Effects of an intervention on internalized HIV-related stigma for individuals newly entering HIV care

HIV Stigma, Health, and Violence: A Longitudinal Study among Adolescent Boys with HIV in Soweto, South Africa

There are over 1.4 million adolescents living with HIV in sub-Saharan Africa, the majority of whom acquired the virus through perinatal transmission (PHIV). HIV stigma is particularly high among adolescents living with HIV and is associated with several outcomes that worsen health and increase the risk of onward HIV transmission. We tested associations between internalized HIV stigma and four of these outcomes over a one-year period among a sample of adolescent boys living with PHIV in Soweto, South Africa. Participants (N = 241) answered questions about internalized HIV stigma at baseline. They completed weekly mobile surveys over the following year to answer questions about their experiences with depression, binge drinking, medication adherence, and violence victimization. Using generalized linear mixed models, we found that baseline internalized HIV stigma was associated with increased odds of depression (OR 1.74), alcohol misuse (OR 2.09), and violence victimization (OR 1.44) and decreased odds of medication adherence (OR 0.60) over the course of a year. These outcomes negatively impact the health and wellbeing of adolescents living with PHIV and increase their risk of transmitting HIV to their partners in the future. Our findings provide novel, longitudinal evidence for the deleterious effects of HIV stigma. To improve health outcomes for adolescents with PHIV, it will be crucial to develop effective HIV stigma reduction interventions that address specific developmental, gendered, and cultural experiences.

The association between stigma and wellbeing in an Italian cohort of PLWH: The role of social support and personal factors

Our aim was to assess the association between different types of stigma and physical, behavioural and emotional wellbeing, and to evaluate whether these associations were mediated by the level of social support, age, education, sex and time from HIV diagnosis in an Italian cohort of people living with HIV (PLWH). We enrolled 96 PLWH and had them complete a cross-sectional online survey that included the "HSS-12", the "SF-12" and the "DASS-21". We performed linear regression analyses to explore the associations between the HSS-12 scores and cART adherence, viral load, SF-12 and DASS-21 scores, and a mediation analysis to identify mediators in the significant associations. We showed that higher level of depression and worse perception of mental health were significantly associated with higher HSS-12 "personalised stigma" (p = .009, p = .020) "disclosure concerns" (p = .012, p = .039), "concerns about public attitudes" (p =.007, p = .005) and "negative self-image" scores; (p < .001, p = .001); worse perception of physical health status was associated with higher HSS-12 "personalised stigma" scores (p = .018); higher level of anxiety and stress were associated with higher "negative self-image" scores (0.001 and p < .001). The association between higher HSS-12 "negative self-image" and higher levels of depression, anxiety and stress were mediated by lower age (a*b = +0.10; a*b = +0.12; a*b = +0.11). This study may have important implications for clinical practice as it contributes to understanding the characteristics and consequences of HIV-related stigma in a population of PLWH with excellent viroimmunological status and therapeutic adherence.

Longitudinal Associations of Experienced and Perceived Community Stigma With Antiretroviral Therapy Adherence and Viral Suppression in New-to-Care People With HIV: Mediating Roles of Internalized Stigma and Depression Symptoms

BACKGROUND

Although cross-sectional studies have suggested that HIV-related stigma and depression symptoms may result in poor HIV treatment and health outcomes, few studies have investigated potential longitudinal mechanisms in these relationships. Furthermore, longitudinal effects of HIV-related stigma on health outcomes have not been examined in people with HIV (PWH) newly initiating HIV clinical care. We examined longitudinal associations between experienced and perceived community stigma and health outcomes (antiretroviral therapy [ART] adherence and viral load), mediated by internalized stigma and depression symptoms among new-to-care PWH in the United States.

SETTING/METHODS

Data were obtained from 371 PWH who initiated HIV medical care at 4 HIV sites at baseline and 48 weeks later between December 2013 and 2018. Validated measures were used to assess experienced stigma, perceived community stigma, internalized stigma, depression symptoms, and ART adherence, and viral load was obtained from medical records at the final study visit.

RESULTS

Serial mediation models revealed significant indirect effects of experienced stigma and perceived community stigma on ART adherence and on viral suppression, first through internalized stigma and then through depression symptoms.

CONCLUSIONS

These results suggest that PWH may tend to internalize HIV-related stigma when they experience acts of stigmatization or perceive negative attitudes in society, which in turn may result in negative effects on psychological and physical well-being. These findings about how stigma in society may be an antecedent mechanism for PWH to develop internalized stigma, which in turn affects individual health outcomes, can be used to tailor both individual-level and community-level interventions.

Systematic review and quantitative and qualitative comparative analysis of interventions to address HIV-related stigma and discrimination

A strong global commitment exists to eliminate HIV-related stigma and discrimination, and multiple strategies to reduce or eliminate stigma and discrimination have been tried. Using a PICOTS framework and applying the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) criteria, we undertook a systematic review to determine the success of interventions aiming to address internalized stigma, stigma and discrimination in healthcare, and at the legal or policy level, and to identify their critical success factors. Random effects meta-analyses summarized results wherever possible. We carried out a component analysis to identify and characterize successful interventions. Internalized stigma interventions were diverse: across all studies, we found a reduction of stigma but it was not statistically significant [standardized mean difference (SMD) 0.56; confidence interval (CI) 0.31-1.02; 17 studies). For interventions to address stigma and discrimination in healthcare settings, effect estimates varied considerably but most studies showed positive effects (SMD 0.71; CI 0.60-0.84, 8 studies). Boosted regression analyses found that a combined approach comprising education, counseling, community participation, support person, and access to a HIV specialist often yielded success. Studies of efforts to address stigma and discrimination through law and policy documented, mostly qualitatively, the effect of court cases and directives. Across a range of settings and populations, promising interventions have been identified that, through diverse pathways, have positively impacted the types of stigma and discrimination studied. This evidence base must be built upon and brought to scale to help reach global HIV-related targets and, most importantly, improve the health and quality of life of people with HIV.

Correlates of Internalized HIV Stigma: A Comprehensive Systematic Review

Internalized HIV stigma is prevalent and research on internalized HIV stigma has increased during the past 10 years. The aim of this systematic review was to synthesize research on internalized HIV stigma and relationships with various health-related variables in order to better inform the development of interventions aimed at reducing internalized HIV stigma. We reviewed 176 studies with a quantitative design reporting correlates that were peer-reviewed, published in English before January 2021, drawn from PubMed, PSYCHINFO, Web of Science, EBSCO, and Scopus. Synthesis showed consistent associations between internalized stigma and negative psychological (e.g., depression, anxiety), social (e.g., lack of social support, discrimination, nondisclosure, and intersecting stigmas), and health (e.g., substance use, treatment nonadherence, negative clinical HIV outcomes) variables. We argue for a more socioecological approach to internalized stigma, with greater attention for intersectional stigmas, and more longitudinal research, if we are to effectively develop interventions that reduce internalized stigma.

The Thai Internalized HIV-related Stigma Scale

Introduction

Internalized stigma among people living with HIV has been linked to a range of negative consequences. The current study describes the development and validation of a contextually appropriate internalized HIV-related Stigma Scale for people living with HIV in Thailand.

Methods

The study was carried out in two stages from 2018 to 2019: developing items based on the findings of focus group discussions and pilot testing the original list of items and validating the instrument. In the cross-sectional survey stage, a sample of 400 people living with HIV was used to validate the test items in accordance with their psychometric characteristics.

Results

The study’s outcome was the 22-item Thai Internalized HIV-related Stigma Scale (Thai-IHSS). The exploratory factor analysis showed that the Thai-IHSS consisted of four components: negative thoughts toward self (5 items), anticipated negative thoughts (7 items), effects of negative thought toward self (6 items), and effects of negative thoughts toward family and access to healthcare services (4 items).

Discussion

The Thai-IHSS had acceptable concurrent, convergent, and congruent validity according to the findings. Additionally, the 8-item Thai-IHSS brief, which included two items for each component, was detailed. The Thai-IHSS is valid and reliable for use in Thailand and other countries with comparable sociocultural environments.

HIV-Related Stigma, Social Support, and Symptoms of Mental Health Disorders Among People with HIV Initiating HIV Care in Cameroon

HIV-related stigma has been associated with poor mental health among people with HIV (PWH). Social support is a potentially modifiable factor that may buffer negative mental health sequelae of HIV-related stigma. Little is known about the extent to which the modifying effect of social support differs across mental health disorders. Interviews were conducted with 426 PWH in Cameroon. Log binomial regression analyses were used to estimate the association between high anticipated HIV-related stigma and low social support from family or friends and symptoms of depression, anxiety, post-traumatic stress disorder (PTSD), and harmful alcohol use, separately. Anticipated HIV-related stigma was commonly endorsed with ∼80% endorsing at least 1 of 12 stigma-related concerns. In multivariable analyses, high anticipated HIV-related stigma was associated with greater prevalence of symptoms of depression {adjusted prevalence ratio (aPR) 1.6 [95% confidence interval (CI) 1.1-2.2]} and anxiety [aPR 2.0 (95% CI 1.4-2.9)]. Low social support was associated with greater prevalence of symptoms of depression [aPR 1.5 (95% CI 1.1-2.2)], anxiety [aPR 1.7 (95% CI 1.2-2.5)], and PTSD [aPR 1.6 (95% CI 1.0-2.4)]. However, social support did not meaningfully modify the relationship between HIV-related stigma and symptoms of any mental health disorders explored. Anticipated HIV-related stigma was commonly reported among this group of PWH initiating HIV care in Cameroon. Social concerns related to gossip or losing friends were of the greatest concern. Interventions focused on reducing stigma and strengthening support systems may be particularly beneficial and have the potential to improve the mental health of PWH in Cameroon.

Impact of Community Support Workers in Rural Ethiopia on Emotional and Psychosocial Health of Persons Living with HIV: Results of a Three-Year Randomized Community Trial

People living with HIV face multiple psychosocial challenges. In a large, predominantly rural Ethiopian region, 1799 HIV patients new to care were enrolled from 32 sites in a cluster randomized trial using trained community support workers with HIV to provide individual health education, counseling and social support. Participants received annual surveys through 36 months using items drawn from the Centre for Epidemiologic Studies Depression Scale-10, Medical Outcome Study Social Support Survey, and HIV/AIDS Stigma Instrument-PLWA. At 12 months (using linear mixed effects regression models controlling for enrollment site clustering), intervention participants had greater emotional/informational and tangible assistance social support scores, and lower scores assessing depression symptoms and negative self-perception due to HIV status. A significant treatment effect at 36 months was also seen on scores assessing emotional/informational social support, depression symptoms, and internalized stigma. An intervention using peer community support workers with HIV to provide individualized informational and psychological support had a positive impact on the emotional health of people living with HIV who were new to care.(ClinicalTrials.gov protocol ID: 1410S54203, May 19, 2015).

HIV Stigma, HIV status disclosure, and ART adherence in the context of an integrated opioid use disorder and HIV treatment setting in Dar es Salaam, Tanzania

Little is known about social factors, including stigma, that affect antiretroviral therapy (ART) adherence among people enrolled in opioid use disorder treatment (OUDT) in the context of integrated OUDT and HIV treatment models. We qualitatively examined the relationship between HIV stigma, HIV status disclosure, and ART adherence among clients living with HIV at an OUDT clinic with integrated HIV services in Tanzania. We conducted in-depth interviews with 25 clients receiving HIV care at an OUDT clinic in Dar es Salaam, Tanzania between January and April 2020. HIV stigma, particularly anticipated stigma, and HIV status disclosure were key factors that affected ART adherence. Participants feared non-voluntary HIV status disclosure to and HIV stigma from their peers enrolled in OUDT. Most participants reported concealing their HIV status from peers at the OUDT clinic and not associating with other clients living with HIV at the clinic. Reducing HIV stigma and enhancing clinic structures and procedures to maintain privacy and confidentiality are essential to mitigating the effects of stigma on ART adherence.

What do young people know about HIV? Results of a cross sectional study on 18-24-year-old students

Introduction

Increasing people's knowledge of transmission, prevention, early diagnosis, and available treatments is a key step toward HIV control; it means setting the conditions for empowerment and enabling individuals to make aware choices about the prevention strategy best suited to their needs. This study aims to identify unmet needs on HIV knowledge among freshman students.

Methods

A cross sectional study was carried out at the University of Cagliari, which is an Italian public state university. Data were collected by means of an anonymous questionnaire; the final sample included 801 students.

Results

Results offer a detailed picture of students' knowledge and perceptions of HIV. Several topics deserve to be better understood by students, but the main gaps relate to the pre-exposure prophylaxis and the decreased likelihood of sexually transmitting HIV due to early treatments. Students' vision of the quality of life of people living with HIV was negatively affected by perceiving as relevant the effects of HIV on physical health or on sexual/affective domains, while conversely, it seemed positively affected by knowing that current treatments are useful for counteracting physical symptoms and decreasing the possibility of transmitting HIV.

Conclusion

Being aware of the potential benefits of current therapies could favour a less negative view, in line with the current state of the beneficial effects of HIV treatment. Universities are a valuable setting to bridge the HIV knowledge gap and thus also contribute to tackling stigma and actively promoting HIV testing.

Determinants of COVID-19 vaccine acceptability among older adults living with HIV

Since the emergency approval of several therapeutic coronavirus disease 2019 (COVID-19) vaccines in the United States, >500 million doses have been administered. However, there have been disparities in vaccine acceptability and uptake. We examined demographic, human immunodeficiency virus (HIV) disease, and psychosocial factors associated with COVID-19 vaccine acceptability in older adults (≥50 years) living with HIV in the Coachella Valley, California. Participants completed a 1-time anonymous online questionnaire assessing their demographic (i.e., age, race, education, etc), HIV disease (i.e., viral suppression, years living with HIV, acquired immunodeficiency syndrome diagnosis), psychosocial (i.e., HIV-related stigma, personal mastery, depression, etc) characteristics, and COVID-19 vaccine acceptability. Respondents were offered an electronic $20 United States dollar (USD) gift card for survey completion. Descriptive, univariable, and multivariable tests were conducted to analyze the data. Between September 2020 and February 2021, 114 surveys were completed. Eighty-six (75%) agreed/strongly agreed with the COVID-19 vaccine acceptability statement that they saw no problem with receiving a COVID-19 vaccine if one became available. Among those who agreed/strongly agreed, the mean age was 62.2 years (standard deviation = 7.20); 86% self-identified as White; 95% male; 91% with more than high school education; and 31% with annual income <$20,000 USD. Among respondents who disagreed/strongly disagreed, the mean age was 59.9 years (standard deviation = 4.85); 50% self-identified as White; 50% male; 64% with more than high school education; and 4% with annual income <$20,000 USD. In the univariable analyses, those who disagreed/strongly disagreed with the COVID-19 vaccine acceptability statement were significantly more likely to be living with HIV for fewer years, experiencing higher levels of HIV-related stigma and depression, and with lower levels of personal mastery. In the multivariable logistic regression model, self-identification as female vs male and unemployed vs employed was significantly associated with decreased COVID-19 vaccine acceptability (odds ratio = 0.09, 95% confidence interval: 0.01-0.71 and odds ratio = 0.08, 95% confidence interval: 0.01-0.70 respectively), adjusting for ethnicity, marital status, education, disability, years living with HIV, HIV-related stigma, and depression. Additional studies are needed to understand vaccine-related decision-making among older adults living with HIV. Programmatic efforts may also be necessary to disseminate accurate information/resources about COVID-19 vaccines to those with more recent HIV diagnoses, experiencing HIV-related stigma and depression, with lower levels of personal mastery, and facing socioeconomic disparities.

Psychiatric comorbidity and psychosocial stressors among people initiating HIV care in Cameroon

Background

Psychiatric comorbidity, the presence of two or more mental health disorders, has been associated with suboptimal HIV treatment outcomes. Little is known about the prevalence of psychiatric comorbidity among people with HIV (PWH) in sub-Saharan Africa.

Methods

We conducted interviews with PWH initiating HIV care in Cameroon between June 2019 and March 2020. Depression, anxiety, post-traumatic stress disorder (PTSD), and harmful drinking were dichotomized to represent those with and without symptoms of each. Psychiatric comorbidity was defined as having symptoms of two or more disorders assessed. Moderate or severe household hunger, high anticipatory HIV-related stigma, low social support, and high number of potentially traumatic events were hypothesized as correlates of psychiatric comorbidity. Bivariable log binomial regression models were used to estimate unadjusted associations between psychosocial stressors and psychiatric comorbidity.

Results

Among 424 participants interviewed, the prevalence of psychiatric comorbidity was 16%. Among those with symptoms of at least one mental health or substance use disorder (n = 161), the prevalence of psychiatric comorbidity was 42%. The prevalence of psychiatric comorbidity was 33%, 67%, 76%, and 81% among those with symptoms of harmful drinking, depression, anxiety, and PTSD, respectively. Among individuals with symptoms of a mental health or substance use disorder, a high number of potentially traumatic events (prevalence ratio (PR) 1.71 [95% CI 1.21, 2.42]) and high anticipatory HIV-related stigma (PR 1.45 [95% CI 1.01, 2.09]) were associated with greater prevalence of psychiatric comorbidity.

Conclusion

Psychiatric comorbidity was common among this group of PWH in Cameroon. The effectiveness and implementation of transdiagnostic or multi-focus mental health treatment approaches in HIV care settings should be examined.

Behavioral and social interventions to promote optimal HIV prevention and care continua outcomes in the United States

PURPOSE OF REVIEW

This review reports on trends in behavioral and social intervention research in the United States published over the past year (2020-2021) investigating HIV prevention and care outcomes, organized by the level of intervention focus - individual, dyadic, and organizational.

RECENT FINDINGS

Researchers have continued to develop and evaluate behavioral and social interventions to reduce HIV acquisition risk and disease progression. With few exceptions, social and behavioral interventions have primarily focused on individuals as the unit of behavior change. Interventions operating at the individual-, dyadic-, and organizational-level have made strides to reduce HIV transmission risk and disease progressing by addressing mental health, substance use, stigma, peer and romantic relationships, and, to some extent, structural vulnerabilities.

SUMMARY

Social and behavioral interventions continue to be critical in addressing HIV inequities in the United States. An important gap in the literature is the need for multilevel interventions designed and implemented within existing community-based organizations and local healthcare settings. We call on researchers to continue to attend to the structural, environmental, and economic vulnerabilities that shape HIV inequities in the development of multilevel approaches necessary to realize the full potential of existing and emerging HIV prevention and care strategies.

Examining HIV Stigma, Depression, Stress, and Recent Stimulant Use in a Sample of Sexual Minority Men Living with HIV: An Application of the Stigma and Substance Use Process Model

Sexual minority men (SMM) with HIV are disproportionately impacted by stigma and mental health disorders. Guided by the Stigma and Substance Use Process Model, we evaluated how HIV stigma impacts mental health outcomes among SMM with HIV. Data were drawn from Thrive With Me, an RCT of an mHealth intervention targeting ART adherence among SMM with HIV. Path analyses tested the relationships between HIV stigma, depression, stress, and recent stimulant use. Overall, 49.1% (194/401) had depression symptoms, 68.8% (276/401) had moderate-to-high stress, and 28.1% (111/401) had detectable stimulant use in urine samples at baseline. In path analyses, baseline internalized HIV stigma was associated with depression and stress 5-months post-baseline and enacted stigma was associated with recent stimulant use 11-months post-baseline. We identified internalized and enacted HIV stigma, but not anticipated stigma, as potentially important intervention targets for stimulant use, depression, and stress among SMM with HIV.

Stigma is associated with illness self-concept in individuals with concealable chronic illnesses

OBJECTIVES

Previous research suggests that chronic illnesses can elicit stigma, even when those illnesses are concealable. Such stigmatization is assumed to lead to a stigmatized identity. Additionally, chronic illness affects one's self-concept, as one reconstructs a sense of self with illness incorporated. However, no research has examined the interplay between stigma and self-concept in those with concealable chronic illnesses. Therefore, we investigated the extent to which experienced, anticipated, and internalized stigma are associated with illness self-concept in individuals living with concealable chronic illnesses. Furthermore, we explored if the aforementioned aspects of stigma are associated with enrichment in the self-concept in the same cohort.

DESIGN

An online correlational survey of people with concealable chronic illness (N = 446).

METHODS

Participants completed self-report measures of chronic illness-specific measures of stigma and illness self-concept, both negative and positive.

RESULTS

Results indicated that there is a positive relationship between experienced, anticipated, and internalized stigma and illness self-concept, indicating that stigma is associated with increased preoccupation and perceived impact of one's illness on the self. Although there is also a negative relationship between anticipated and internalized stigma and enrichment, only internalized stigma is associated with enrichment over and above the effects of control variables such as personal control.

CONCLUSIONS

Our findings bridge the existing literature on illness self-concept and stigma for chronic illness groups, with a specific focus on those with concealable chronic illnesses. More varied approaches to coping with illness should be encouraged, including encouraging enrichment aspects to potentially act as a buffer between the effects of stigma and illness self-concept.

Disclosure Concerns and Viral Suppression in People Newly Initiating HIV Care: The Role of Internalized HIV Stigma

BACKGROUND

Research on how disclosure concerns affect health outcomes for people living with HIV (PLWH) has yielded inconsistent results. Theoretically, disclosure concerns could predict either poorer antiretroviral therapy (ART) adherence (PLWH worried about disclosure may not want to take their medication in front of others) or better ART adherence (stronger concerns may enhance treatment adherence to avoid unintentional disclosure). Furthermore, internalized stigma (which is positively associated with disclosure concerns) predicts worse ART adherence (an effect potentially in the opposite direction of the direct effect of disclosure concerns).

SETTING/METHODS

One hundred eighty-six PLWH initiating HIV care at 4 US clinics completed measures of disclosure concerns, internalized stigma, and ART adherence. Viral load data were obtained from medical records. We examined the indirect effect of disclosure concerns on outcomes, adjusting for the suppressor effect of internalized stigma. That is, we examined whether the association between disclosure concerns and ART adherence/viral suppression is stronger and positive when controlling for the effect of internalized stigma.

RESULTS

Disclosure concerns were more strongly associated with better viral suppression and ART adherence when internalized stigma was in the model, suggesting that internalized stigma suppressed this association. Similarly, internalized stigma led to higher disclosure concerns, which in turn led to better ART adherence and higher likelihood of viral suppression. However, internalized stigma also had a direct effect in the opposite direction of this indirect effect.

CONCLUSIONS

Findings highlight the importance of addressing effects of internalized stigma and disclosure concerns jointly when attempting to understand effects on health outcomes among new-to-care PLWH.

The impact of food insecurity on HIV outcomes in Senegal, West Africa: a prospective longitudinal study

Background

Understanding the impact of food insecurity on HIV outcomes is critical for the development and implementation of effective, evidence-based interventions to address food insecurity and improve the HIV care cascade. We conducted a prospective, longitudinal study to determine the impact of food insecurity on HIV outcomes in Senegal, West Africa.

Methods

HIV-infected individuals presenting for care and initiation of ART through the Senegalese National AIDS program in Dakar and Ziguinchor were eligible for enrollment. Data were collected using interviews, clinical evaluations, laboratory analyses, and chart review at enrollment, month 6, and month 12. Logistic regression was used to determine the association between food insecurity and HIV outcomes.

Results

Among the 207 participants in this study, 70% were female and the median age was 37 years. The majority (69%) were food insecure at enrollment, 29% were severely food insecure, and 38% were undernourished. Nearly a third (32%) had no formal education, 23% practiced agriculture, and 40% owned livestock. The median daily food expenditure per person was $0.58. The median round trip transportation time to clinic was 90 min (IQR 30–240). The median cost of transportation to clinic was $1.74. At month 12, 69% were food insecure, 23% were severely food insecure, and 14% were undernourished. At month 12, 43% had not disclosed their HIV status; food insecurity was associated with non-disclosure of HIV-status due to fear of stigmatization and feelings of shame. Severe food insecurity was a strong predictor of loss to follow-up (OR 3.13 [1.08–9.06]) and persistent severe food insecurity was associated with virologic failure (OR 5.14 [1.01–26.29]) and poor adherence to ART 8.00 [1.11–57.57]. Poor nutritional status was associated with poor immunologic recovery (OR 4.24 [1.56–11.47]), virologic failure (OR 3.39 [1.13–10.21]), and death (OR 3.35 [1.40–8.03]).

Conclusion

Severity and duration of food insecurity are important factors in understanding the relationship between food insecurity and HIV outcomes. Our findings highlight the importance of nutritional status, socioeconomic opportunity, and self-stigmatization in the complex pathway between food insecurity and HIV outcomes. Interdisciplinary, multisectoral efforts are needed to develop and implement effective interventions to address food insecurity among people living with HIV.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10444-1.

Changes in Internalized Stigma and HIV Health Outcomes in Individuals New to HIV Care: The Mediating Roles of Depression and Treatment Self-Efficacy

There is limited research on the effects of stigma on health outcomes among new-to-HIV care individuals. We examined the effect of changes in internalized stigma over time on health behaviors and outcomes such as viral suppression, antiretroviral therapy (ART) adherence, and visit adherence among new-to-HIV care individuals. We also analyzed the mediating effects of adherence self-efficacy and depressive symptoms in these associations. Participants were 186 persons living with HIV who initiated care at four HIV clinical sites in the United States and had diverse geographical and ethnic backgrounds. Baseline and 48-week follow-up assessments included measures of internalized stigma, ART adherence, depressive symptoms, and adherence self-efficacy. HIV visit adherence and viral load data were extracted from clinic records. Age, race, gender, insurance status, and site were controlled in all analyses. Logistic regression analyses were used to examine predictors of adherence and viral suppression. Change (decrease) in internalized stigma was calculated by subtracting follow-up internalized stigma scores from baseline scores and served as the main predictor. Mediation analyses included calculation of 95% confidence intervals for the indirect effects using bootstrapping. Decreases in internalized stigma over time were positively associated with viral suppression, ART adherence, and visit adherence. Adherence self-efficacy significantly mediated these effects of decrease in internalized stigma on all outcomes. Depressive symptoms only mediated the association between decrease in internalized stigma and ART adherence. Interventions that address internalized stigma and depressive symptoms, as well as adherence self-efficacy, may significantly improve adherence and viral suppression outcomes for individuals new to HIV care.