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

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.

The impact of syndemic burden, age, and sexual minority status on internalized HIV stigma among people living with HIV in South Florida

Internalized HIV stigma has been associated with several poor mental and physical health outcomes among people living with HIV (PLWH); yet, little research has explored how internalized HIV stigma may be affected by syndemic burden. This study sought to examine the relationship between syndemic conditions and HIV stigma over and above the potential effects of two social determinants of health, age and sexual minority status, using a linear regression approach (N = 1343). Syndemic burden was significantly positively associated with internalized HIV stigma above and beyond the effects of age and sexual minority status (b = 0.23). Additionally, age (b = -0.02) and being a sexually minority (b = -0.31) were significantly negatively associated with internalized HIV stigma. Findings should inform future treatment targets for this population by specifically working to reduce internalized HIV stigma for people with a greater syndemic burden and, potentially, among young adults and heterosexual PLWH.

Assessing HIV-related stigma in the clinical setting: are providers in Florida interested?

HIV-related stigma is a key contributor to poor HIV-related health outcomes. The purpose of this study is to explore implementing a stigma measure into routine HIV care focusing on the 10-item Medical Monitoring Project measure as a proposed measure. Healthcare providers engaged in HIV-related care in Florida were recruited. Participants completed an interview about their perceptions of measures to assess stigma during clinical care. The analysis followed a directed content approach. Fifteen participants completed the interviews (87% female, 47% non-Hispanic White, case manager 40%). Most providers thought that talking about stigma would be helpful (89%). Three major themes emerged from the analysis: acceptability, subscales of interest, and utility. In acceptability, participants mentioned that assessing stigma could encourage patient-centered care and serve as a conversation starter, but some mentioned not having enough time. Participants thought that the disclosure concerns and negative self-image subscales were most relevant. Some worried they would not have resources for patients or that some issues were beyond their influence. Participants were generally supportive of routinely addressing HIV-related stigma in clinical care, but were concerned that resources, especially to address concerns about disclosure and negative self-image, were not available.

Community Perceptions of HIV Stigma, Discriminatory Attitudes, and Disclosure Concerns: A Health Facility-Based Study in Selected Health Districts of South Africa

Research data about HIV stigma perceptions and discriminatory attitudes among the general population are limited. Furthermore, the willingness of HIV-negative individuals to engage with HIV prevention and disclosure interventions has not been established in South Africa. The study investigated community perceptions of stigma as well as discriminatory attitudes towards HIV disclosure to understand if and how these perceptions might influence the uptake of disclosure interventions. This facility-based study used a validated questionnaire to measure the four constructs of HIV stigma among 670 adults recruited from health districts of two provinces of South Africa. Of these, 72% were female, 87% had ever been tested for HIV, and 31% knew someone who has HIV. Stigma towards people living with HIV (PLHIV) is widespread in the general population. A high proportion (75%) endorsed disclosure concerns, 75% perceived stigma to be common, and 56% endorsed negative statements indicating perceived stigma in communities. Fear, moral and social judgement, and rejection underlined their perceptions about PLHIV. Almost half (45.7%) were unwilling to care for family members sick with AIDS, suggesting negative distancing reactions and discriminatory attitudes towards PLHIV. The widespread discriminatory attitudes and the perceived stigma that is evident in the general population might heighten the disclosure concerns endorsed, promote non-disclosure, and increase HIV transmission. To design interventions, it is crucial to be cognisant of disclosure concerns, discriminatory attitudes, and perceived stigma evident in communities. Thus, the findings underscore the need to increase efforts to challenge and reduce community drivers of negative discriminatory attitudes and perceived stigma.

Public health services and intersectional stigma: a social sciences perspective with implications for HIV service design and delivery

PURPOSE OF REVIEW

Understanding stigma is important for improving HIV care services and gaps in HIV service delivery have been attributed to stigma. This review article synthesizes recent evidence on stigma and its implications for HIV service design and delivery. Given the intersectional nature of stigma, we will focus on HIV stigma as well as related forms of stigma based on one's race, sexual identity, gender identity and other identities.

RECENT FINDINGS

Stigma remains a barrier to achieving equity in HIV services. Individualistic measures of stigma remain influential and are associated with barriers to accessing HIV health services. Recent work also highlights stigma measured at a structural level and its impact on HIV services contexts. Individuals situated at intersections of marginalized identities continue to face greatest injustices, and although intersectional approaches have been adapted to design services at a micro level, few focus on structural change. Recent evidence for mitigating stigma indicates some success for psychosocial interventions that target internalized stigma. Furthermore, community-led approaches show promise in addressing stigma that manifests in HIV health services settings.

SUMMARY

Interventions that address individual-level stigma and structural stigma are needed. Theoretical and applied antistigma research is needed to make HIV services more equitable.

Talking to My Partners About PrEP: Factors Associated with PrEP-Related Communication in a Longitudinal US Study of Sexual Minority Men Living with HIV

Treatment as prevention and pre-exposure prophylaxis (PrEP) have reduced HIV transmission among sexual minority men (SMM). However, little is known about PrEP-related communication in serodiscordant partnerships. In 2015-2016, 965 US SMM living with HIV (Mage = 39; 63% White, 19% Black, 18% Latinx) enrolled in a year-long longitudinal study with surveys every 3 months (2,850 surveys). Multilevel models explored factors associated with PrEP-related communication with HIV-negative partners. Most participants (77%) reported PrEP-related communication. Participants were more likely to discuss PrEP during periods with more sexual partners, AOR = 2.89, p < .001, and group sex, AOR = 1.99, p = .001. Those with more partners on average, β = 0.48, p < .001, and those engaging in other drug use more frequently, β = 0.11, p = .002, were more likely to discuss PrEP. PrEP-related communication was more common for men who disclosed their HIV status, β = 0.22, p < .001, and who had undetectable viral loads, β = 0.25, p = .007. Communication was also more common for those with higher incomes, β = 0.12, p = .02, and from larger cities, β = 0.07, p = .048, and less common for Black participants, β =  - 0.29, p = .003, and older participants, β =  - 0.18, p < .001. PrEP-related communication increased over the course of the study, AOR = 1.16, p= .02. PrEP can confer additional HIV prevention benefits within serodiscordant partnerships, and future research should continue to explore the role PrEP plays in these partnerships.