HIV- and AIDS-Related Stigma: Psychosocial Aspects in a Representative Spanish Sample

Factors influencing the health-related quality of life of older men and women living with HIV in Spain

The number of older people living with HIV (OPLHIV) is increasing worldwide. However, little is known about the factors that better predict their health-related quality of life (HRQoL). We administered the validated WHOQoL-HIV BREF questionnaire to 247 Spanish OPLHIV (192 men and 55 women). In addition to the six domains of the questionnaire, we constructed a seventh domain as theaverage of punctuations of all domains. Multivariable Poisson regression models with robust estimates by sex were constructed for the seven domains (14 in total). The best-subset selection method together with Mallow's Cp metric was used to select the model factors. The percentage of variability explained by Poisson models ranged from15-38% for men and 29-70% for women. The analysis showed that women were most affected by ageing (four domains), mobility impairments (five domains), and mental disorders (five domains). The factors with the greatest negative influence on men were heterosexuality (six domains), mental disorders (six domains), being single (five domains), and poverty risk (three domains). Physical activity was found to improve HRQoL in both men (six domains) and women (four domains). Future OPLHIV programmes would benefit from considering sex specific HRQoL factors. This could also improve the cost-effectiveness of interventions.

Sex differences in health-related quality of life and poverty risk among older people living with HIV in Spain: A cross-sectional study

BACKGROUND

Current antiretroviral therapies have increased the life expectancy of people living with HIV (PLHIV). There is, however, limited evidence regarding the health-related quality of life (HRQoL) and living conditions of older people living with HIV (OPLHIV) in Spain.

METHODS

We implemented a self-administered online questionnaire to identify sex differences in HRQoL and poverty risk among Spanish OPLHIV (PLHIV ≥50 years). Participants were contacted through non-governmental organisations. We used the standardised WHOQoL-HIV BREF questionnaire and the Europe 2020 guidelines to estimate HRQoL and poverty risk respectively. The statistical analysis included multivariable generalised linear models with potential confounding variables and robust estimates.

RESULTS

The study included 247 OPLHIV (192 men and 55 women). On the WHOQoL-HIV BREF questionnaire, men scored higher on 84% of items and in all six domains. Women had significantly lower HRQoL in five domains: physical health (β: -1.5; 95% CI: -2.5, -0.5; p: 0.002), psychological health (β: -1.0; 95% CI: -1.9, -0.1; p: 0.036), level of independence (β: -1.1; 95% CI: -1.9, -0.2; p: 0.019), environmental health (β: -1.1; 95% CI: -1.8, -0.3; p: 0.008), and spirituality/personal beliefs (β: -1.4; 95% CI: -2.5, -0.3; p: 0.012). No statistical differences were found in the domain of social relations. Poverty risk was considerable for both men (30%) and women (53%), but women were significantly more likely to experience it (OR: 2.9; 95% CI: 1.3, 6.5; p: 0.009).

CONCLUSION

The aging of PLHIV is a public health concern. Our findings indicate that HRQoL and poverty risk among Spanish OPLHIV differ significantly by sex. Spain should, therefore, implement specific policies and interventions to address OPLHIV needs. The strategies must place a high priority on the reduction of sex inequalities in HRQoL and the enhancement of the structural conditions in which OPLHIV live.

Sleep quality, social rhythms, and depression among people living with HIV: a path analysis based on social zeitgeber theory

Background

People living with HIV frequently report sleep disturbances. The social zeitgeber theory, which proposes that stressful life events can interfere with sleep and even depression by destabilizing daily routines, provides new insights into identifying predictors of sleep disturbances and improving sleep in people living with HIV.

Objective

To explain the pathways affecting sleep quality in people living with HIV based on social zeitgeber theory.

Methods

A cross-sectional study was conducted to assess sleep quality, social rhythms, depression, social support, and coping styles from December 2020 to February 2021. The hypothetical model was tested and respecified by performing path analysis and a bias-corrected bootstrapping method using IBM AMOS 24 software. The report of this study followed the STROBE checklist.

Results

A total of 737 people living with HIV participated in the study. The final model presented a good fit (goodness of fit = 0.999, adjusted goodness of fit index = 0.984, normed fit index = 0.996, comparative fit index = 0.998, Tucker-Lewis index = 0.988, root mean square error of approximation = 0.030, chi-squared/degree of freedom = 1.646), explaining 32.3% of the variance in sleep quality among people living with HIV. Lower social rhythm stability was directly associated with poorer sleep quality, and depression mediated the relationship between social rhythms and sleep quality. Social support and coping styles affected sleep quality through social rhythms and depression.

Limitation

The cross-sectional study design precludes making assumptions about causality among factors.

Conclusion

This study validates and extends the applicability of the social zeitgeber theory in the HIV context. Social rhythms have direct and indirect effects on sleep. Social rhythms, sleep, and depression is not simply linked in a cascading sequence but is theoretically linked in a complex way. More studies are needed to explore the predictors of social rhythms, and interventions for stabilizing social rhythms have the potential to alleviate sleep disturbances and depression in people living with HIV.

Social dimensión of HIV and state response

HIV infection is strongly conditioned by social factors. Two of the most significant obstacles in the response to HIV is the stigma and the discrimination that is still associated with it. The stigmatization process occurs through individual drivers and structural facilitators that interweave with overlapping stigmas. These stig-mas manifest in several forms and lead to complex consequences that negatively influence prevention, diagnosis, treatment and quality of life. This article reviews these issues and the evidence of stigma in Spain. The response to HIV requires a strong political commitment. However, the economic crisis and the lack of leadership from institutions have slowed down the progress achieved in Spain. HIV must be placed at the forefront of the political agenda in order to achieve international goals.

Content analysis of Spanish judgements addressing the sexual transmission of HIV: 1996-2016

This study performed a content analysis of the language of the Spanish judgements addressing the sexual transmission of HIV in order to determine its possible interrelationship with HIV-related stigma. All judgements and writs dictated by Spanish penal and civil jurisdictions between 1981 and December 2016 were obtained through a systematic search of the Spanish legal databases. The inclusion criterion was that the possible transmission of HIV was judged as an individual infraction, regardless of whether other infractions were involved. Twenty judgements were selected and analysed through direct content analysis assisted by the software MAXQDA 12. The majority of the cases (85%) were brought before the penal jurisdiction. Most of the judgements applied the crimes of bodily harm or grievous bodily harm (75%). Aspects closely related to the determinants of HIV-related stigma, such as the perception of HIV as a severe and easily transmitted infection, and attributions of responsibility and blame to people with HIV, were found in the judgements' reasoning. They were associated with outdated scientific and technical knowledge. Furthermore, some arguments found are repeated literally and successively in several judgments from different years, ignoring medical advances. Most plaintiffs were unaware of their sexual partner's HIV status. The scarce results found regarding the concealment of HIV status suggested that fear of stigma could be the reason thereof. The results suggested that training legal professionals in the epidemiological, clinical, and social aspects of HIV could influence stigma reduction, leading to a more objective consideration of the characteristics of this infection.

Psychosocial determinants of HIV testing across stages of change in Spanish population: a cross-sectional national survey

Background

The goal of this research is to study the psychosocial determinants of HIV-testing as a function of the decision or change stage concerning this health behavior. The determinants considered in the major ongoing health models and the stages contemplated in the Precaution Adoption Process Model are analysed.

Methods

A cross-sectional survey was administered to 1,554 people over 16 years of age living in Spain by a computer-assisted telephone interview (CATI). The sample design was randomised, with quotas of sex and age. The survey measured various psychosocial determinants of health behaviors considered in the main cognitive theories, the interviewees' stage of change concerning HIV-testing (lack of awareness, decision not to act, decision to act, action, maintenance, and abandonment), and the signal for the action of getting tested or the perceived barriers to being tested.

Results

Approximately two thirds of the population had not ever had the HIV test. The predominant stage was lack of awareness. The most frequently perceived barriers to testing were related to the health system and to the stigma. We also found that the psychosocial determinants studied differed depending on the respondents' stage of change. Perception of risk, perceived self-efficacy, proximity to people who had been tested, perceived benefits of knowing the diagnosis, and a positive instrumental and emotional attitude were positively associated with the decision and maintenance of testing behavior. However, unrealistic underestimation of the risk of HIV infection, stereotypes about the infection, and the perceived severity of HIV were associated with the decision not to be tested.

Conclusions

There are various sociocognitive and motivational profiles depending on people’s decision stage concerning HIV-testing. Knowing this profile may allow us to design interventions to influence the psychosocial determinants that characterise each stage of change.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4148-4) contains supplementary material, which is available to authorized users.

Adaptation of the HIV Stigma Scale in Spaniards with HIV

The primary goal of this study was to adapt Berger, Ferrans, & Lahley (2001) HIV Stigma Scale in Spain, using Bunn, Solomon, Miller, & Forehand (2007) version. A second goal assessed whether the four-factor structure of the adapted scale could be explained by two higher-order dimensions, perceived external stigma and internalized stigma. A first qualitative study (N = 40 people with HIV, aged 28-59) was used to adapt the items and test content validity. A second quantitative study analyzed construct and criterion validity. In this study participants were 557 people with HIV, aged 18-76. The adapted HIV Stigma Scale for use in Spain (HSSS) showed a good internal consistency (α = .88) and good construct validity. Confirmatory Factor Analyses yielded a first-order, four-factor structure and a higher-order, bidimensional structure with the two expected factors (RMSEA = .051, 90% CI [.046, .056]; RMR = .073; GFI = .96; AGFI = .96; CFI = .98). Negative relations were found between stigma and quality of life (r = -.39; p < .01), self-efficacy to cope with stigma (r = -.50; p < .01) and the degree of HIV status disclosure (r = -.35; p < .01). Moreover, the people who had suffered AIDS-related opportunistic infections had a higher score in the Perceived External Stigma dimension than those who had not suffered them, t (493) = 3.02, p = .003, d = 0.26.

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.