Experienced HIV-Related Stigma in Health Care and Community Settings: Mediated Associations With Psychosocial and Health Outcomes

A Moderated Mediation Analysis of HIV and Intersectional Stigmas and Antiretroviral Adherence in People Living with HIV in the Dominican Republic

Experiencing HIV and intersectional stigmas in healthcare settings may affect antiretroviral treatment (ART) adherence among people with HIV (PWH), given their need for frequent interactions with clinical settings and healthcare providers. Considering the importance of reducing stigmas to promote well-being and the need to elucidate how stigma influences health across various settings, we examined how experienced HIV stigma in Dominican Republic healthcare settings impacts ART adherence through internalized HIV stigma and whether race or sexual orientation stigma moderates this relationship. Participants were 471 PWH (aged 17-71) who were recruited from two HIV clinics in the Dominican Republic in 2021-2022. Results revealed a significant mediation effect (B=-0.10, SE = 0.05, CI [-0.234, - 0.014]) after adjusting for effect of age and time since HIV diagnosis, suggesting that experienced HIV stigma in healthcare settings was associated with more internalized HIV stigma (B = 0.39, SE = 0.11, p = .001), subsequently linked to lower ART adherence (B=-0.26, SE = 0.11, p = .016). The indirect effect was significant at low levels of race stigma (B=-0.16, SE = 0.09, CI [-0.369, - 0.001]) but not at high levels of race stigma (B=-0.06, SE = 0.05, CI [-0.175, 0.038]). This indirect effect was also significant at low levels of sexual orientation stigma (B=-0.19, SE = 0.10, CI [-0.401, - 0.023]) but not at high levels of sexual orientation stigma (B=-0.04, SE = 0.06, CI [-0.160, 0.074]). These findings suggest that addressing experienced HIV stigma in Dominican Republic healthcare settings, along with various dimensions of HIV-related stigma (e.g., internalized stigma) and intersecting stigmas (e.g., race, sexual orientation), is vital for improving health outcomes, such as optimal ART adherence.

Gallstones as a cause in presumed acute alcoholic pancreatitis: observational multicentre study

BACKGROUND

Data on the incidence and clinical relevance of gallstones in patients with suspected acute alcoholic pancreatitis are lacking and are essential to minimize the risk of recurrent acute pancreatitis. The aim of this study was to assess the incidence of gallstones and the associated rate of recurrent acute pancreatitis in patients with presumed acute alcoholic pancreatitis.

METHODS

Between 2008 and 2019, 23 hospitals prospectively enrolled patients with acute pancreatitis. Those diagnosed with their first episode of presumed acute alcoholic pancreatitis were included in this study. The term gallstones was used to describe the presence of cholelithiasis or biliary sludge found during imaging. The primary outcome was pancreatitis recurrence during 3 years of follow-up.

RESULTS

A total of 334 patients were eligible for inclusion, of whom 316 were included in the follow-up analysis. Gallstone evaluation, either during the index admission or during follow-up, was performed for 306 of 334 patients (91.6%). Gallstones were detected in 54 patients (17.6%), with a median time to detection of 6 (interquartile range 0-42) weeks. During follow-up, recurrent acute pancreatitis occurred in 121 of 316 patients (38.3%), with a significantly higher incidence rate for patients with gallstones compared with patients without gallstones (59% versus 34.2% respectively; P < 0.001), while more patients with gallstones had stopped drinking alcohol at the time of their first recurrence (41% versus 24% respectively; P = 0.020). Cholecystectomy was performed for 19 patients with gallstones (36%). The recurrence rate was lower for patients in the cholecystectomy group compared with patients who did receive inadequate treatment or no treatment (5/19 versus 19/34 respectively; P = 0.038).

CONCLUSION

Gallstones were found in almost one in every five patients diagnosed with acute alcoholic pancreatitis. Gallstones were associated with a higher rate of recurrent pancreatitis, while undergoing cholecystectomy was associated with a reduction in this rate.

A Content Analysis of HIV-Related Stigmatizing Language in the Scientific Literature, From 2010-2020: Findings and Recommendations for Editorial Policy

Despite negative effects of HIV-related stigma on people with HIV, some scientific literature continues to use stigmatizing terms. Our study aimed to explore the use of HIV-related stigmatizing language in the scientific literature between 2010 and 2020 based on 2015 UNAIDS terminology guidelines. We searched for articles with the stigmatizing term "HIV/AIDS-infected" or any variations that were peer-reviewed, published between 2010 and 2020, and in English or with an English translation. Our search yielded 26,476 articles that used the stigmatizing term of interest. Frequencies on the variables of interest (journal, year, and country) were run. The use of these terms increased from 2010 to 2017 and decreased from 2018 to 2020. Most journals using the terms were HIV/AIDS specific or on infectious diseases, but the journal with the greatest frequency of use was on general science and medicine. Thirty-six percent of the articles emanated from the United States. To reduce the use of stigmatizing language in the HIV literature, action should be taken by authors, reviewers, editors,educators, and publishers should create formal policies promoting use of non-stigmatizing language.

Navigating HIV-Related Stigma in Switzerland: A Qualitative Study

Objectives: This study sought to understand how people living with HIV experience, perceive, and navigate stigma in their everyday life and in care settings in an urban French-speaking area in Switzerland. Methods: Semi-structured interviews were carried out with 19 people living with HIV in Lausanne concerning their experience of HIV-related stigma in both everyday life and in healthcare settings. Content analysis was performed to identify main and sub-themes. Results: "Living with HIV" posed little or no difficulty for participants. However, the burden of anticipated and internalized HIV-related stigma played a disproportionately large role in their lives. Participants considered the general population's low level of knowledge about HIV as problematic in this regard. While participants reported few examples of enacted stigma generally, healthcare environments were sometimes experienced as sites of prejudice and discrimination. However, some healthcare professionals were also sources of information and knowledge, contributing to participants' "journeys of self-acceptance." Conclusion: Even in an urban environment in a country with ready access to healthcare and education, HIV-related stigma remains a concern for people living with HIV.

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.

Racial Differences in Social Determinants of Health and Outcomes Among Hispanic/Latino Persons with HIV-United States, 2015-2020

BACKGROUND

Hispanic/Latino people with HIV (PWH) experience disparities in health outcomes compared with other racial and ethnic groups. Disaggregated data based on race for Hispanic/Latino PWH in the United States are rarely reported, potentially masking inequities.

METHODS

The Medical Monitoring Project (MMP) is a complex sample survey of adults with diagnosed HIV. We used weighted interview and medical record data collected from June 2015-May 2021 to examine differences in social determinants of health (SDH) and health outcomes by self-reported race among Hispanic/Latino adults with diagnosed HIV.

RESULTS

Compared with White Hispanic/Latino PWH, Black Hispanic/Latino PWH were more likely to be unemployed (PR, 1.4; CI, 1.2-1.8), have a disability (PR, 1.3; CI, 1.2-1.5), have experienced homelessness (PR, 1.8; CI, 1.2-2.6), and have been incarcerated (PR, 2.6; CI, 1.5-4.5). American Indian/Alaska Native (AI/AN) (PR, 1.8; CI, 1.1-2.7) and multiracial (PR, 2.0; CI, 1.4-2.9) Hispanic/Latino PWH were more likely to have experienced homelessness than White Hispanic/Latino PWH. Black (PR, 1.3; CI, 1.2-1.5) and multiracial (PR, 1.2; CI, 1.1-1.5) Hispanic/Latino PWH were more likely to be virally unsuppressed than White Hispanic/Latino PWH.

CONCLUSION

Black, multiracial, and AI/AN Hispanic/Latino PWH experience disparities in SDH and HIV outcomes. Lumping Hispanic/Latino people into one racial and ethnic category obscures health disparities, which might limit our progress towards reaching national HIV goals. Future studies should consider disaggregating by other factors such as Hispanic origin, place of birth, immigration status, and primary language. Doing so recognizes the diversity of the Hispanic/Latino population.

Communication and coordination of care for people living with HIV: a qualitative study of the patient perspective

BACKGROUND

There is growing consensus that primary health care (PHC) providers have an important role in providing holistic, preventative care for people living with human immunodeficiency virus (PLHIV). In regional Australia, HIV care is primarily delivered through specialist services, thus adequate coordination and communication between specialist and PHC professionals is crucial. This study aimed to explore patient experiences of the coordination of care and health care professional communication for PLHIV in regional Australia.

METHODS

Semi-structured interviews with PLHIV in a regional area of Australia were conducted in March to April 2022. Interviews were conducted via video conferencing, face-to-face, or via telephone call. Interviews were audio-recorded and manually transcribed. Transcripts were coded inductively and thematic analysis was conducted to explore perspectives on communication and coordination.

RESULTS

Thirteen participants were interviewed. Most participants were male, aged 50-70, were diagnosed with HIV more than ten years ago, and had been living in regional Australia long-term. Through qualitative analysis, themes emerged in the following areas: (1) Patient perception of care coordination; (2) Patient understanding of modality of communication; (3) Positive attitudes towards communication between healthcare professionals; and (4) Concerns for information sharing between healthcare professionals. Many participants highlighted lack of clarity around care coordination as a key issue in their healthcare, with some citing themselves as the primary care coordinator. Participants identified that coordination and communication between PHC professionals and specialist services are essential in the delivery of their health care, but some were hesitant for this to occur. Hesitancy was entrenched in some patients' distrust of healthcare due to previous experiences of confidentiality breaches and stigma.

CONCLUSION

This study identifies the need for clarity in coordination between health care professionals to deliver safe and effective HIV care, which may occur through care plans. Patient support for communication between healthcare providers may be strengthened by ensuring trust in the people and systems involved. Eliminating stigma in healthcare as well as building more trustworthy electronic-based communication technologies are essential components to trust-building between PLHIV and healthcare systems.

Intersectional Discrimination in HIV Healthcare Settings Among Persons with Diagnosed HIV in the United States, Medical Monitoring Project, 2018-2019

Experiences with stigma and discrimination in healthcare settings are associated with negative health outcome for persons with HIV (PWH). PWH may experience discrimination due to the intersection of multiple marginalized social identities. Describing these experiences is important for informing interventions and strategies to reduce stigma and discrimination. We report experiences with discrimination in HIV healthcare settings attributed to multiple characteristics, e.g., sexual orientation, race/ethnicity, income, or social class, and/or injection drug use, among a nationally representative sample of persons with diagnosed HIV in the United States using data from the Medical Monitoring Project (MMP). We calculated weighted prevalences and associated 95% confidence intervals for any discrimination and discrimination attributed to multiple characteristics (intersectional discrimination). Among those experiencing discrimination, nearly 1 in 4 persons reported intersectional discrimination, with a higher burden among key populations of focus for HIV prevention and treatment. Discrimination was attributed to HIV status (62.5%), sexual orientation (60.4%), and race/ethnicity (54.3%). Persons who experienced intersectional discrimination were less likely to have a regular HIV care provider, have trust in HIV care or treatment information from healthcare providers, and be antiretroviral treatment or HIV care visit adherent. Future studies should explore methods to operationalize and assess experiences with intersectional stigma and discrimination and use the outcomes to inform qualitative research that provides more context and a deeper understanding of experiences with intersectional discrimination among PWH.

Health Care Provider Stigma Toward Patients With Substance Use Disorders: Protocol for a Nationally Representative Survey

BACKGROUND

The US overdose epidemic is an escalating public health emergency, accounting for over 100,000 deaths annually. Despite the availability of medications for opioid use disorders, provider-level barriers, such as negative attitudes, exacerbate the treatment gap in clinical care settings. Assessing the prevalence and intensity of provider stigma, defined as the negative perceptions and behaviors that providers embody and enact toward patients with substance use disorders, across providers with different specialties, is critical to expanding the delivery of substance use treatment.

OBJECTIVE

To thoroughly understand provider stigma toward patients with substance use disorders, we conducted a nationwide survey of emergency medicine and primary care physicians and dentists using a questionnaire designed to reveal how widely and intensely provider attitudes and stigma can impact these providers' clinical practices in caring for their patients. The survey also queried providers' stigma and clinical practices toward other chronic conditions, which can then be compared with their stigma and practices related to substance use disorders.

METHODS

Our cross-sectional survey was mailed to a nationally representative sample of primary care physicians, emergency medicine physicians, and dentists (N=3011), obtained by American Medical Association and American Dental Association licensees based on specified selection criteria. We oversampled nonmetropolitan practice areas, given the potential differences in provider stigma and available resources in these regions compared with metropolitan areas. Data collection followed a recommended series of contacts with participants per the Dillman Total Design Method, with mixed-modality options offered (email, mail, fax, and phone). A gradually increasing compensation scale (maximum US$250) was implemented to recruit chronic nonresponders and assess the association between requiring higher incentives to participate and providers stigma. The primary outcome, provider stigma, was measured using the Medical Condition Regard Scale, which inquired about participants' views on substance use and other chronic conditions. Additional survey measures included familiarity and social engagement with people with substance use disorders; clinical practices (screening, treating, and referring for a range of chronic conditions); subjective norms and social desirability; knowledge and prior education; and descriptions of their patient populations.

RESULTS

Data collection was facilitated through collaboration with the National Opinion Research Center between October 2020 and October 2022. The overall Council of American Survey Research Organizations completion rate was 53.62% (1240/2312.7; physicians overall: 855/1681.9, 50.83% [primary care physicians: 506/1081.3, 46.79%; emergency medicine physicians: 349/599.8, 58.2%]; dentists: 385/627.1, 61.4%). The ineligibility rate among those screened is applied to those not screened, causing denominators to include fractional numbers.

CONCLUSIONS

Using systematically quantified data on the prevalence and intensity of provider stigma toward substance use disorders in health care, we can provide evidence-based improvement strategies and policies to inform the development and implementation of stigma-reduction interventions for providers to address their perceptions and treatment of substance use.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/47548.

A community health worker and mobile health app intervention to improve adherence to HIV medication among persons with HIV: the CHAMPS study protocol

BACKGROUND

Persons with HIV (PWH) can now achieve a near-normal life expectancy due to antiretroviral therapy (ART). Despite widespread availability of ART in the United States (US), many of the country's approximate 1.1 million PWH are not achieving viral suppression due to poor ART adherence. Viral suppression rates are particularly low in Alabama (AL, 62%) and New York City (NYC, 67%). There is mixed evidence on the efficacy of community health workers (CHW) and mHealth interventions for improving ART adherence and viral suppression in PWH thus, we sought to combine these interventions and test the efficacy for improving health outcomes in PWH.

METHODS

The CHAMPS study is a two-arm randomized controlled trial among 300 PWH with suboptimal primary care appointment adherence (n = 150 in AL and 150 in NYC) over the course of 12 months. Participants are randomly assigned to CHAMPS (intervention) or a standard-of-care (control) arm. Participants in the intervention arm are given a CleverCap pill bottle that syncs to the WiseApp to track medication adherence, reminds users to take their medication at a set time, and enables communication with CHW. All participants complete baseline, 6-month, and 12-month follow-up visits where surveys are administered and, CD4 and HIV-1 viral load are obtained through blood draw.

DISCUSSION

Maintaining ART adherence has significant implications in HIV management and transmission. mHealth technologies have been shown to optimize the provision of health services, produce positive changes in health behavior, and significantly improve health outcomes. CHW interventions also provide personal support to PWH. The combination of these strategies may provide the necessary intensity to increase ART adherence and clinic attendance among PWH at highest risk for low engagement. Delivering care remotely enables CHW to contact, assess, and support numerous participants throughout the day, reducing burden on CHW and potentially improving intervention durability for PWH. The adoption of the WiseApp coupled with community health worker sessions in the CHAMPS study has the potential to improve HIV health outcomes, and will add to the growing knowledge of mHealth and CHW efforts to improve PWH medication adherence and viral suppression.

TRIAL REGISTRATION

This trial was registered with Clinicaltrials.gov (NCT04562649) on 9/24/20.

A simulation and experiential learning intervention for labor and delivery providers to address HIV stigma during childbirth in Tanzania: study protocol for the evaluation of the MAMA intervention

BACKGROUND

The experience of HIV stigma during intrapartum care can impact women's trust in the health care system and undermine their long-term commitment to HIV care engagement. Delivery of respectful maternity care (RMC) to women living with HIV (WLHIV) can improve quality of life and clinical outcomes. The goal of this study is to conduct an evaluation of MAMA (Mradi wa Afya ya Mama Mzazi, Project to Support the Health of Women Giving Birth), a simulation team-training curriculum for labor and delivery providers that addresses providers' instrumental and attitudinal stigma toward WLHIV and promotes the delivery of evidence-based RMC for WLHIV.

METHODS

The MAMA intervention will be evaluated among healthcare providers across six clinics in the Kilimanjaro Region of Tanzania. To evaluate the impact of MAMA, we will enroll WLHIV who give birth in the facilities before (n = 103 WLHIV) and after (n = 103 WLHIV) the intervention. We will examine differences in the primary outcome (perceptions of RMC) and secondary outcomes (postpartum HIV care engagement; perceptions of HIV stigma in the facility; internal HIV stigma; clinical outcomes and evidence-based practices) between women enrolled in the two time periods. Will also assess participating providers (n = 60) at baseline, immediate post, 1-month post training, and 2-month post training. We will examine longitudinal changes in the primary outcome (practices of RMC) and secondary outcomes (stigma toward WLHIV; self-efficacy in delivery intrapartum care). Quality assurance data will be collected to assess intervention feasibility and acceptability.

DISCUSSION

The implementation findings will be used to finalize the intervention for a train-the-trainer model that is scalable, and the outcomes data will be used to power a multi-site study to detect significant differences in HIV care engagement.

TRIAL REGISTRATION

The trial is registered at clinicaltrials.gov, NCT05271903.

Structural violence within communities and its impact on the well-being of people with HIV (PWH)

Structural violence (SV) is the concept that there are often invisible and intangible structures in place, whether political, economic, legal, cultural, religious, or social, that can inhibit individuals from reaching their full potential. There is a need to better understand the influence of SV on the well-being of people with HIV (PWH) in the Deep South. To address this gap in the literature, we interpreted data using a Structural Violence framework. In this community-based participatory research, in-depth interviews (n = 40) were conducted with PWH who previously established HIV medical care. In our study, we found that SV can have a widespread impact in communities, negatively impacting access to key tangible and emotional resources. SV themes included community crime and instability, financial insecurity, and disparate access to numerous resources known to influence health. Structures exacerbating unequal access to resources appear engrained within communities and often went unrecognized by participants as disadvantageous to achieving optimal HIV health. Greater effort is necessary to elucidate the influence and role of violent structures on access to key resources for and by PWH. A clearer understanding of SV's influence on HIV health can inform changes addressing these structural barriers to HIV health.

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.

Re-validation and cultural adaptation of the brief, standardized assessment tool for measuring HIV-related stigma in healthcare settings in Almaty, Kazakhstan

The HIV epidemic continues to grow in Kazakhstan and HIV stigma remains a major barrier to HIV prevention and treatment in the country. HIV stigma in healthcare setting may also discourage people living with HIV (PLHIV) from getting the care needed. Therefore, studying the attitudes of healthcare workers towards PLHIV is important and requires well-constructed measurement tools adapted to the specific cultural context. In our study, we aimed to adapt and re-validate a brief questionnaire on HIV stigma among healthcare workers in Almaty, Kazakhstan. We held focus group discussions to obtain input on an existing questionnaire and surveyed 448 primary healthcare providers to psychometrically evaluate the scale. The final HIV-stigma scale consisted of 15 items, 6 of them measuring negative opinions about PLHIV and the rest assessing stigmatizing health facility policies towards PLHIV. Both HIV-stigma subscales demons6trated adequate psychometric properties (with Cronbach's alpha α = 0.57 for the first and α = 0.86 for the second subscale, and with factor loadings >0.35 within each subscale). High numbers of respondents holding negative attitudes towards PLHIV, detected in this sample (87%; n = 380), may suggest the need for immediate actions addressing HIV stigma in healthcare in Kazakhstan.

Impact of harm reduction care in HIV clinical settings on stigma and health outcomes for people with HIV who use drugs: study protocol for a mixed-methods, multisite, observational study

INTRODUCTION

Our previous pilot work suggests relational harm reduction strengthens relationships between people with HIV (PWH) who use drugs and their healthcare providers and improves HIV health outcomes. However, there is limited research examining ways that structural (eg, strategies like syringe service programmes) and/or relational (patient-provider relationship) harm reduction approaches in HIV clinical settings can mitigate experiences of stigma, affect patient-provider relationships and improve outcomes for PWH who use drugs. Our mixed methods, multisite, observational study aims to fill this knowledge gap and develop an intervention to operationalise harm reduction care for PWH who use drugs in HIV clinical settings.

METHODS AND ANALYSIS

Aim 1 will explore the relationship between healthcare providers' stigmatising attitudes towards working with PWH who use drugs and providers' acceptance and practice of structural and relational harm reduction through surveys (n=125) and interviews (n=20) with providers. Aim 2 will explore the interplay between patient-perceived harm reduction, intersectional stigma and clinical outcomes related to HIV, hepatitis C (if applicable) and substance use-related outcomes through surveys (n=500) and focus groups (k=6, total n=36) with PWH who use drugs. We will also psychometrically evaluate a 25-item scale we previously developed to assess relational harm reduction, the Patient Assessment of Provider Harm Reduction Scale. Aim 3 will use human-centred design approaches to develop and pretest an intervention to operationalise harm reduction care for PWH who use drugs in HIV clinical settings.

ETHICS AND DISSEMINATION

This study was approved via expedited review by the University of Pittsburgh Institutional Review Board (STUDY21090002). Study findings will be presented in peer-reviewed journals and public health conferences as well as shared with patient participants, community advisory boards and harm reduction organisations.

TRIAL REGISTRATION NUMBER

NCT05404750.

Fear of stigma from health professionals and family/neighbours and healthcare avoidance among PLHIV in Morocco: results from the Stigma Index survey Morocco

Background

Enacted or anticipated stigma among people living with HIV (PLHIV) can negatively impact healthcare engagement. We identified factors associated with having avoided HIV health services for fear of stigma among PLHIV in Morocco.

Methods

The Stigma Index survey was conducted in Morocco in March-June 2016. Factors associated with avoiding HIV testing and treatment services for fear of stigma by (A) health personnel or family/neighbours and (B) health personnel and family/neighbours compared to people who did not avoid health services for fear of stigma from either of the two sources were assessed using multinomial logistic regression models.

Results

Among 583 respondents, 280 (48.0%) were women and median number of years living with HIV was 5[IQR:2–7]. Half of the respondents reported avoiding health services for fear of stigma by health personnel and/or family/neighbours: (A) n = 228, 39.1% and (B) n = 68, 11.7%. After adjustment on perceived health status, not having had easy access to antiretroviral treatment ((A) aRR [95% CI] = 1.76[1.16; 2.68]; (B) 2.18[1.11; 4.27]), discrimination by PLHIV ((A) 1.87[1.12; 3.13]; (B) 3.35[1.63; 6.88]) and exclusion from social activities ((A) 1.70[1.10; 2.61]; (B) 2.63[1.39; 5.00]) were associated with having avoided health services for fear of stigma by health personnel or/and family/neighbours. Being female (2.85[1.48; 5.47]), not having been referred for an HIV test for suspected symptoms 3.47[1.67; 7.22], having discussed sexual/reproductive health with a health professional (4.56[2.38; 8.71]), and not having the feeling to influence decisions on local projects for PLHIV (3.47[1.37; 7.83], were associated with having avoided health services for fear of stigma by both sources.

Conclusion

Results suggest a cumulative effect of fear of stigma and discrimination among PLHIV in Morocco. PLHIV who have experienced discrimination may seek to avoid similar situations at the expense of their health. These results should inform multi-level interventions and broader advocacy efforts to reduce stigma and discrimination.

Internalized HIV-Related Stigma and Neurocognitive Functioning Among Women Living with HIV

The prevalence of HIV-associated neurocognitive impairment persists despite highly effective antiretroviral therapy (ART). In this study we explore the role of internalized stigma, acceptance of negative societal characterizations, and perceptions about people living with HIV (PLWH) on neurocognitive functioning (executive function, learning, memory, attention/working memory, psychomotor speed, fluency, motor skills) in a national cohort of women living with HIV (WLWH) in the United States. We utilized observational data from a multicenter study of WLWH who are mostly African American living in low-resource settings. Neurocognitive function was measured using an eight-test battery. A multiple linear regression model was constructed to investigate the relationship between internalized stigma and overall neurocognitive functioning (mean of all neurocognitive domain standardized T-scores), adjusting for age, education, race, previous neuropsychological battery scores, illicit drug use, viral load, and years on ART. Our analysis revealed that internalized HIV-related stigma is significantly associated with worse performance on individual domain tests and overall neurocognitive performance (B = 0.27, t = 2.50, p = 0.01). This suggests HIV-related internalized stigma may be negatively associated with neurocognitive functioning for WLWH. This finding highlights a specific psychosocial factor associated with poor neurocognitive function that may be targeted to better promote the health of PLWH. Future research on the longitudinal relationship between these variables and the effects of other stigma dimensions on poor neurocognitive function would provide further insights into the pathways explaining the relationship between internalized stigma and neurocognition.

Associations Between Experienced HIV Stigma, Resulting Consequences, and the HIV Care Continuum: Moderating Effects of Two Resilience Characteristics Among Persons Living with HIV (PLWH) in Louisiana

INTRODUCTION

HIV-related stigma continues to serve as a major barrier to HIV care. HIV stigma reduction interventions are urgently needed to promote and protect the health of persons living with HIV (PLWH). Resilience has been identified as a potential leverage to mitigate the impact of HIV-related stigma among PLWH.

METHODS

We examined whether two resilience measures (i.e., social support and resilience assets and resources [RAR]) moderated the relationship between experienced HIV stigma and the HIV care continuum as well as how they moderated the relationship between the consequences of experienced HIV stigma (CES) and the HIV care continuum among 300 PLWH in Louisiana. Separate bootstrapping analyses were conducted to test for evidence of moderated moderation.

RESULTS

Most participants were Black (79%) and had been living with HIV for 10 years or more. A relatively high sample of men who have sex with men (MSM) were enrolled (37%). The most common CES were depression (67%). The most common manifestation of experienced HIV stigma was being gossiped about (53%). Participants reported moderate levels of social support. In terms of RAR, most participants (71%) reported that they knew of groups that could support them in responding to experienced HIV stigma. After adjusting for potential covariates, social support and RAR both significantly moderated the relationship between experienced HIV stigma and length of time since their last HIV care visit, B(SE) = .003(.001), p = .03. At high levels of RAR and high levels of social support, those with higher levels of experienced HIV stigma reported a longer length of time since their last HIV care visit than those who reported lower levels of experienced HIV stigma (B(SE) = .17(.04), p < .001). RAR moderated the relationship between social support and HIV care, B(SE) = .01(.004), p < .001. Those who experienced greater CES reported a longer length of time since their last doctor's visit B(SE) = .04(.02), p < .05. Experienced HIV stigma was not significantly associated with viral load results. However, social support significantly moderated the relationship between experienced stigma and viral load results. At higher levels of social support, those who experienced lower levels of stigma were more likely to report an undetectable viral load than those who had higher levels of stigma, B(SE) = - .13(.03), p < .001. Finally, both RAR and social support moderated the relationship between CES and viral load results. Those who reported higher levels of RAR B(SE) = - .07(.02), p < .001, and social support, B(SE) = - .02(.01), p < .05, also reported having an undetectable viral load at most recent HIV care visit. CES was not significantly related to reporting an undetectable viral load (p = .61).

CONCLUSIONS

Enrolled PLWH already have some level of resilience which plays an important protective role within the context of the HIV care continuum up to a certain extent. Interventions to enhance the RAR and social support components may be useful especially among MSM and persons who have been living with HIV for a shorter period of time.

Trends in HIV Stigma Experienced by People Living With HIV in the Netherlands: A Comparison of Cross-Sectional Surveys Over Time

We investigated whether HIV stigma has changed in recent years. We compared data on stigma settings and manifestations from 2007 (n = 667) and, specifically for health care, 2009 (n = 262), to data acquired in 2019/2020 (n = 258). Results showed reductions in stigma from friends, family, acquaintances, at work, in the financial services sector, and in media, but stigmatizing messages in media remained highly prevalent. Stigma in the LGBTQI+ community, with sexual partners, and while partying also remained prevalent and, disconcertingly, relatively unchanged. Stigma in health care increased. HIV stigma was positively related to psychological distress, and negatively related to social support and medication adherence. Further, most participants were familiar with U=U and PrEP, but 13.3% questioned the accuracy of U=U. Stigma reduction efforts should focus on reducing stigma in media, in the LGBTQI+ community and while dating, and in health care, with U=U as a key message.

The Intersectionality of HIV-Related Stigma and Tobacco Smoking Stigma With Depressive and Anxiety Symptoms Among Women Living With HIV in the United States: A Cross-sectional Study

ABSTRACT

This study examined the intersectionality of HIV-related stigma, tobacco smoking stigma, and mental health among women living with HIV who were daily smokers. This secondary analysis used baseline data from 2 pilot smoking cessation studies. Participants received either an HIV-tailored or an attention-control intervention focused on smoking cessation as an outcome. There were significant positive relationships between HIV-related stigma and depressive and anxiety symptoms. In contrast, tobacco smoking stigma had no significant relationship with either of the symptoms when HIV-related stigma was controlled. However, there was a significant interaction effect (β = 1.37, p = .02) of tobacco smoking stigma with internalized HIV-related stigma on anxiety symptoms. Tobacco smoking stigma worsened anxiety symptoms for women who had high internalized HIV-related stigma. Health care providers should understand the effect of HIV-related stigma on mental health and address the intersectionality of HIV-related stigma with other socially disapproved behaviors, such as tobacco smoking.

HIV-Related Stigma Research as a Priority at the National Institutes of Health

The National Institutes of Health (NIH) recognizes that, despite HIV scientific advances, stigma and discrimination continue to be critical barriers to the uptake of evidence-based HIV interventions. Achieving the Ending the HIV Epidemic: A Plan for America (EHE) goals will require eliminating HIV-related stigma. NIH has a significant history of supporting HIV stigma research across its Institutes, Centers, and Offices (ICOs) as a research priority. This article provides an overview of NIH HIV stigma research efforts. Each ICO articulates how their mission shapes their interest in HIV stigma research and provides a summary of ICO-relevant scientific findings. Research gaps and/or future opportunities are identified throughout, with key research themes and approaches noted. Taken together, the collective actions on the part of the NIH, in tandem with a whole of government and whole of society approach, will contribute to achieving EHE's milestones.

Patient and Provider Perspectives on HIV Stigma in Healthcare Settings in Underserved Areas of the US South: A Mixed Methods Study

Stigma experienced in healthcare settings is a barrier to ending the HIV epidemic. Using a convergent parallel mixed methods approach, we collected qualitative data from 14 focus groups with People with HIV (PWH) and Healthcare workers (HCW) and quantitative survey data (N = 762 PWH and N = 192 HCW) from seven HIV healthcare clinics outside of major urban areas in the southeastern US. Four key themes emerged: (1) HIV-related stigma and discrimination in healthcare settings; (2) experiences of intersectional stigma; (3) disclosure concerns in healthcare settings; and (4) impact of stigma on HIV-related health behavior. Implications for future stigma interventions in healthcare settings include the importance of engaging PWH in the development of interventions, the need for interventions in settings that do not specialize in HIV care, and the importance of engaging all staff when addressing HIV-related stigma.

High Provider Trust Associates with High HIV Antiretroviral Adherence Among Women Living with HIV in a Metropolitan Washington, DC Cohort

Trust in providers and health care systems (HCSs) has been associated with higher HIV antiretroviral (ART) adherence; however, most previous studies enrolled primarily men and did not concurrently assess provider trust, HCS distrust, and clinical/biological outcomes. We enrolled 239 Washington, DC Women's Interagency HIV Study (WIHS) women: 167 with HIV (WWH) and 72 without HIV. In 2006 and 2017-2018, women completed surveys on provider trust and HCS distrust. Clinical, social, and demographic covariates were obtained during the 2017-2018 WIHS study visit. Descriptive analyses included chi-squared and Mann-Whitney tests. Wilcoxon signed-rank tests assessed trust measure change over time. Logistic (provider trust) and linear (HCS distrust) models were constructed in R. The majority of women were African American/Black (76.9%) with a median age of 52 (interquartile range 48, 58) and currently insured (99.6%). In multi-variable analyses, women with HIV (WWH) had higher odds of high provider trust [adjusted odds ratio (aOR) 2.90, 95% confidence interval (CI) 1.34, 6.45], with ≥95% ART adherence associated with high provider trust among only WWH (aOR 4.13, 95% CI 1.14, 15.92). Multi-variable models also showed 3.40-point higher HCS distrust scores among WWH who reported ≥95% ART adherence (p = 0.03). CD4 count and HIV viral load were not associated with provider trust or HCS distrust. Provider (p = 0.67) and HCS (p = 0.65) trust did not significantly change in this population at two time points for 10 years. Self-reported antiretroviral therapy adherence significantly associated with high provider trust, yet also with high HCS distrust, revealing a nuanced relationship to providers and the HCS among WWH.

The Mediating Role of Social Support and Resilience Between HIV-Related Stigmas and Patient Activation Among Young Black Women Living With HIV in the Southern United States: A Cross-sectional Study

ABSTRACT

Little is known about the construct of patient activation for engaging in favorable self-management behaviors in people with HIV. We conducted a cross-sectional study among young Black women with HIV (n = 84) to examine the association between stigma and patient activation and the mediating role of social support and resilience. Social support mediated the relationship between the following dimensions of stigma and patient activation: internalized (β = -0.20, SE = 0.08, CI [-0.369 to -0.071]) and anticipated in health care settings (β = -0.06, SE = 0.04, CI [-0.177 to -0.001]). Resilience mediated the relationship between the following dimensions of stigma and patient activation: anticipated in health care (β = -0.20, SE = 0.08, CI [-0.387 to -0.057]) and community settings (β = -0.15, SE = 0.08, CI [-0.318 to -0.017]), and enacted in community settings (β = -0.14, SE = 0.09, CI [-0.332 to -0.001]). Our findings suggest intrapersonal and interpersonal mechanisms by which various dimensions of stigma contribute to patient activation, thus identifying social support, resilience, and patient activation as potential intervention targets.

Cross-Cultural Adaptation and Psychometric Assessment of an Arabic Version of the Health Care Provider HIV/AIDS Stigma Scale

HIV stigma among health care providers in the Arab world is understudied due to a lack of valid and reliable measures. Data from 352 Egyptian physicians was used to validate an Arabic version of the Health Care Provider HIV/AIDS Stigma Scale (HPASS). Exploratory factor analysis (n = 1 9 4) suggested a 3 -factor structure. Confirmatory factor analysis (n = 1 5 8) validated the three-factor solution with 18 items, which explained 5 3 .3 6% of the variance. All items loaded on their designated constructs, which ranged from 0 .58 to 0 .82 (prejudice) to 0 .58 to 0 .66 (stereotypes) and 0 .52 to 0 .91 (discrimination). The prejudice, stereotypes, and discrimination subscales consisted of seven, five, and six items, respectively. The internal consistency (α = 0 .9 0) and the test-retest reliability demonstrated (r = 0 .9 5) were excellent. The cultural adaptation of the Arabic version of HPASS suggests that it is a suitable scale for assessing HIV stigma among Arab health care providers.

Sociodemographic Correlates of Self-reported Discrimination in HIV Health Care Settings Among Persons With Diagnosed HIV in the United States, Medical Monitoring Project, 2018-2019

BACKGROUND

HIV-related discrimination in health care settings is associated with negative health outcomes among persons with HIV (PWH). This article describes and compares differences in the prevalence of self-reported experiences with discrimination in health care settings by sociodemographic and clinical care factors among persons with diagnosed HIV in the United States.

METHODS

We analyzed interview and medical record data collected during June 2018-May 2019 from 3850 PWH who had received HIV care in the past 12 months. We calculated weighted percentages and associated 95% confidence intervals and assessed the association between any experience of discrimination and selected sociodemographic and clinical characteristics using prevalence ratios with predicted marginal means.

RESULTS

Approximately 25% of PWH who had an HIV care visit in the past 12 months reported experiencing any discrimination. Experiences with discrimination were significantly more prevalent among persons aged 18-29 years (34%); transgender persons (41%); persons of gay (25%), bisexual (31%), or other (40%) sexual orientations; and persons who did not have a regular provider (39%), lived at/below poverty level (28%), were homeless (39%) or incarcerated (37%) in the past 12 months. PWH who experienced discrimination were more likely to have missed at least one HIV care visit, not be taking antiretroviral therapy, and have missed antiretroviral therapy doses. Recent and sustained viral suppression were not significantly associated with experiencing any discrimination.

CONCLUSIONS

Interventions that address the sociocultural and structural factors associated with discrimination in all health care settings are needed to improve health outcomes among PWH and end the HIV epidemic in the United States.

Psychometric Properties of the Berger HIV Stigma Scale: A Systematic Review

Addressing HIV-related stigma requires the use of psychometrically sound measures. However, despite the Berger HIV stigma scale (HSS) being among the most widely used measures for assessing HIV-related stigma, no study has systematically summarised its psychometric properties. This review investigated the psychometric properties of the HSS. A systematic review of articles published between 2001 and August 2021 was undertaken (CRD42020220305) following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Additionally, we searched the grey literature and screened the reference lists of the included studies. Of the total 1241 studies that were screened, 166 were included in the review, of which 24 were development and/or validation studies. The rest were observational or experimental studies. All the studies except two reported some aspect of the scale's reliability. The reported internal consistency ranged from acceptable to excellent (Cronbach's alpha ≥ 0.70) in 93.2% of the studies. Only eight studies reported test-retest reliability, and the reported reliability was adequate, except for one study. Only 36 studies assessed and established the HSS's validity. The HSS appears to be a reliable and valid measure of HIV-related stigma. However, the validity evidence came from only 36 studies, most of which were conducted in North America and Europe. Consequently, more validation work is necessary for more precise insights.

Addressing intersectional stigma as a care barrier for HIV-positive people who inject drugs: Design of an RCT in St. Petersburg, Russia

Background

HIV-positive people who inject drugs (PWID) experience stigma related to their substance use and HIV, with adverse consequences to their health care utilization and mental health. To help affected individuals cope with their intersectional stigma and reduce its negative impact on health and health care, we adapted a behavioral stigma coping intervention for this HIV key population.

Objective

To conduct a randomized controlled trial (RCT) testing the ‘Stigma Coping to Reduce HIV risks and Improve substance use Prevention and Treatment’ (SCRIPT) intervention, a community-based, adapted form of Acceptance and Commitment Therapy (ACT), for PWID living with HIV in St. Petersburg, Russia.

Methods

We recruited 100 PWID living with HIV from civil society organizations (CSO) delivering harm reduction and HIV prevention services in St. Petersburg, Russia. We randomized participants 2:1 to receive either the intervention (three adapted ACT sessions in a group format over one month and usual CSO care) or usual CSO care alone. ACT aims to help affected individuals cope with stigma by increasing their psychological flexibility to handle stigma-related negative expectations, emotions and experiences. The primary outcomes were satisfaction with the intervention, and changes in HIV and substance use stigma scores.

Conclusions

Stigma coping interventions targeting HIV-positive PWID outside of formal health care settings may help them confront negativities in their lives originating from intersectional stigma and reduce stigma's impact as a health care barrier.

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HIV-positive people who inject drugs face stigma due to both substance use and HIV.

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Interventions are scarce to help this population reduce stigma as care barrier.

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We recruited participants outside of the formal health care setting in Russia.

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We partnered with multiple organizations to recruit and retain stigmatized people.

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We evaluated the intervention's effects on stigma, health care, & health outcomes.

Examining the Relationships Between Experienced and Anticipated Stigma in Health Care Settings, Patient-Provider Race Concordance, and Trust in Providers Among Women Living with HIV

Stigma in health care settings can have negative consequences on women living with HIV, such as increasing the likelihood of missed visits and reducing trust in their clinical providers. Informed by prior stigma research and considering knowledge gaps related to the effect of patient-provider race concordance, we conducted this study to assess if patient-provider race concordance moderates the expected association between HIV-related stigma in health care settings and patients' trust in their providers. Moderation analyses were conducted using Women's Interagency HIV Study data (N = 931). We found significant main effects for patient-provider race concordance. Higher experienced stigma was associated with lower trust in providers in all patient-provider race combinations [White-White: B = -0.89, standard error (SE) = 0.14, p = 0.000, 95% confidence interval, CI (-1.161 to -0.624); Black patient-White provider: B = -0.19, SE = 0.06, p = 0.003, 95% CI (-0.309 to -0.062); and Black-Black: B = -0.30, SE = 0.14, p = 0.037, 95% CI (-0.575 to -0.017)]. Higher anticipated stigma was also associated with lower trust in providers [White-White: B = -0.42, SE = 0.07, p = 0.000, 95% CI (-0.552 to -0.289); Black patient-White provider: B = -0.17, SE = 0.03, p = 0.000, 95% CI (-0.232 to -0.106); and Black-Black: B = -0.18, SE = 0.06, p = 0.002, 95% CI (-0.293 to -0.066)]. Significant interaction effects indicated that the negative associations between experienced and anticipated HIV-related stigma and trust in providers were stronger for the White-White combination compared with the others. Thus, we found that significant relationships between HIV-related experienced and anticipated stigma in health care settings and trust in providers exist and that these associations vary across different patient-provider race combinations. Given that reduced trust in providers is associated with antiretroviral medication nonadherence and higher rates of missed clinical visits, interventions to address HIV-related stigma in health care settings may improve continuum of care outcomes.

Temporal trends in self-reported HIV stigma and association with adherence and viral suppression in the African Cohort Study

HIV stigma is a major barrier to HIV care and treatment among people living with HIV (PLWH). Evidence suggests that expansion in antiretroviral therapy (ART) may reduce stigma. However, there are limited longitudinal studies examining temporal trends in HIV stigma in sub-Saharan Africa in the Undetectable = Untransmittable (U = U) era. We longitudinally assessed temporal trends in self-reported experienced stigma and the association of experienced stigma with ART adherence and viral suppression among PLWH enrolled in the African Cohort Study (AFRICOS). AFRICOS is an ongoing cohort study enrolling PLWH in Uganda, Kenya, Tanzania, and Nigeria. As of 1 March 2020, 2937 PLWH enrolled in AFRICOS and had available data. In 2013, 22% of participants reported stigma at the enrollment visit and by 2018 the prevalence decreased to 1% overall and was below 2% for all countries. However, there was not a statistically significant change in stigma prevalence in our longitudinal models. In adjusted models, experiencing stigma was associated with a 0.67 decreased odds of ART Adherence (95% confidence interval (CI): 0.56-0.80) and a 0.64 decreased odds of viral suppression (95% CI: 0.73-0.99). HIV-associated stigma was associated with poor self-reported ART adherence and unsuppressed viral load.

The Association between HIV-Stigma and Depressive Symptoms among People Living with HIV/AIDS: A Systematic Review of Studies Conducted in South Africa

BACKGROUND

People living with HIV/AIDS (PLWHA) are at increased risk of stigma and mental illness, and this appears to be a particular issue in South Africa, which is home to 19% of the world's HIV-positive population. This paper aims to systematically review the literature investigating the relationship between HIV-stigma and depressive symptoms among PLWHA in South Africa.

METHODS

A keyword search of four bibliographic databases (CINAHL, Ovid MEDLINE, PsycINFO, and Web of Science) and two grey literature websites was conducted. The quality of eligible studies was assessed using established criteria.

RESULTS

Fourteen quantitative studies were included in the review. PLWHA in South Africa experience high levels of HIV-stigma and depressive symptoms. All forms of stigma were found to be associated with depressive symptoms amongst PLWHA. Prospective findings were mixed, with one study finding that stigma did not predict depressive symptoms over 36 months, and another that depressive symptoms predicted stigma 12 months later, suggesting a potentially bidirectional relationship. Females and young adults may be particularly vulnerable to HIV-stigma and its negative psychological effects. Some support was found for the moderating role of social support in the relationship between stigma and depressive symptoms across different sub-populations.

LIMITATIONS

Few studies conducted prospective analyses or tested mediation/moderation.

CONCLUSIONS

Despite limitations, this study highlights the importance of understanding the mechanisms underlying HIV-stigma across different sub-populations in South Africa. This may lead to more effective and context-specific interventions to combat adverse mental health outcomes.

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 role of unintended pregnancy in internalized stigma among women living with HIV in Kenya

BACKGROUND

Kenya has successfully expanded HIV treatment, but HIV-related stigma and discrimination, and unintended pregnancy remain issues for many Kenyan women living with HIV. While HIV-related stigma can influence the health seeking behaviors of those living with HIV, less is known about how reproductive health outcomes influence internalized stigma among women living with HIV.

METHODS

Baseline data only were used in this analysis and came from an implementation science study conducted in Kenya from 2015 to 2017. The analytic sample was limited to 1116 women who are living with HIV, between 18 to 44 years old, and have ever experienced a pregnancy. The outcome variable was constructed from 7 internalized stigma statements and agreement with at least 3 statements was categorized as medium/high levels of internalized stigma. Unintended pregnancy, categorized as unintended if the last pregnancy was mistimed or unwanted, was the key independent variable. Univariate and multivariate logistic regression models were used to assess the association between unintended pregnancy and internalized stigma. Associations between internalized stigma and HIV-related discrimination and violence/abuse were also explored.

RESULTS

About 48% agreed with at least one internalized stigma statement and 19% agreed with at least three. Over half of women reported that their last pregnancy was unintended (59%). Within the year preceding the survey, 52% reported experiencing discrimination and 41% reported experiencing violence or abuse due to their HIV status. Women whose last pregnancy was unintended were 1.6 times (95% CI 1.2-2.3) more likely to have medium/high levels of internalized stigma compared to those whose pregnancy was wanted at the time, adjusting for respondents' characteristics, experiences of discrimination, and experiences of violence and abuse. Women who experienced HIV-related discrimination in the past 12 months were 1.8 times (95% CI 1.3-2.6) more likely to have medium/high levels of internalized stigma compared to those who experienced no discrimination.

CONCLUSIONS

Results suggest that unintended pregnancy is associated with internalized stigma. Integrated HIV and FP programs in Kenya should continue to address stigma and discrimination while increasing access to comprehensive voluntary family planning services for women living with HIV.

Family Support for Adolescent Girls and Young Women Living With HIV in Zambia: Benefits, Challenges, and Recommendations for Intervention Development

ABSTRACT

Lack of family involvement is barrier to antiretroviral therapy adherence among adolescent girls and young women (AGYW). This study assessed family support for AGYW's engagement along the HIV care continuum to inform the design of a family-focused intervention in Lusaka, Zambia. We conducted 16 in-depth interviews and four focus group discussions with 40 AGYW living with HIV. Three strategies were identified to strengthen family support. First, emotional and instrumental support are highly valued by AGYW and should be further developed or reinforced. Second, AGYW wanted more informational support and open discussion of HIV from family, and an intervention should aim to enhance these types of support. Third, existing appraisal support reinforced anticipated stigma among AGYW and discouraged disclosure, yet participants wished for more interactions with peers living with HIV. Appraisal support should therefore be reframed to help AGYW decide to whom they should disclose and how to do so safely.

Reduction in Stigma Drivers Partially Mediates the Effect of a Stigma Reduction Intervention Among Nursing Students in India: The DriSti Cluster Randomized Controlled Trial

BACKGROUND

HIV stigma in health care settings acts as a significant barrier to health care. Stigma drivers among health professionals include transmission fears and misconceptions and pre-existing negative attitudes toward marginalized groups vulnerable to HIV. The DriSti intervention, consisted of 2 sessions with videos and interactive exercises on a computer tablet and one interactive face-to-face group session, mostly tablet administered, was designed to target key stigma drivers that included instrumental stigma, symbolic stigma, transmission misconceptions and blame to reduce HIV stigma, and discrimination among nursing students (NS) and ward staff and tested in a cluster randomized trial.

SETTING

This report focuses on second and third year NS recruited from a range of nursing schools that included private, nonprofit, and government-run nursing schools in south India.

RESULTS

Six hundred seventy-nine NS received intervention and 813 NS were in the wait-list control group. Twelve months outcome analyses showed significant reduction among intervention participants in endorsement of coercive policies (P < 0.001) and in the number of situations in which NS intended to discriminate against PLWH (P < 0.001). Mediation analysis revealed that the effects of intervention on endorsement of coercive policies and intent to discriminate against PLWH were partially mediated by reductions in key stigma drivers.

CONCLUSIONS

This brief scalable stigma reduction intervention targeting key stigma drivers fills a critical gap in identifying the mechanistic pathways that aid in stigma reduction among health professionals.

Factors Associated With HIV-Related Stigma Toward People Living With HIV Among Nurses in Liangshan Yi Autonomous Prefecture, China: A Cross-Sectional Study

Background: The Liangshan Yi Autonomous Prefecture has one of the most serious human immunodeficiency virus (HIV) epidemics in China. Evidence shows HIV-related stigma toward people living with HIV (PLWH) among nurses impedes HIV prevention and treatment. However, only limited research about HIV-related stigma toward PLWH from the perspective of nurses in Liangshan has been conducted. Objective: This study aimed to assess HIV-related stigma toward PLWH among nurses and determine factors associated with it in Liangshan, China. Design: We conducted a cross-sectional survey using a stratified, random cluster sampling method. Participants: Registered nurses (N = 1,248; primary hospitals = 102, secondary hospitals = 592, tertiary hospitals = 554) who were aged 18 or older, worked in the selected hospitals for at least 6 months, and consented to participate were recruited. Methods: All participants completed an anonymous online survey measuring sociodemographic characteristics, HIV-related stigma and HIV knowledge. We used multiple stepwise regression analysis to examine factors associated with HIV-related stigma toward PLWH among these nurses. Results: The mean score of HIV-related stigma among nurses was 50.7 (SD = 8.3; range 25-78). Nurses who were more experienced, had higher levels of education, and were working in tertiary hospitals reported higher level of HIV-related stigma. Those who had better HIV knowledge, reported a willingness to receive HIV-related training, were working in areas that had a high prevalence of HIV, had prior experience working in AIDS specialized hospitals, and worked in hospitals that had policies to protect PLWH showed a lower level of HIV-related stigma toward PLWH. Conclusions: Our findings suggested that providing culturally congruent education and training about HIV and care, and having hospitals that promoted policies protecting PLWH, may reduce HIV-related stigma toward PLWH among nurses in China.

Influence of Spirituality, HIV Stigma and Education on HIV Knowledge in Rural African American Congregants in the Deep South: Additional Findings from Project FAITHH

HIV incidence has shifted racially and geographically in the United States and now represents higher proportions of African Americans living in the Rural South. Lower levels of HIV knowledge may be the culprit behind the increasing HIV rates observed in the Rural South. The purpose of this study was to investigate the individual and joint correlates of HIV knowledge in a sample of rural African Americans. Baseline data from a faith-based anti-stigma intervention (Project FAITHH, N= 210) was used to assess associations between sociodemographic characteristics, spirituality, stigma, and HIV knowledge scores. Associations were examined with recursive partitioning. Statistical significance was determined at P< 0.05 with a two-sided test. Recursive partitioning revealed five distinct groups based on the data. HIV knowledge scores were highest among participants who attended some college (P < 0.001) with lower levels of individual stigma (P < 0.001). HIV knowledge scores were lowest among less educated individuals (P < 0.001) who had lower levels of perceived community stigma (P = 0.002). Future interventions designed to improve HIV knowledge in rural African Americans should consider tailoring content to those who have the greatest deficits in HIV knowledge, which may be based on perceived community stigma and education levels.

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

OBJECTIVE

Considering the association between internalized HIV-related stigma and treatment adherence, an intervention addressing HIV treatment adherence may have the added benefit of reducing internalized stigma. The 'integrating ENGagement and Adherence Goals upon Entry' (iENGAGE) intervention was developed to facilitate adjustment to living with HIV among individuals newly engaged in HIV care. We evaluated the effects of this intervention on internalized stigma and examined whether the effect is moderated by depressive symptoms and coping styles.

DESIGN

The iENGAGE intervention was tailored individually to improve information, motivation, and behavioral skills to promote treatment adherence and viral suppression. Three hundred and seventy-one participants initiating HIV care at four sites in the United States were randomly assigned to either the intervention receiving four face-to-face sessions or standard of care control arm.

METHODS

Baseline and 48-week follow-up assessments were conducted, which included validated measures of internalized HIV-related stigma, depressive symptoms, and coping mechanisms (behavioral disengagement and self-blame) as secondary outcomes. A repeated measures ANOVA evaluated the effect of the intervention on change in internalized HIV stigma. Furthermore, the moderating effects of depressive symptoms and coping mechanisms on the decrease in internalized stigma were examined.

RESULTS

The decrease in internalized stigma from baseline to 48 weeks was significantly larger in the intervention arm compared with the control arm. This effect was significantly moderated by baseline levels of depressive symptoms and self-blame.

CONCLUSION

The multifaceted iENGAGE intervention is effective in reducing internalized stigma for new-to-HIV care individuals, especially with higher depressive symptoms or when using higher levels of self-blame coping.

A multilevel intervention to reduce stigma among alcohol consuming men living with HIV receiving antiretroviral therapy: findings from a randomized control trial in India

OBJECTIVE

To examine the effectiveness of a multilevel intervention to reduce HIV stigma among alcohol consuming men living with HIV in India.

DESIGN

A crossover randomized controlled trial in four sites.

SETTING

Government ART centres (ARTCs) offering core services in the greater Mumbai area.

PARTICIPANTS

Seven hundred and fifty two (188 per site) alcohol-consuming male PLHIV on ART were recruited.

INTERVENTION

Multilevel intervention to reduce alcohol consumption and promote adherence by addressing stigma, implemented at the individual (individual counselling, IC), group (group intervention, GI) and community levels (collective advocacy, CA) in three distinct sequences over three cycles of 9 months each.

MAIN OUTCOME MEASURE

HIV stigma, measured using the 16-item Berger Stigma scale.

METHODS

The article examines the effectiveness of the interventions to reduce stigma using Linear Mixed Model regression.

RESULTS

At baseline, 57% of participants had moderate-high levels of stigma (scores >40). All three counseling interventions were effective in reducing stigma when delivered individually, in the first cycle (collective advocacy: βcoeff = -9.71; p < 0.001; group intervention: βcoeff = -5.22; p < 0.001; individual counselling: βcoeff = -4.43; p < 0.001). At then end of the second cycle, effects from the first cycle were sustained with no significant change in stigma scores. At the end of the third cycle, the site, which received CA+IC+GI sequence had maximum reduction in stigma scores (βcoeff = -10.29; p < 0.001), followed by GI+CA+IC (βcoeff = -8.23, p < 0.001).

CONCLUSION

Baseline findings suggest that stigma remains a problem even with experienced patients, despite advances in treatment and adherence. Results of multilevel stigma reduction interventions argue for inclusion in HIV prevention and treatment program.

Exploring Changes in Racial/Ethnic Disparities of HIV Diagnosis Rates Under the "Ending the HIV Epidemic: A Plan for America" Initiative

OBJECTIVES

Racial/ethnic disparities in HIV diagnosis rates remain despite the availability of effective treatment and prevention tools in the United States. In 2019, President Trump announced the "Ending the HIV Epidemic: A Plan for America" (EHE) initiative to reduce new HIV infections in the United States at least 75% by 2025 and at least 90% by 2030. The objective of this study was to show the potential effect of the EHE initiative on racial/ethnic disparities in HIV diagnosis rates at the national level.

METHODS

We used 2017 HIV diagnoses data from the Centers for Disease Control and Prevention National HIV Surveillance System. We developed a counterfactual scenario to determine changes in racial/ethnic disparities if the 2017 HIV diagnosis rates were reduced by 75% in the geographic regions targeted by the EHE initiative. We used 4 measures to calculate results: rate ratio, population-attributable proportion (PAP), Gini coefficient, and Index of Disparity.

RESULTS

The relative measures of racial/ethnic disparity decreased by 9%-21% in the EHE scenario compared with the 2017 HIV diagnoses data. The largest decrease was in the Hispanic/Latino:white rate ratio (-20.6%) and in the black:white rate ratio (-18.2%). The PAP measure decreased by 11.5%. The absolute versions of the Index of Disparity (unweighted and weighted) were approximately 50% lower in the EHE scenario than in the 2017 HIV diagnoses data.

CONCLUSIONS

EHE efforts could reduce but will not eliminate racial/ethnic disparities in HIV diagnosis rates. Efforts to address racial/ethnic disparities should continue, and innovative approaches, specifically those that focus on social and structural factors, should be developed and implemented for populations that are disproportionately affected by HIV in the United States.

Spontaneous iliac vein rupture in the setting of a long dwelling intravenous vena cava filter

Venous thromboembolism impacts as many as 600,000 individuals each year in the United States, leading to significant morbidity and mortality. While typically treated with anticoagulants, retrievable inferior vena cava (IVC) filters may also be used for acute prevention of pulmonary embolism. The FDA recommends removing IVC filters within 29-54 days because long dwelling filters are associated with serious complications from the filter itself, such as perforation of adjacent structures and filter fracture. We report an unusual case in which a patient had an inferior venous cava filter in place for two years before experiencing spontaneous rupture of the left iliac vein. There was no evidence of filter migration or inferior venous cava perforation. Spontaneous iliac vein ruptures are rare, with fewer than 50 reported cases, and are not typically seen with a long-dwelling IVC. This case describes a unique complication of retrievable filters and highlights the importance of retrieving filters as soon as the acute danger of pulmonary embolism has resolved.

Psychosocial Well-Being and HIV-Related Immune Health Outcomes among HIV-Positive Older Adults: Support for a Biopsychosocial Model of HIV Stigma and Health

Evidence suggests that psychosocial stress negatively impacts immunological health in HIV-positive individuals. However, few studies have explored this association in substance-using older adults living with HIV (OALWH). We evaluated the effect of depression, loneliness, substance use problems, and HIV stigma on primary markers of immune function in a sample of 120 OALWH with substance-related issues. HIV stigma correlated with the greatest number of factors, including depression, loneliness, and substance use problems. Older age and antiretroviral adherence were associated with viral suppression, which was in turn associated with higher percentage of CD4 count. Multivariate path analyses demonstrated that lower HIV stigma and viral suppression were the only factors independently associated with higher percentage of CD4 count, with a significant indirect effect of adherence on CD4 through viral suppression. HIV stigma emerged as the most salient factor associated with both psychosocial well-being and immune health in the current study, suggesting that it is a critical factor to consider in future interventions for the rapidly growing population of OALWH.

Conditions of experienced stigma in people living with HIV in Iran: a qualitative comparative analysis

Stigma against people living with HIV (PLWH) seriously affects their quality of life. Moreover it can lead them to hide their HIV status from others, which in turn endangers public health. Many studies dealing with HIV-related stigma focus on the consequences of this phenomenon and pay less attention to the social conditions which affect different types of HIV-related stigma (anticipated, internalized and enacted stigma [ES]). Therefore, in this study, we tried to achieve more understanding about effective causal conditions of various types of experienced stigma. First of all, data were collected from 19 PLWH, using semi-structured interviews from those who had visited the Counseling Center for Behavioral Diseases in Mashhad. Secondly, the data were analyzed by applying a mixture of two methods: thematic analysis and qualitative comparative analysis (Boolean Algebra). The analysis of the data reveals that a combination of informing family members about HIV status, lack of family support, and medical support lead to anticipated stigma; a combination of religious beliefs and poor self-esteem results in internalized stigma and a combination of lack of family support, mistreatment by community, poor self-esteem, poverty and no religious beliefs lead to ES.

Ability to Monitor National Responses to the HIV Epidemic "Beyond Viral Suppression": Findings From Six European Countries

Objective: With more people living with HIV (PLHIV) ageing into their 50s and beyond in settings where antiretroviral therapy is widely available, non-AIDS comorbidities and health-related quality of life (HRQoL) are becoming major challenges. Information is needed about whether national HIV monitoring programmes have evolved to reflect the changing focus of HIV care.

Methods: We created a 56-item English-language survey to assess whether health systems report on common health-related issues for people with HIV including physical and mental health comorbidities, HRQoL, psychosocial needs, and fertility desires. One expert was identified via purposive sampling in each of six countries (Estonia, Italy, the Netherlands, Slovenia, Sweden, and Turkey) and was asked to participate in the survey.

Results: Three respondents reported that the current monitoring systems in their countries do not monitor any of four specified aspects of 10 comorbidities including bone loss, cardiovascular disease, and neurocognitive disorders. Two respondents stated that their countries potentially can report on leading causes of hospital admission among PLHIV, and five on leading cases of death. In three countries, respondents reported that there was the ability to report on the HRQoL of PLHIV. In two countries, respondents provided data on the percentage of PLHIV denied health services because of HIV status in the past 12 months.

Conclusions: This study identified areas for potential HIV monitoring improvements in six European countries in relation to comorbidities, HRQoL, discrimination within health systems, and other issues associated with the changing nature of the HIV epidemic. It also indicated that some countries either currently monitor or have the ability to monitor some of these issues. There are opportunities for health information systems in European countries to expand the scope of their HIV monitoring in order to support decision-making about how the long-term health-related needs of PLHIV can best be met.

Towards an AIDS free generation: Is stigma still an issue in Zambia? Results from a legal environment assessment of the HIV/AIDS/TB program of the Churches Health Association of Zambia

This paper reports on HIV related stigma based on results from an HIV legal environment assessment (LEA) within the Churches Health Association of Zambia HIV/AIDS program. We conducted 9 Focus Group Discussions and 20 Key Informant Interviews with key HIV/AIDS stakeholders that included representatives from network of Zambian people living with HIV. We administered a Survey Questionnaire to 337 people living with HIV (PLHIV) and 233 health workers. Quantitative data were analyzed using SAS v9.4; qualitative data was analyzed using QRS NVIVO version 11.0 Pro. Internalized stigma ranged between 20.8% and 31.8% of PLHIV; more among females than males. About one third (31%, n=104)) of the 337 participants reported that they were aware of being gossiped once, a few times, or often; more among females than males. 62.3%, 63.1%, and 55.1% of the 233 health workers said it was somewhat true or certainly true that in their catchment areas, PLHIV struggle to have an HIV test because of stigma, were hesitant to start ART due to stigma; told them that they had challenges taking their ARVs because of stigma respectively.

Reducing HIV stigma among healthcare providers in India using a partly tablet-administered intervention: the DriSti trial

HIV stigma has long been recognized as a significant barrier in the worldwide fight against HIV. Across cultures, stigma has been shown to cause psychological distress and act as a barrier to engagement in care. Health professionals can serve as a crucial source of HIV stigma, with drivers that include fears and transmission misconceptions and pre-existing negative attitudes towards marginalized groups. To increase their impact, stigma reduction interventions need to be scalable and sustainable as well as adaptable to different cultural contexts. The DriSti intervention was designed to meet these needs through an easily adaptable, mostly tablet-administered, interactive intervention delivered to ward staff (n = 1,557) and nursing students (n = 1,625) in 62 Indian institutions, using a cRCT design, with wait-list controls. Six-month outcome analyses, showed significant reductions in misconceptions (p < .001) and worry about acquiring HIV at work (p < .001). Intervention participants also reported significantly greater reductions in endorsement of coercive policies (p < .001) and in the number of situations in which they intended to discriminate against PLWH (p < .001) than control participants. This brief, scaleable intervention could be adapted for similar populations in the region, using different mHealth platforms and thus has important implications for current global stigma reduction initiatives and training curricula.

Discrimination, Medical Distrust, Stigma, Depressive Symptoms, Antiretroviral Medication Adherence, Engagement in Care, and Quality of Life Among Women Living With HIV in North Carolina: A Mediated Structural Equation Model

BACKGROUND

Women represent 23% of all Americans living with HIV. By 2020, more than 70% of Americans living with HIV are expected to be 50 years and older.

SETTING

This study was conducted in the Southern United States-a geographic region with the highest number of new HIV infections and deaths.

OBJECTIVE

To explore the moderating effect of age on everyday discrimination (EVD); group-based medical (GBM) distrust; enacted, anticipated, internalized HIV stigma; depressive symptoms; HIV disclosure; engagement in care; antiretroviral medication adherence; and quality of life (QOL) among women living with HIV.

METHODS

We used multigroup structural equation modeling to analyze baseline data from 123 participants enrolled at the University of North Carolina at Chapel Hill site of the Women's Interagency HIV Study during October 2013-May 2015.

RESULTS

Although age did not moderate the pathways hypothesized, age had a direct effect on internalized stigma and QOL. EVD had a direct effect on anticipated stigma and depressive symptoms. GBM distrust had a direct effect on depressive symptoms and a mediated effect through internalized stigma. Internalized stigma was the only form of stigma directly related to disclosure. Depressive symptoms were a significant mediator between GBM, EVD, and internalized stigma reducing antiretroviral therapy medication adherence, engagement in care, and QOL.

CONCLUSIONS

EVD, GBM, and internalized stigma adversely affect depressive symptoms, antiretroviral therapy medication adherence, and engagement in care, which collectively influence the QOL of women living with HIV.