Mechanisms for the Negative Effects of Internalized HIV-Related Stigma on Antiretroviral Therapy Adherence in Women

Abstract

Background Internalization of HIV-related stigma may inhibit a person’s ability to manage HIV disease through adherence to treatment regimens. Studies, mainly with white men, have suggested an association between internalized stigma and sub-optimal adherence to antiretroviral therapy (ART). However, there is a scarcity of research with women of different racial/ethnic backgrounds and on mediating mechanisms in the association between internalized stigma and ART adherence. Methods The Women’s Interagency HIV Study (WIHS) is a multi-center cohort study. Women living with HIV complete interviewer-administered questionnaires semi-annually. Cross-sectional analyses for the current article included 1168 women on ART for whom data on medication adherence were available from their last study visit between April 2013 and March 2014, when the internalized stigma measure was initially introduced. Results The association between internalized stigma and self-reported sub-optimal ART adherence was significant for those in racial/ethnic minority groups (AOR = 0.69, p = .009, CI [0.52, 0.91]), but not for non-Hispanic whites (AOR = 2.15, p = .19, CI [0.69, 6.73]). Depressive symptoms, loneliness, and low perceived social support mediated the association between internalized stigma and sub-optimal adherence in the whole sample, as well as in the subsample of minority participants. In serial mediation models, internalized stigma predicted less perceived social support (or higher loneliness), which in turn predicted more depressive symptoms, which in turn predicted sub-optimal medication adherence. Conclusions Findings suggest that interconnected psychosocial mechanisms affect ART adherence, and that improvements in adherence may require multi-faceted interventions addressing both mental health and interpersonal factors, especially for minority women.

Association between Perceived Discrimination in Healthcare Settings and HIV Medication Adherence: Mediating Psychosocial Mechanisms

“…In addition, the study did not have a large proportion of minority women and thus may not be representative of the populations currently living with and at high risk of acquiring HIV. Minority women in the US are disproportionately affected by HIV, 27 have distinct historical bases for medical distrust, 28 and may experience effects of HIV-related stigma in greater magnitude, 29 compared to non-minority groups. Thus, studies addressing this gap in the literature on the association between perceived discrimination in healthcare settings and ART adherence should include samples with a large proportion of minority women.…”

“…Symptoms of depression have consistently been shown to impact HIV medication (ART) adherence across populations. 29,32 According to our conceptual model, perceiving discrimination in healthcare settings may contribute to symptoms of depression—including fatigue, diminished ability to concentrate, and feelings of worthlessness—ultimately impacting the ability of individuals perceiving discrimination to adhere to complex medication regimens.…”

Transitioning From Medicaid Disability Coverage to Long-Term Medicare Coverage: The Case of People Living With HIV/AIDS in California

“…Our analyses document that mental health and substance use disorders are prevalent among disabled PLWHA who had Medi-Cal insurance prior to the enactment of the ACA. It is important to address these conditions, which are major barriers to remaining in treatment for HIV, achieving viral suppression, and returning to employment (Arns, Martin, & Chernoff, 2004; Gonzalez, Batchelder, Psaros, & Safren, 2011; Holtzman et al, 2015; Huynh, Kinsler, Cunningham, & Sayles, 2013; Lucas, 2011; Magidson, Blashill, Safren, & Wagner, 2015; Turan et al, 2016). …”

“…These plans provide more limited access to mental health and substance use treatment than the Ryan White program, which provides to uninsured and underinsured PLWHA a comprehensive range of services that are not provided by any other source (Cahill, Mayer, & Boswell, 2015; Leibowitz et al, 2013). Thus, PLWHA may need to depend on either community providers or wrap-around services from the Ryan White program to support continued engagement in care with the goal of viral suppression (Arns et al, 2004; Cahill et al, 2015; Gonzalez et al, 2011; Holtzman et al, 2015; Huynh et al, 2013; Lucas, 2011; Magidson et al, 2015; Turan et al, 2016). Indeed, a recent study found that post-ACA enrollees in Kaiser Permanente Northern California were more likely to be virally suppressed than a similar group enrolled prior to the ACA (Satre et al, 2016).…”

Healthy Aging in Older Women Living with HIV Infection: a Systematic Review of Psychosocial Factors

“…Despite the increase in older women (age 50+) living with HIV (OWLH), little is known about the psychosocial factors that impact how they live, cope, and age with HIV. Unlike social determinants of health, psychosocial factors are viewed as being amenable to change, resulting in decreased transmission and improved health and thus lessening the burden of AIDS among PLWH [4–10]. Factors such as healthcare utilization, sexual health, stigma, isolation, loneliness, depression, and substance use impact adherence to HIV medications and clinical outcomes in PLWH in general [11–17], but have not been well studied in OWLH.…”