Stigma Related to HIV and Drug Use: Layers, Types, and Relations to Mental Health

Interventions to reduce self-stigma in people who use drugs: A systematic review

BACKGROUND

Substance use stigma is a key barrier to treatment and harm reduction engagement among people who use drugs (PWUD). Previous systematic reviews have focused on interventions to reduce stigma in healthcare providers and the public; less is known about interventions to address self-stigma among PWUD. The purpose of this review is to evaluate the evidence for substance use self-stigma reduction interventions.

METHODS

We reviewed English-language studies published between 2011 and 2023 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (PROSPERO #CRD42022321305). We searched seven bibliographic databases (PubMed; SCOPUS; APA PsycInfo; CINAHL; Social Work Abstracts; Sociological Abstracts; ProQuest Dissertations & Theses). This review included studies if 1) they evaluated the effectiveness of a psychosocial intervention, 2) participants were PWUD, 3) authors reported self-stigma as a primary outcome, 4) the study design was experimental or quasi-experimental. We reviewed, interpreted and reported intervention characteristics and effectiveness using narrative synthesis. We assessed study quality with the Downs & Black checklist.

RESULTS

Among 1195 screened studies, 15 met the inclusion criteria (N = 2280 PWUD). We categorized the interventions according to three approaches: psychotherapeutic (n = 8), psychoeducational (n = 5), and multimodal (n = 2). Most interventions were delivered in clinical settings (n = 11) and in a group format (n = 13). Study quality was fair-to-good and included nine randomized controlled trials (RCTs) and six quasi-experiments. Measurement heterogeneity was high, with 11 different stigma-related scales used across the 15 studies. Eleven studies showed significant favorable effects in at least one stigma measure. Six of these demonstrated positive effects in all stigma measures. Evidence was mixed for all three intervention categories; however, Acceptance and Commitment Therapy, a form of group psychotherapy, demonstrated effectiveness in four of five RCTs incorporating this approach.

CONCLUSIONS

Overall, there is promising evidence for the effectiveness of substance use self-stigma interventions, although more studies are needed to determine which approaches are most effective. Consistent conceptualization and measurement of self-stigma across studies will improve comparability in future intervention trials. Current offerings are largely limited to clinical settings and group-based formats; self-help interventions, available for other stigmatized conditions, could be developed to serve the majority of PWUD not engaged in treatment.

"I am not a junkie": Social categorization and differentiation among people who use drugs

BACKGROUND

Substance use stigma is a form of group-based exclusion, and delineating pathways from stigma to poor health requires a deeper understanding of the social dynamics of people who use drugs (PWUD). Outside of recovery, scant research has examined the role of social identity in addiction. Framed by Social Identity Theory/Self-Categorization Theory, this qualitative study investigated strategies of within-group categorization and differentiation among PWUD and the roles these social categories may play in shaping intragroup attitudes, perceptions, and behaviors.

METHODS

Data come from the Rural Opioid Initiative, a multi-site study of the overdose epidemic in rural United States. We conducted in-depth interviews with people who reported using opioids or injecting any drug (n=355) living in 65 counties across 10 states. Interviews focused on participants' biographical histories, past and current drug use, risk behaviors, and experiences with healthcare providers and law enforcement. Social categories and dimensions along which categories were evaluated were inductively identified using reflexive thematic analysis.

RESULTS

We identified seven social categories that were commonly appraised by participants along eight evaluative dimensions. Categories included drug of choice, route of administration, method of attainment, gender, age, genesis of use, and recovery approach. Categories were evaluated by participants based on ascribed characteristics of morality, destructiveness, aversiveness, control, functionality, victimhood, recklessness, and determination. Participants performed nuanced identity work during interviews, including reifying social categories, defining 'addict' prototypicality, reflexively comparing self to other, and disidentifying from the PWUD supra-category.

CONCLUSION

We identify several facets of identity, both behavioral and demographic, along which people who use drugs perceive salient social boundaries. Beyond an addiction-recovery binary, identity is shaped by multiple aspects of the social self in substance use. Patterns of categorization and differentiation revealed negative intragroup attitudes, including stigma, that may hinder solidary-building and collective action in this marginalized group.

Comparative efficacy and acceptability of non-pharmacological interventions for depression in people living with HIV: A systematic review and network meta-analysis

BACKGROUND

Treatment for depression in people living with HIV has increasingly turned to non-pharmacological treatments due to the adverse reactions of pharmacotherapy. However, it remains unclear which non-pharmacological treatment is the most effective and acceptable for depression in people living with HIV.

OBJECTIVE

To compare and rank the efficacy and acceptability of different non-pharmacological treatments for depression in people living with HIV.

DESIGN

A systematic review and Bayesian network meta-analysis.

METHODS

We systematically searched PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, PsycArticles, CINAHL, ProQuest, OpenGrey, and international trial registers for published and unpublished studies from their inception to September 1, 2022, and searched key conference proceedings from January 1, 2020, to September 25, 2022. We searched for randomized controlled trials of any non-pharmacological treatments for depression in adults living with HIV (≥18 years old). Primary outcomes were efficacy (mean change scores in depression) and acceptability (all-cause discontinuation). We used a random-effects network meta-analysis model to synthesize all available evidence. The methodological quality of the included studies was assessed using the Cochrane Collaboration Risk of Bias Tool. We registered this study in PROSPERO, number CRD42021244230.

RESULTS

A total of 53 randomized controlled trials were included in this network meta-analysis involving seven non-pharmacological treatments for depression in people living with HIV. For efficacy, mind-body therapy, interpersonal psychotherapy, cognitive-behavioral therapy, supportive therapy, and education were significantly more effective than most control conditions (standardized mean differences ranged from -0.96 to -0.36). Rankings probabilities indicated that mind-body therapy (79%), interpersonal psychotherapy (71%), cognitive-behavioral therapy (62%), supportive therapy (57%), and education (57%) might be the top five most significantly effective treatments for depression in people living with HIV, in that order. For acceptability, only supportive therapy and interpersonal psychotherapy were significantly less acceptable than most control conditions (odds ratios ranged from 1.92 to 3.43). Rankings probabilities indicated that education might be the most acceptable treatment for people living with HIV (66%), while supportive therapy (26%) and interpersonal psychotherapy (10%) might rank the worst. The GRADE assessment results suggested that most results were rated as "moderate" to "very low" for the confidence of evidence.

CONCLUSIONS

Our study confirmed the efficacy and acceptability of several non-pharmacological treatments for depression in people living with HIV. These results should inform future guidelines and clinical decisions for depression treatment in people living with HIV.

HIV, substance use, and intersectional stigma: Associations with mental health among persons living with HIV who inject drugs in Russia

HIV stigma is associated with negative physical and mental health outcomes. Intersectional stigma among persons living with HIV (PLHIV) results from interrelated, synergistic impacts of experiencing multiple stigma forms. Its relation with mental health outcomes is still an emerging area of study in this key population. This study aimed to evaluate associations of intersectional stigma, defined as endorsing high levels of HIV and substance use stigmas, with depressive and anxiety symptoms in a cohort of 111 PLHIV who inject drugs in St. Petersburg, Russia. Over a third of participants (37%) reported experiencing intersectional stigma (i.e., both stigma scores above the median). In adjusted analysis, lower Patient Health Questionnaire depression scale (PHQ-9) scores (beta (β=-4.31, 95% CI: -7.11 - -1.51, p = 0.003) and Generalized Anxiety Disorders Scale (GAD-7) scores (β=-3.64, 95% CI: -5.57 - -1.71, p < 0.001) were associated with having low scores for both HIV and substance use stigmas. Lower PHQ-9 scores (β=-3.46, 95% CI: -5.72 - -1.19, p = 0.003) and GAD-7 scores (β=-3.06, 95% CI: -4.62 - -1.50, p < 0.001) were also associated with high stigma on either HIV or substance use stigma scales. Controlling for demographics, depressive symptoms approximately linearly increased from both forms of stigma low to experiencing either form of stigma high to experiencing intersectional stigma, while levels of anxiety symptoms were comparable among participants with both types of stigma low and one stigma high. Participants who experienced intersectional stigma reported the greatest severity of both depressive and anxiety symptoms, as compared to individuals who endorsed low stigma scores (i.e., low stigma on both HIV and substance use stigma scales) or high scores of only one form of stigma. This suggests that intersectional stigma in this population of PLHIV who inject drugs in Russia is linked with worsened mental health outcomes, exceeding the effects of experiencing one form of stigma alone. Interventions to help people cope with intersectional stigma need to consider affective symptoms and tailor coping strategies to address impacts of multiple forms of mental health distress.

Impact of Stigma on Clinician Training for Opioid Use Disorder Care: A Qualitative Study in a Primary Care Learning Collaborative

PURPOSE

We undertook a study to examine how stigma influences the uptake of training on medication for opioid use disorder (MOUD) in primary care academic programs.

METHODS

We conducted a qualitative study of 23 key stakeholders responsible for implementing MOUD training in their academic primary care training programs that were participants in a learning collaborative in 2018. We assessed barriers to and facilitators of successful program implementation and used an integrated approach to develop a codebook and analyze the data.

RESULTS

Participants represented the family medicine, internal medicine, and physician assistant fields, and they included trainees. Most participants described clinician and institutional attitudes, misperceptions, and biases that enabled or hindered MOUD training. Perceptions included concerns that patients with OUD are "manipulative" or "drug seeking." Elements of stigma in the origin domain (ie, beliefs by primary care clinicians or the community that OUD is a choice and not a disease), the enacted domain (eg, hospital bylaws banning MOUD and clinicians declining to obtain an X-Waiver to prescribe MOUD), and the intersectional domain (eg, inadequate attention to patient needs) were perceived as major barriers to MOUD training by most respondents. Participants described strategies that improved the uptake of training, including giving attention to clinician concerns, clarifying the biology of OUD, and ameliorating clinician fears of being ill equipped to provide care for patients.

CONCLUSIONS

OUD-related stigma was commonly reported in training programs and impeded the uptake of MOUD training. Potential strategies to address stigma in the training context, beyond providing content on effective evidence-based treatments, include addressing the concerns of primary care clinicians and incorporating the chronic care framework into OUD treatment.

Individual-, Interpersonal- and Institutional-Level Factors Associated with HIV Stigma Among Youth in Kenya

HIV stigma remains a barrier in achieving optimal HIV treatment. We studied the prevalence and predictors of HIV stigma among adolescents and youth with HIV (AYWHIV) ages 15-24 years in Western Kenya. Of 1011 AYWHIV, 69% were female with a median age of 18 years. Most (59%) attended adolescent clinic days, and 40% attended support groups. One-quarter (27%) had experienced physical, 18% emotional, and 7% sexual violence. The majority of AYWHIV (88%) reported disclosure concerns, 48% reported perceived community stigma, 36% experienced, and 24% internalized stigma. Compared to AYWHIV attending adolescent clinics, those in general/adult clinics had higher internalized stigma. Similarly, having dropped out of school was associated with higher internalized stigma. AYWHIV in sexual relationships had higher experienced stigma and disclosure concerns. Lastly, exposure to violence was associated with higher experienced, internalized, perceived community stigma and disclosure concerns. These risk factors can be targeted when developing stigma-prevention interventions.

Stigma experienced by people living with HIV who are on methadone maintenance treatment and have symptoms of common mental disorders in Hanoi, Vietnam: a qualitative study

BACKGROUND

Stigma around human immunodeficiency virus (HIV), injection drug use (IDU), and mental health disorders can be co-occurring and have different impacts on the well-being of people living with HIV (PWH) who use drugs and have mental health disorders. This stigma can come from society, health professionals, and internalized stigma. A person who has more than one health condition can experience overlapping health-related stigma and levels of stigma which can prevent them from receiving necessary support and healthcare, serving to intensify their experience with stigma. This study investigates HIV, drug use, and mental health stigmas in three dimensions (social, internalized, and professional) around PWH on methadone maintenance treatment (MMT) who have common mental disorders (CMDs) including depression, anxiety, and stress-related disorders in Hanoi, Vietnam.Please check and confirm whether corresponding author's email id is correctly identified.The cooresponding author's email is correct METHODS: We conducted semi-structured, in-depth interviews (IDIs) (n = 21) and two focus group discussions (FGDs) (n = 10) with PWH receiving MMT who have CMD symptoms, their family members, clinic health care providers, and clinic directors. We applied thematic analysis using NVIVO software version 12.0, with themes based on IDI and FGD guides and emergent themes from interview transcripts.

RESULTS

The study found evidence of different stigmas towards HIV, IDU, and CMDs from the community, family, health care providers, and participants themselves. Community and family members were physically and emotionally distant from patients due to societal stigma around illicit drug use and fears of acquiring HIV. Participants often conflated stigmas around drug use and HIV, referring to these stigmas interchangeably. The internalized stigma around having HIV and injecting drugs made PWH on MMT hesitant to seek support for CMDs. These stigmas compounded to negatively impact participants' health.

CONCLUSIONS

Strategies to reduce stigma affecting PWH on MMT should concurrently address stigmas around HIV, drug addiction, and mental health. Future studies could explore approaches to address internalized stigma to improve self-esteem, mental health, and capacities to cope with stigma for PWH on MMT.

TRIAL REGISTRATION

NCT04790201, available at clinicaltrials.gov.

Drug use stigma, antiretroviral therapy use, and HIV viral suppression in a community-based sample of people with HIV who inject drugs

OBJECTIVE

To examine the association of drug use stigma with antiretroviral therapy (ART) use and HIV viral suppression among people with HIV who inject drugs in India.

DESIGN

Cross-sectional biobehavioral survey.

METHODS

Between August 2016 and May 2017, persons aged at least 18 years who reported injection drug use in the past 2 years were recruited via respondent-driven sampling (RDS) in 12 Indian cities (approximately 1000 per city). The analysis was restricted to participants with laboratory-confirmed HIV infection who self-reported a prior HIV diagnosis and were eligible for ART per concurrent national HIV treatment guidelines. Enacted and internalized drug use stigma were each measured by five to six-item subscales. The study outcomes were HIV viral suppression (<150 copies/ml) and self-reported past 30-day ART use. RDS-II weighted multivariable logistic regression with a city-level random-intercept was used to estimate adjusted odds ratios (aOR) and corresponding 95% confidence intervals (CIs).

RESULTS

Among 971 ART-eligible participants previously diagnosed with HIV, 65.1% reported ART use and 56.1% were virally suppressed. Reporting any enacted stigma (vs. none) was associated with lower odds of ART use [aOR = 0.26 (95% CI = 0.15-0.44)] and viral suppression [aOR = 0.49 (95% CI = 0.31-0.78)]. High internalized stigma scores (>median vs. ≤median) were associated with lower odds of viral suppression among participants aged at least 35 years [aOR = 0.51 (95% CI = 0.27-0.97)] but not among participants aged less than 35 years [aOR = 1.22 (95% CI = 0.57-2.60)]. Similar associations were observed in analyses restricted to participants ever linked to HIV care.

CONCLUSION

Drug use stigma may be a barrier to HIV viral suppression among people with HIV who inject drugs, thereby hindering efforts to achieve HIV control.

HIV-related stigma, symptoms of depression and their association with suicidal ideation among people living with HIV in Ho Chi Minh City, Vietnam

To date, little are known about HIV-related stigma, symptoms of depression (SOD) and suicidal ideation among people living with HIV (PLHIV) in Vietnam. This study aimed to estimate the level of stigma, SOD and suicidal ideation and to explore the direction and magnitude of the relationship between stigma, SOD and suicidal ideation among Vietnamese PLHIV. A cross-sectional study was conducted in four outpatient clinics providing healthcare services including antiretroviral therapy (ART) for PLHIV in Ho Chi Minh City. At each clinic, patients were chosen using the systematic sampling technique. Participants underwent face-to-face interviews through a pre-defined structural questionnaire that included validated scales. Among 777 PLHIV in the analysis, most were male (81.1%) and the average age was 34.3 (SD = 8.8) years. Two-thirds of PLHIV had a moderate-to-high level of HIV stigma. Symptoms of depression were identified in 41.4% of PLHIV. Suicidal ideation was reported by 26.3% of PLHIV. Based on univariate and multivariate logistic regression, higher levels of SOD and HIV stigma were positively associated with suicidal ideation. For PLHIV with extreme stigma and SOD, the probability of having suicidal ideation was up to 80%. The prevalence and association found in this study indicates that interventions for SOD and stigma not only help reduce these two problems but also help address and minimize suicidal ideation in this vulnerable population. In Vietnam, to optimize such interventions, the involvement of families and communities is crucial.

Assessment of a psychiatric intervention at community level for people who inject drugs in a low-middle income country: the DRIVE-Mind cohort study in Hai Phong, Viet Nam

Background

Access to psychiatric care for people who inject drugs (PWID) is limited/absent and stigmatized in most low-middle-income countries (LMICs). Innovative interventions are needed. We aimed to describe and assess the impact of a community-based psychiatric intervention among PWID in Hai Phong, Vietnam

Methods

In a cohort study with one year psychiatric follow-up, PWID diagnosed with a psychotic disorder, a major depressive episode, or suicide risk, were recruited from the wider Drug-Related Infections in ViEtnam (DRIVE) project in the city of Hai Phong. The community-based psychiatric intervention included specialized follow-up (free consultations with psychiatrists, free medication, referral to mental health department for hospitalization when necessary) and support from community-based organisations (case management, harm reduction, administrative support, linkage to HIV care, methadone maintenance treatment and mental health support). The main outcome was reduction/remission of symptoms. Access to and retention in psychiatric care, quality-of-life and stigmatization were also measured pre and post-intervention.

Findings

Among the 1212 participants screened from March to May 2019, 271 met the inclusion criteria, 233 (86.3%) accepted the intervention and 170 completed the follow-up (72.9%). At inclusion, 80.6% were diagnosed with current depression, 44.7% with psychotic disorder and 42.4% with suicide risk. After a one-year follow-up, these proportions dropped to 15.9%, 21.8%, and 22.9% respectively. Quality-of-life and perceived stigma related to mental health were also significantly improved, while drug use decreased only marginally.

Interpretation

Community-based psychiatric interventions are both feasible and efficient in the Vietnamese context. Similar interventions should be implemented and evaluated in other, different LMICs.

Funding

: This work was supported by grants from NIDA (US) (#DA041978) and ANRS (France) (#13353). The funding agencies had no role in designing the research, data analyses, or preparation of the report.

Psychometric performance of the perceived stigma of substance abuse scale (PSAS) among patients on methadone maintenance therapy in Vietnam

BACKGROUND

People who inject drugs (PWID) and patients on methadone maintenance therapy (MMT) face severe stigma and discrimination. However, there are limited measures assessing stigma towards individuals with substance use disorders or MMT patients, particularly in Vietnam, and few studies have examined the psychometric properties of existing measures. This study aims to examine the performance of the eight-item Perceived Stigma of Substance Abuse Scale (PSAS), created in the United States, among a population of MMT patients in Vietnam.

METHODS

A cross-sectional survey was conducted among 400 adult patients enrolled in an urban MMT clinic. Substance use stigma was measured using the PSAS. We conducted confirmatory factor analysis (CFA) and assessed construct validity, reliability and known-group validity.

RESULTS

The original eight-item scale was unidimensional, but yielded mixed goodness-of-fit indicators. Ultimately, dropping two items and allowing the errors of the items related to childcare to correlate improved the goodness-of-fit indicators. (RMSEA = 0.025; CFI = 0.999; and SRMR = 0.018). The shortened scale demonstrated acceptable reliability (Cronbach's α = 0.766). The mean stigma scores were significantly higher among individuals not working, but did not significantly vary by length of time in MMT, marital status, education attainment, HIV status, depression, concurrent injection drug use or missed methadone dose.

CONCLUSIONS

The shortened six-item scale demonstrated good construct validity and acceptability reliability, but it did not demonstrate many a priori hypothesized known-group validity associations. Further research should consider a mixed-methods validation approach.

Intersecting Stigmas among HIV-Positive People Who Inject Drugs in Vietnam

HIV-related stigma remains a barrier to ART adherence among people living with HIV (PLWH) globally. People who inject drugs (PWID) may face additional stigma related to their behavior or identity; yet, there is little understanding of how these stigmas may co-exist and interact among these key populations. This study aims to explore the existence of multiple dimensions of HIV-related stigma, and how they may intersect with stigma related to drug injection. The study took place in Vietnam, where the HIV epidemic is concentrated among 3 key population groups; of those, PWID account for 41% of PLWH. The vast majority (95%) of PWID in Vietnam are male. Data came from in-depth interviews with 30 male PWID recruited from outpatient clinics, where they had been receiving ART medications. Deductive, thematic analysis was employed to organize stigma around the 3 dimensions: enacted, anticipated, and internalized stigma. Findings showed that HIV- and drug use-related stigma remained high among participants. All 3 stigma dimensions were prevalent and perceived to come from different sources: family, community, and health workers. Stigmas related to HIV and drug injection intersected among these individuals, and such intersection varied widely across types of stigma. The study revealed nuanced perceptions of stigma among this marginalized population. It is important for future studies to further investigate the influence of each dimension of stigma, and their interactive effects on HIV and behavioral outcomes among PWID.