Improving health outcomes for women with HIV: the potential impact of addressing internalized stigma and depression

The Impact of Human Immunodeficiency Virus on Women in the United States

Substantial improvements have been made in reducing HIV incidence rates among women in the United States. However, numerous disparities affect women's risk of HIV acquisition, in addition to affecting treatment outcomes for women living with HIV. As people with HIV continue to live longer due to antiretroviral therapy, clinicians must be cognizant of various health, financial, and social implications that can affect HIV self-management. Successfully ending the HIV epidemic will require more targeted approaches on prevention, linkage to care, and treatment while also addressing underlying factors that affect women's engagement in HIV-related services across the HIV care continuum.

A Bayesian network analysis to examine the effects of HIV stigma processes on self-concept and depressive symptoms among persons living with HIV

OBJECTIVE

This study examines the relationships between HIV stigma dimensions, self-related mechanisms, and depressive symptoms among persons living with HIV.

BACKGROUND

HIV stigma hinders the well-being of individuals living with HIV, which is linked to depressive symptoms and increased risk of poor clinical outcomes. However, the mechanisms underlying stigma's impact on depression are poorly understood. Psychosocial theories propose that experiencing HIV stigma leads to internalized stigma, impacting self-concept and mental health.

METHOD

Using Bayesian network analysis, we explored associations among HIV stigma processes (experienced, anticipated, internalized, perceived community stigma, and HIV status disclosure) and self-related mechanisms (self-esteem, fear of negative evaluation [FNE], self-blame coping, and social exclusion), and depressive symptoms.

RESULTS

Our diverse sample of 204 individuals, primarily men, gay/bisexual, Black, and lower-middle SES, who experienced stigma showed increased anticipated, internalized, and perceived community stigma, FNE, and depressive symptoms. Internalized stigma contributed to self-blame coping and higher depressive symptoms. Anticipated and perceived community stigma and FNE correlated with increased social exclusion.

DISCUSSION

This study investigates potential mechanisms through which HIV stigma may impact depression. Identifying these mechanisms establishes a foundation for future research to inform targeted interventions, enhancing mental health and HIV outcomes among individuals living with HIV, especially from minority backgrounds. Insights gained guide evidence-based interventions to mitigate HIV stigma's detrimental effects, ultimately improving overall well-being and health-related outcomes for people with HIV.

Intersectional Stigma, Fear of Negative Evaluation, Depression, and ART Adherence Among Women Living with HIV Who Engage in Substance Use: A Latent Class Serial Mediation Analysis

Women Living with HIV (WLHIV) who use substances face stigma related to HIV and substance use (SU). The relationship between the intersection of these stigmas and adherence to antiretroviral therapy (ART), as well as the underlying mechanisms, remains poorly understood. This study aimed to examine the association between intersectional HIV and SU stigma and ART adherence, while also exploring the potential role of depression and fear of negative evaluation (FNE) by other people in explaining this association. We analyzed data from 409 WLHIV collected between April 2016 and April 2017, Using Multidimensional Latent Class Item Response Theory analysis. We identified five subgroups (i.e., latent classes [C]) of WLHIV with different combinations of experienced SU and HIV stigma levels: (C1) low HIV and SU stigma; (C2) moderate SU stigma; (C3) higher HIV and lower SU stigma; (C4) moderate HIV and high SU stigma; and (C5) high HIV and moderate SU stigma. Medication adherence differed significantly among these classes. Women in the class with moderate HIV and high SU stigma had lower adherence than other classes. A serial mediation analysis suggested that FNE and depression symptoms are mechanisms that contribute to explaining the differences in ART adherence among WLHIV who experience different combinations of intersectional HIV and SU stigma. We suggest that FNE is a key intervention target to attenuate the effect of intersectional stigma on depression symptoms and ART adherence, and ultimately improve health outcomes among WLHIV.

Optimizing PMTCT Adherence by Treating Depression in Perinatal Women with HIV in South Africa: A Pilot Randomized Controlled Trial

BACKGROUND

South Africa (SA) has the greatest HIV prevalence in the world, with rates as high as 40% among pregnant women. Depression is a robust predictor of nonadherence to antiretroviral therapy (ART) and engagement in HIV care; perinatal depression may affect upwards of 47% of women in SA. Evidence-based, scalable approaches for depression treatment and ART adherence in this setting are lacking.

METHOD

Twenty-three pregnant women with HIV (WWH), ages 18-45 and receiving ART, were randomized to a psychosocial depression and adherence intervention or treatment as usual (TAU) to evaluate intervention feasibility, acceptability, and preliminary effect on depressive symptoms and ART adherence. Assessments were conducted pre-, immediately post-, and 3 months post-treatment, and included a qualitative exit interview.

RESULTS

Most (67.6%) eligible individuals enrolled; 71% completed at least 75% of sessions. Compared to TAU, intervention participants had significantly greater improvements in depressive symptoms at post-treatment, β =  - 11.1, t(24) =  - 3.1, p < 0.005, 95% CI [- 18.41, - 3.83], and 3 months, β =  - 13.8, t(24) =  - 3.3, p < 0.005, 95% CI [- 22.50, - 5.17]. No significant differences in ART adherence, social support, or stigma were found. Qualitatively, perceived improvements in social support, self-esteem, and problem-solving adherence barriers emerged as key benefits of the intervention; additional sessions were desired.

CONCLUSION

A combined depression and ART adherence intervention appears feasible and acceptable, and demonstrated preliminary evidence of efficacy in a high-need population. Additional research is needed to confirm efficacy and identify dissemination strategies to optimize the health of WWH and their children.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03069417. Protocol available at https://clinicaltrials.gov/ct2/show/NCT03069417.

Resilience and Optimism as Moderators of the Negative Effects of Stigma on Women Living with HIV

Resilience and optimism may not only have main effects on health outcomes, but may also moderate and buffer negative effects of stressors. We examined whether dispositional resilience and optimism moderate the associations between HIV-related stigma in health care settings and health-related outcomes (trust in HIV health care providers and depression symptoms) among women living with HIV (WLHIV). One thousand four hundred five WLHIV in nine US cities completed validated questionnaires for cross-sectional analyses. Higher self-reported experienced and anticipated stigma and lower resilience and optimism were associated with higher depression symptoms and with lower trust in HIV providers. Importantly, resilience moderated the effects of experienced stigma (but not of anticipated stigma): When resilience was high, the association of experienced stigma with higher depression symptoms and lower trust in HIV providers was weaker compared with when resilience was low. Further, significant moderation effects suggested that when optimism was high, experienced and anticipated stigma was both less strongly associated with depression symptoms and with lower trust in one's HIV care providers compared with when optimism was low. Thus, the effects of experienced stigma on depression symptoms and provider trust were moderated by both resilience and optimism, but the effects of anticipated stigma were moderated only by optimism. Our findings suggest that in addition to their main effects, resilience and optimism may function as buffers against the harmful effects of stigma in health care settings. Therefore, optimism and resilience may be valuable intervention targets to reduce depression symptoms or improve trust in providers among populations that experience or anticipate stigma, such as WLHIV.

Dehumanizing language, motherhood in the context of HIV, and overcoming HIV stigma - the voices of Rwandan women with HIV: A focus group study

BACKGROUND

Stigma is an underlying cause of health inequities, and a major barrier to HIV prevention, care, and treatment. Experiences of HIV stigma have been shown to reduce engagement in care across the HIV care continuum, from testing and diagnosis to long-term retention in care and anti-retroviral therapy adherence. In Rwanda, approximately 130,000 women are living with HIV, representing a prevalence rate (3.7%) which is substantially higher than Rwandan men (2.2%). Both the national Rwanda and City of Kigali HIV and AIDS strategic plans identify stigma as a key concern for reducing the burden of HIV.

OBJECTIVES

The first objective of this study was to understand the sources of HIV-related stigma among women living with HIV in Rwanda. The second objective was to understand the cultural, linguistic, and contextual context of HIV-related stigma and the intersection of HIV-related stigma to the HIV care continuum (engagement in care, medication/treatment adherence) among women with HIV in Rwanda.

DESIGN

This study used a cross-sectional, qualitative design.

SETTING AND PARTICIPANTS

Three-three women from urban and rural settings in Rwanda were recruited from public HIV treatment and care centers to participate in this study.

METHOD

Focus groups discussions, guided by a structured interview guide, were used to collect qualitative data. Framework analysis was used to analyze the data, which was collected during July 2018.

RESULTS

The participants in this study highlighted that Rwandan women with HIV experience all forms of stigma - enacted, anticipated, perceived, and internalized - associated with HIV as well as structural stigma. Further, three major themes - dehumanizing language, importance of motherhood in the context of HIV, and overcoming HIV stigma - emerged from the data.

CONCLUSION

The results of this study are among the few to give voice and perspective to the stigma experiences of Rwandan women with HIV. The women with HIV participating in this study shed light on the pervasive and culturally constructed effects of stigma that continue to exist. Further, the findings from this study highlighted the significant intersection of the role dehumanizing language experienced by Rwandan women with HIV. Additionally, the intersectional identities of being a woman with HIV and a mother and their relationship to societal and cultural norms and expectations must be considered concurrently. Finally, the beneficial effects of support groups was identified as key in helping Rwandan women with HIV to accept self.