Voices of Women Facing HIV-Related Stigma in the Deep South

Loneliness and social isolation in people with HIV

PURPOSE OF REVIEW

Antiretroviral therapy (ART) has significantly extended the life expectancy of people with HIV (PWH). However, as this population ages, they face increased risk of social isolation and loneliness (SIL), driven by stigma, discrimination, and shrinking social networks. SIL is a major public health issue, closely linked to mental health conditions, reduced adherence to treatment, and lower health-related quality of life (HRQoL). This review examines the prevalence, risk factors, health impacts, and interventions related to SIL, highlighting its critical importance for improving HRQoL in PWH.

RECENT FINDINGS

SIL is common among PWH and strongly associated with HIV-related stigma, depression, anxiety, and systemic inflammation. These factors accelerate aging and contribute to chronic conditions while undermining ART outcomes. Recent research supports the effectiveness of interventions like psychological therapies and social prescribing in reducing SIL and improving HRQoL. However, progress is limited by the lack of standardized tools to assessment SIL, which hampers consistent research and the development of targeted solutions.

SUMMARY

Addressing SIL is essential to advancing holistic and person-centered HIV care. Integrating SIL evaluation into routine clinical practice, creating standardized assessment tools, and implementing targeted interventions can improve HRQoL and reduce health burdens, particularly as the aging PWH population grows.

Comparison of At-Home Versus In-Clinic Receipt of Long-Acting Injectable Cabotegravir/Rilpivirine

BACKGROUND

The need for frequent travel to a clinic could impair access to injectable antiretroviral therapy for persons living with human immunodeficiency virus type 1 (HIV-1) infection. We hypothesized that allowing persons receiving treatment with long-acting injectable cabotegravir plus rilpivirine (LA CAB/RPV) to receive and store the medication in their own refrigerator prior to in-home administration by a healthcare provider would be as safe and effective as receiving treatment in a clinic.

METHODS

Persons prescribed LA CAB/RPV in the Infectious Diseases clinic at the Medical University of South Carolina were offered enrollment in this non-randomized, observational study between August 2021 and December 2022. After in-clinic receipt of the initial LA CAB/RPV injection, participants chose to receive each subsequent injection over the following 12-months either in clinic or at home.

RESULTS

The 33 enrolled participants were primarily Black (64%), male (73%), and had a median age of 46. Three participants stopped LA CAB/RPV and transitioned to oral antiretroviral therapy due to allergy (n = 1), loss of virologic suppression (n = 1), and visit adherence (n = 1) concerns. A comparable number of participants received treatment primarily in clinic (n = 18) relative to at home (n = 15). Injection site pain/soreness was common (52% of injections) but did not differ between groups. There were no differences in safety or efficacy between groups and both groups reported high treatment satisfaction. All participants were virologically suppressed and retained in care at the end of the study.

CONCLUSIONS

At-home administration of LA CAB/RPV by a healthcare provider was comparably safe, effective, and associated with high participant satisfaction relative to in-clinic administration.

How Does Anticipated HIV Stigma Affect Medication Adherence? A Longitudinal Path Analysis Model

Prior research has documented that anticipated HIV stigma may play an important predictive role in medication adherence among people living with HIV (PLWH). However, longitudinal data on the mechanisms underlying this linkage are scarce. The current study aimed to explore the longitudinal mediation association among anticipated HIV stigma, medication adherence support, HIV self-management, and medication adherence. A four-wave sample consisting of 1,098 Chinese PLWH (Mage = 38.63, SD = 9.20; 63.9% male) with a six-month interval was used in the current study. Participants were asked to complete self-report questionnaires. A path analysis model was analyzed. Results indicate that anticipated HIV stigma at baseline was positively related to medication adherence at Time 4 (T4). Medication adherence support at Time 2 (T2) and HIV self-management at Time 3 (T3) serially mediated the anticipated HIV stigma at Time 1 (T1) and medication adherence at T4. These findings provide critical insights into the mediating roles of medication adherence support and HIV self-management in the relationship between anticipated HIV stigma and medication adherence over time. Such an understanding has important implications for the development of tailored interventions and public health strategies aimed at improving medication adherence among PLWH in the context of HIV-related stigma.

'Don't judge me 'til you walk through my shoes': A qualitative investigation of the experiences of women living with HIV

OBJECTIVE

Women living with the human immunodeficiency virus (HIV) are less of a focus in the HIV literature, which tends to focus on the HIV experiences of men who have sex with men (MSMs). Hence, we conducted a qualitative study that examined: (a) the type of stigma and discrimination that women living with HIV experience related to their HIV status, (b) the source of this stigma and discrimination, (c) their responses related to this stigma and discrimination, and (d) the ways in which women living with HIV cope with these experiences of stigma and discrimination.

DESIGN

Participants consisted of 14 self-identified women living with HIV that were recruited at a community organization in the Southern United States that provides services to individuals living with HIV. The participants ranged in age from 27 to 65 (M = 47.92, SD = 13.08). The sample primarily identified as Black (N = 12), followed by White (N = 1) and Multiracial (N = 1). Most women were cisgender (N = 13) with one woman identifying as transgender (N = 1).

RESULTS

Fourteen women participated in one of two focus groups (seven in each focus group), which were audio recorded and transcribed. We identified 24 categories across five domains (Stigma and Discrimination, Source of Stigma and Discrimination, Response to Stigma and Discrimination, Coping with Stigma and Discrimination, and Support).

CONCLUSIONS

This study identified that women living with HIV experience stigma and discrimination in a multitude of ways from different sources. Moreover, women with HIV responded to and coped in negative and positive ways. Multidimensional approaches including personal and community education may help alleviate the stigma and discrimination faced by women living with HIV.

A qualitative metasynthesis of stigma in women living with HIV in the United States

Our goal was to synthesize qualitative studies on HIV-related stigma as experienced by women living with HIV (WLWH) in the U.S. Qualitative metasynthesis techniques as developed by Sandelowski et al. (Res Nurs Health 30(1):99-111, 2007) were used to integrate and update findings on stigma in WLWH in the U.S. in 43 reports of qualitative studies conducted between 2004 and 2023 with 1118 participants. Developed themes explored a collective narrative of women first surviving the intersectionality of multiple sources of stigma, discovering non-linear pathways to transcend their stigma, and finally experiencing resilience through their transcendence of stigma. While this metasynthesis revealed similarities to an earlier metasynthesis in the ubiquity and persistence of stigma, they differ primarily in women's abilities to find agency in managing and opposing their stigma. This cognitive reframing of their stigma helped women to redefine stigma as ignorance and move towards a more positive assessment of the self. In doing so, they separated themselves from their stigma and the damaging effects of it. Findings from this metasynthesis may serve as a useful tool for the development of stigma reduction interventions specific to the needs and experiences of WLWH in the U.S.

Examining Stigma and Disclosure Among Women With HIV in the Southern United States: Qualitative Study Guided by the Adaptive Leadership Framework for Chronic Illness

ABSTRACT

Stigma is a fundamental cause of health inequities. Guided by the Adaptive Leadership Framework for Chronic Illness (ALFCI), this descriptive qualitative study explored the challenges of stigma and disclosure experienced by women with HIV (WWH) in the Southern United States. A convenience sample of 22 WWH aged 36 to 62 years were interviewed for this study. Analysis of participant interviews revealed that WWH face a multitude of stigma-related technical and adaptive challenges, which are consistent with the ALFCI. Once identified, technical challenges, such as recognizing the need for support, lack of trust, and fear of rejection, can be overcome by technical work, including providing assistance with HIV disclosure and building a trusted network. By identifying specific adaptive and technical challenges faced by WWH and engaging in technical and adaptive work, the WWH and the provider can reduce the fear of disclosure and the effect of stigma.

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

BACKGROUND

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

OBJECTIVES

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

DESIGN

This study used a cross-sectional, qualitative design.

SETTING AND PARTICIPANTS

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

METHOD

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

RESULTS

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

CONCLUSION

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

A Review of the State of the Science of HIV and Stigma: Context, Conceptualization, Measurement, Interventions, Gaps, and Future Priorities

ABSTRACT

Stigma is a fundamental cause of health inequities. As such, stigma is a major barrier to HIV prevention, care, and treatment. This review will examine the concept of stigma, explicating the mechanisms of action of HIV-related stigma while also examining intersectional stigma and structural stigma. Instruments to measure HIV-related stigma and its mechanisms of action, as well as stigma enacted and experienced by HIV health care providers, will also be reviewed. This article will conclude with a review of stigma interventions, gaps in the literature, and priorities for future HIV, intersectional, and structural stigma research.

Applying a Nursing Perspective to Address the Challenges Experienced by Cisgender Women in the HIV Status Neutral Care Continuum: A Review of the Literature

ABSTRACT

The field of HIV research has grown over the past 40 years, but there remains an urgent need to address challenges that cisgender women living in the United States experience in the HIV neutral status care continuum, particularly among women such as Black women, who continue to be disproportionately burdened by HIV due to multiple levels of systemic oppression. We used a social ecological framework to provide a detailed review of the risk factors that drive the women's HIV epidemic. By presenting examples of effective approaches, best clinical practices, and identifying existing research gaps in three major categories (behavioral, biomedical, and structural), we provide an overview of the current state of research on HIV prevention among women. To illustrate a nursing viewpoint and take into account the diverse life experiences of women, we provide guidance to strengthen current HIV prevention programs. Future research should examine combined approaches for HIV prevention, and policies should be tailored to ensure that women receive effective services that are evidence-based and which they perceive as important to their lives.

Retrospective analysis of adherence to HIV treatment and healthcare utilization in a commercially insured population

AIMS

Single-tablet regimens (STRs) can improve antiretroviral therapy (ART) adherence; however, the relationship between long-term adherence and patient healthcare resource utilization (HRU) is unclear. The objective of this study was to assess long-term ART adherence among people living with HIV (PLHIV) using STRs and multi-tablet regimens (MTRs) and compare HRU over time by adherence.

MATERIALS AND METHODS

This retrospective study analyzed medical and pharmacy claims (Optum Clinformatics Data Mart Database). Included PLHIV were aged ≥18 years, had ≥1 medical claim with an HIV diagnosis, and had pharmacy claims for a complete STR or MTR. Adherence was analyzed as the proportion of days covered (PDC), stratified as ≥95%, very high; 90-95%, high; 80-90%, moderate; <80%, low. Cumulative all-cause and HIV-related HRU were calculated across 4 years. Among PLHIV with ≥4-year follow-up, HRU was assessed by adherence.

RESULTS

Among 15,153 PLHIV included, 63% achieved PDC ≥90% during Year 1. Among the subgroup of PLHIV with ≥4-year follow-up (N = 3,818), the proportion maintaining PDC ≥90% fell from 67% in Year 1 to 54% by Year 4. The difference from Years 1 to 4 in the proportion of PLHIV with PDC ≥90% was 13% and 17% in the STR and MTR groups, respectively. Cumulative HRU across the 4-year follow-up was higher in PLHIV with low vs high adherence (27% with low adherence had ≥1 emergency room visit vs 17% for very high, p < .0001; 15% with low adherence had ≥1 inpatient stay vs 7% for very high, p < .0001).

CONCLUSIONS

ART adherence showed room for improvement, particularly over the long term. PLHIV receiving STRs exhibited higher adherence vs those receiving MTRs; this difference increased over time. The proportion of PLHIV with higher HRU was significantly higher among those with lower adherence and became greater over time. Interventions and alternative therapies to improve adherence among PLHIV should be explored.

A Systematic Mixed Studies Review of the Intersections of Social-Ecological Factors and HIV Stigma in People Living With HIV in the U.S. South

The role of stigma on psychological wellness and treatment outcomes in people living with HIV (PLWH) has been well documented. However, within the context of the southern United States, the intersection between HIV-related stigma and social-ecological factors has been understudied. Thus, a results-based convergent, mixed synthesis design was used to examine the manifestations of HIV-related stigma in PLWH in the U.S. South. A literature search was conducted using PsycINFO, PubMed (includes MEDLINE), and CINAHL. The first level of screening by title and abstract was administered on 1,829 articles. A full-text screening of 169 studies was completed, and a total of 30 relevant articles were extracted. The mixed synthesis highlighted intervention strategies that can reduce HIV-related stigma while promoting positive health-behavior change. The findings of this review underscored the uniqueness of PLWH in the south and demonstrated the crucial role of intersectionality in investigating HIV-related stigma in treating and preventing HIV.

'Today I feel strong': African American women overcoming HIV-related stigma

Objective: African American account for more than 60% of women living with HIV/AIDS in the United States. This population is disproportionately affected in areas of diagnosis, treatment, and morbidity. HIV-related stigma has been found to play a pivotal role in the experiences of African American women living with HIV/AIDS (WLWHA) impacting self-perception, treatment adherence, depression, interpersonal relationships, and overall quality of life. Limited studies have explored the ways in which HIV-related stigma impacts the self-perceptions of African American WLWHA. To explore these experiences, this study examined the ways in which HIV-related stigma impacts the intrapersonal experiences of African American WLWHA.Design: A phenomenological investigation was conducted to explore the experiences of African American WLWHA.Main Outcome Measure: In-depth, semi-structured qualitative interviews.Results: Interpretive phenomenological analysis revealed four emergent themes: (1) increased vulnerability; (2) processing the diagnosis of HIV/AIDS; (3) surviving HIV/AIDS; and (4) quality of life.Conclusion: Findings of this study contribute to existing literature by highlighting the intricacies of the lived experiences of African American WLWHA from initial diagnosis to present day. Exploring the trajectory of the illness among this population allows for a deeper understanding of the ways in which HIV/AIDS impacts the intrapersonal experiences and self-perceptions of WLWHA.

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.

A generation at risk: a cross-sectional study on HIV/AIDS knowledge, exposure to mass media, and stigmatizing behaviors among young women aged 15-24 years in Ghana

HIV/AIDS stigmatizing behaviors are a huge barrier to early detection and treatment of individuals with the AIDS virus. HIV/AIDS stigma and related consequences are debilitating, especially for vulnerable populations. This study sought to assess whether young women's HIV/AIDS knowledge levels and exposure to mass media (television and radio) have an influence on their stigmatizing behaviors and role as agents of stigma towards individuals living with HIV and AIDS. The data used for this study originated from the Ghana Multiple Indicator Cluster Survey 2011. Binary and multiple (stepwise) logistic regression analyses were used to examine the associations between HIV/AIDS knowledge, frequency of exposure to mass media, and HIV/AIDS stigmatizing behaviors among young women aged 15-24 years in Ghana. Of the 3573 young women, 80% of 15-19-year-olds and 76% of 20-24-year-olds had at least one stigmatizing behavior towards persons living with HIV/AIDS (PLHA). Young women with increased knowledge regarding HIV/AIDS and frequent exposure to mass media (television and radio) had lesser tendency to stigmatize or act as agents of stigma towards PLHA (proportion with at least one stigmatizing behavior per subgroup - HIV/AIDS knowledge: those with highest knowledge score 579 [70.1%], those with lowest knowledge score 28 [90.3%]; mass media: those with daily exposure 562 [73.4%], those not exposed at all 249 [89.2%]). There was a graded negative 'exposure-response' association between the ranked variables: HIV/AIDS knowledge, mass media, and HIV/AIDS stigmatizing behaviors. The significant inverse association between HIV/AIDS knowledge, frequency of exposure to mass media, and HIV/AIDS stigmatizing behaviors persisted even after adjusting for all other covariates in the multiple logistic regression models. It is extremely important to increase HIV/AIDS-related knowledge and reduce stigma among young women in Ghana through targeted HIV/AIDS factual knowledge transfer. The use of mass media for communication of issues regarding HIV/AIDS, its mode of transmission, and associated stigma should be emphasized among women in Ghana.