florida

Misconceptions about HIV transmission and prevention may inhibit individuals' accurate assessment of their level of risk. We used venue-based sampling to conduct a cross-sectional study of heterosexually active adults (N = 1,221) within areas exhibiting high poverty and HIV/AIDS rates in Miami-Dade and Broward counties in 2007. Two logistic regression analyses identified correlates of holding inaccurate beliefs about HIV transmission and prevention. Belief in incorrect HIV prevention methods (27.2%) and modes of transmission (38.5%) was common. Having at least one incorrect prevention belief was associated with being Hispanic compared to white (non-Hispanic), being depressed, and not knowing one's HIV status. Having at least one incorrect transmission belief was associated with being younger, heavy alcohol use, being depressed, not having seen a physician in the past 12 months, and not knowing one's HIV status. Among low-income heterosexuals, HIV prevention and transmission myths are widespread. Debunking them could have HIV prevention value.

HIV treatment adherence, patient health literacy, and health care provider-patient communication: results from the 2010 AIDS Treatment for Life International Survey

BACKGROUND

Little is known about patients' health literacy regarding antiretroviral therapy (ART) adherence and drug resistance and patient-provider communication about these topics.

DESIGN AND METHODS

The AIDS Treatment for Life International Survey was a multicountry cross-sectional study (January-March 2010) including 2035 HIV-infected adults. A 40-minute interview was conducted using a standardized self-report adherence questionnaire.

RESULTS

Overall, 57% of patients reported a 30-day recall of 100% adherence (Latin America: 89%; Africa: 73% vs North America: 45% and Asia Pacific: 47%; P < .01). Overall, 18% identified HIV drug resistance as a "good thing" in North America (35%) and Africa (24%). Only 71% said their health care providers had offered practical recommendations about adherence, 62% of the patients in North America and 80% in Latin America and Africa.

CONCLUSIONS

Optimal ART adherence remains a challenge globally. There is a critical need to improve patient-provider communication about the importance of ART adherence and its benefits for patient's health.

Study of tuberculosis and AIDS stigma as barriers to tuberculosis treatment adherence using validated stigma scales

BACKGROUND

Adherence to tuberculosis (TB) treatment is important for TB control. The effect of stigma on adherence has not been well quantified.

OBJECTIVE

To identify the effects of TB and acquired immune-deficiency syndrome (AIDS) stigma on missed doses during TB treatment.

DESIGN

Validated TB and AIDS stigma scales assessing perceived and experienced/felt stigma were administered in a prospective cohort of 459 TB patients at TB treatment initiation and after 2 months. Repeated measures and multivariable models estimated the effects of stigma on the rate of missed doses.

RESULTS

Fifty-six per cent of patients missed no doses, and associations between stigma and missed doses were minimal. Heterogeneity of effects was observed, how- ever, with higher experienced and felt TB stigma increasing missed doses among women (adjusted RR 1.22, 95%CI 1.10-1.34) and human immunodeficiency virus (HIV) co-infected patients (aRR 1.39, 95%CI 1.13-1.72). Experienced and felt AIDS stigma also increased missed doses among HIV co-infected patients (aRR 1.43, 95%CI 1.31-1.56).

CONCLUSION

Stigma has a minimal effect in this population with good adherence. Among women and HIV co-infected patients, however, experienced and felt stigma, and not perceived stigma, increased the rate of missed doses. Further research is needed to determine if stigma or coping interventions among these subgroups would improve adherence.

The impact of stigma on medication adherence among HIV-positive adolescent and young adult females and the moderating effects of coping and satisfaction with health care

To explore whether HIV stigma negatively impacts adherence to antiviral medications in HIV-infected adolescent women, moderational analysis was conducted and factors identified that could alter said relationship. Study participants were 178 adolescent females age 15-24, enrolled between 2003-2005, from 5 different cities and 60 provided adherence information. Findings reported by this cohort of 60 adolescent women included: medication adherence, 64.3% reporting adherence at baseline and 45.0% at 12 months; HIV stigma score of 57.60 (standard deviation [SD], 11.83; range, 25-86). HIV stigma was not found to be a significant predictor when binary logit regression was run with medication adherence at 1 year. Using moderational analysis, factors that could moderate stigma's effect on medication adherence was still pursued and identified the following to be significant at 12 months: health care satisfaction (B = -0.020, standard error [SE] = 0.010, p < .05); and Coping (proactive coping strategies [B = 0.012, SE = 0.005, p < .05]; turning to family [B = 0.012, SE = 0.016, p < 0.05]; spiritual coping [B = 0.021, SE = 0.010, p < 0.05]; professional help [B = 0.021, SE = 0.010, p < 0.05]; physical diversions [B = 0.016, SE = 0.007, p < 0.05]). Factors that had no significant moderating effects included: social support measures (mean = 74.9; median = 74.0) and depression score greater than 16 = 43%. We conclude that HIV-infected adolescent women experience HIV stigma and poor adherence over time. Factors like health care satisfaction and coping may minimize stigma's effect on medication adherence. Our findings are tempered by a small sample size and lack of a direct relationship between stigma and adherence on binary logit regression analysis.

Empathy and avoidance in treating patients living with HIV/AIDS (PLWHA) among service providers in China

This study aims to investigate health care providers' empathy levels and its association with avoidance in providing service to patients living with HIV/AIDS (PLWHA) in China. A total of 1760 health service providers were randomly sampled from 40 county hospitals in two provinces of China. Using a self-administered questionnaire, participants' demographic characteristics, work history, empathy level, and avoidance attitudes toward PLWHA were collected in a cross-sectional survey. Empathy was higher among participants aged 31-40 years, those who had an associated medical degree, and those who had served in the medical profession for less than 20 years. Nurses, younger providers, and providers with lower education tended to avoid contact with PLWHA. Multiple linear regression model showed that a higher level of empathic attitude toward patients was significantly negatively associated with avoidance attitude toward PLWHA. Service providers' empathy level plays an important role in providing quality care to HIV-infected patients. Future stigma reduction interventions should cultivate empathy as a platform for understanding, effective communication, and trusting provider-patient relationships. PLWHA could potentially benefit from attitudinal change in medical settings.

Women and vulnerability to HAART non-adherence: a literature review of treatment adherence by gender from 2000 to 2011

A literature review of original research articles on adherence to antiretroviral therapy (ART) in developed countries, covering January 2000 to June 2011, was conducted to determine if gender differences exist in the prevalence of nonadherence to ART. Of the 1,255 articles reviewed, only 189 included data on the proportion of the study population that was adherent and only 57 (30.2%) of these reported proportional adherence values by gender. While comparing articles was challenging because of varied reporting strategies, women generally exhibit poorer adherence than men. Thirty of the 44 articles (68.2%) that reported comparative data on adherence by gender found women to be less adherent than men. Ten articles (17.5%) reported significant differences in proportional adherence by gender, nine of which showed women to be less adherent than men. These findings suggest that in multiple studies from developed countries, female gender often predicts lower adherence. The unique circumstances of HIV-positive women require specialized care to increase adherence to ART.

Knowledge and perceptions of HIV-infected patients regarding HIV transmission and treatment in Ho Chi Minh City, Vietnam

Patient education concerning HIV and antiretroviral (ARV) medications is important for optimal outcomes. The authors assessed the knowledge and perceptions of HIV-infected patients in an ARV education program in Ho Chi Minh City, Vietnam. Of 185 patients, 64 (35%) receiving ARV medications, nearly 80% correctly answered questions regarding HIV. Correct responses were associated with higher education (P < .05) and longer duration of HIV diagnosis (P < .05). A lack of knowledge was observed in 40% of respondents who believed HIV and AIDS were the same and 70% of respondents who believed ARV medications cured HIV. Greater embarrassment of living with HIV was associated with female gender (P < .05) and lower education (P < .05). Patients were concerned over ARV medication use (27%) and its side effects (38%). The study population's knowledge of HIV/AIDS and ARV medications, perceived stigmatization, and areas of knowledge deficits underscore the need for effective patient education programs addressing poorly understood issues around HIV/AIDS.

Stigma mediates the relationship between self-efficacy, medication adherence, and quality of life among people living with HIV/AIDS in China

Although the relationship between self-efficacy and health-related behaviors is well known, limited data are available describing the association between self-efficacy and HIV stigma. Specifically, it is not known if the relationship between self-efficacy and health outcomes is mediated by HIV stigma. This study aimed to test these relationships. Data were collected from 202 HIV/AIDS patients in China using questionnaires measuring self-efficacy for disease management, self-reported 7 day medication adherence, perceived HIV/AIDS stigma and quality of life. The total mean score for self-efficacy was 6.73 (range, 2.78-10.0), and the total mean score for HIV stigma was 102.24 (range, 57.0-148.0). Seventy-four percent (150/202) of subjects reported missing no medication doses during past 7 days, and 73% (148/202) subjects reported a quality of life score over 60. There was a moderate level of association between self-efficacy and HIV stigma (Pearson r=-0.43, p=0.000). High self-efficacy predicted better medication adherence (odds ratio [OR]=1.82, 95% confidence interval [CI]=1.40-2.36) and better quality of life (OR=1.28, 95% CI=1.03-1.60) after controlling for demographic and HIV related characteristics. HIV stigma partially mediated the relationship between self-efficacy and medication adherence (OR=1.64, 95% CI=1.26-2.15; Sobel test result Z=1.975, p=0.048). HIV stigma totally mediated the relationship between self-efficacy and quality of life (OR=1.15, 95% CI=0.91-1.46; Sobel test result Z=2.362, p=0.018). The results suggest that, although self-efficacy is an important predictor for medication adherence and quality of life, HIV stigma as a mediator should not be neglected. Health care providers should also evaluate HIV stigma conditions when seeking to improve self-efficacy through interventions.